Aquatic rehbilitation

1. AQUATIC EXERCISE
Pembimbing:
DR. dr. Tirza Tamin, SpKFR-K
Presentan:
Setia Wati Astri Arifin

2. Introduction
DEFINITION
The use of multidepth immersion pools or
tanks that facilitate the application of various
established therapeutic interventions
Schrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5th ed. Philadelphia: F. A.
Davis Company, 2007. p. 273
PURPOSE
facilitate functional recovery by providing an
environment that augments a patient’s ability to
perform various therapeutic interventions

3. Goals
Schrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5th ed.
Philadelphia: F. A. Davis Company, 2007. p. 273
ROM exercise
Resistance
training
Weight-
bearing
activities
Delivery of
manual
techniques
Access to the
patient
Cardiovascular
exercise
Functional
activity
replication
Minimize risk
of injury or
reinjury
Relaxation

4. Principles And Properties Of Water
Buoyancy
Hydrostatic Pressure
Viscosity Flow
•Laminar flow parallel
•Turbulent flow not
move parallelThermodynamics
Schrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5th ed.
Philadelphia: F. A. Davis Company, 2007. p. 273
Becker BE, Cole AJ. Aquatic Rehabilitation. In: DeLisa JA, Frontera RW, Gans BM, Robinson L, Walsh NE, editors. Physical
medicine and rehabilitation: principle and practice

5. AdvantagesBuoyancy 
weightlessness and joint
unloading increase
active motion
Hydrostatic pressure
reduces or limits effusion,
assists venous return,
induces bradycardia, and
centralizes peripheral blood
flow
Viscosity  resistance with
all active movements
Turbulence  destabilizer
& tactile sensory stimulus
Reduces stress and reduces
pain to a great extent
Disadvantages
Cost
• Cost of building and
maintaining a
rehabilitation pool
Specified personnel
• Physiatrists and
therapies must be
trained in aquatic
safety and therapy
procedures
Thermoregulation

6. Mobility
• Buoyant equipment may assist the movement initially
• Warm temperature may increase soft tissue extensibility
• Stretch techniques are used in two ways: active & passive
Trunk stabilization
• Consist of 6 steps: walking and marching; jumping in high
duck position; arm circling and straight arm pulls; arm
supported open chain hip, knee and ankle flexion and
extension in backward position; arm supported open chain
hip, knee and ankle flexion and extension in forward
position; aqua jogging
Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and
Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.

7. Beginning Aquatic Rehabilitation
• As early as possible after the injury to
minimize effect of immobilization
• Start with walking in water  patient learns
to move in this new therapy-medium, feels
quite relaxed and pain and fear are reduced
Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and
Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.

8. Design
Similar to land-based programs
Depends on:
• Type of injury/surgery
• Treatment protocols
• Results/muscle imbalances found in
evaluation
• Goals
Hoogenboom B, Lomax N. Aquatic therapy in rehabilitation. In: Prentice WE, editor. Rehabilitation techniques for sports
medicine and athletic training. 4th ed. New York: McGraw Hill, 2004. p. 326

9. Exercise Technique
The four variables
that can be
manipulated to
alter resistance or
assistance
1. Position or direction of
movement in the
water
2. Water depth
3. Lever arm length
4. Use of flotation or
weighted equipment
Brody LT. Aquatic physical therapy. In: Hall CM, Brody LT, editors. Therapeutic exercise , moving toward function. 2nd ed.
Philadelphia: Lippincott Williams & Wilkins. p. 330

10. Temperature Regulation
• Maintain between 26⁰C and 33⁰C for mobility exercise
Because,
– Patients are unable to maintain adequate core warmth
during immersed exercise at temperatures less than 25⁰C
– Hot water immersion (> 37⁰C) may increase the
cardiovascular demands at rest and with exercise
• Cardiovascular training and aerobic exercise should be
performed in water temperatures between 26⁰C and
28⁰C
Schrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5th ed.
Philadelphia: F. A. Davis Company, 2007. p. 273

11. Similar with land-
based exercise,
except for its
mechanic-
kinematic
Water will provide
additional
resistance to the
body core
Upper
extremity
Strengthening exercises
can be performed
completely non weight
bearing in the open
chain
Weight bearing can be
increased by reducing
the depth or by using
weight belts
Lower
extremity
Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and
Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.

12. Special Equipment
Pools
 in-ground swimming pool
 minimum range 4–5 m
 depth 1.2 - 1.4 m
Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and
Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.

13. Inflatable Cervical Collar
 maintain head
Floatation Ring
 positioning and relaxation
Buoyancy Belt
 supine, prone, or vertically for shallow and
deep water position
Special Equipment

14. Special Equipment
Swim Bars/
Buoyant
dumbbells
maintain head
Gloves
generates resistance
Hand Paddles
generates resistance

15. Special Equipment
Hydro-tone®
Bells and Boots
 generates
resistance
Kickboards
generates resistance
Ergocycle
generates resistance

16. Precautions
• need an orientation period
Fear of Water
Neurological Disorders
• patients with controlled epilepsy require close monitoring
Seizures
• angina and abnormal blood pressure need close monitoring
Cardiac Dysfunction
• Small, open wounds and tracheotomies may be covered by waterproof
dressings
• Patients with intravenous lines, Hickman lines, and other open lines require
proper clamping and fixation
Small Open Wounds and Lines
Schrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5th ed. Philadelphia: F. A.
Davis Company, 2007. p. 273

17. Contraindication
Schrepfer R. Aquatic Exercise. In: Kisner C, Colby LA, editors. Therapeutic exercise, foundations and techniques. 5th ed. Philadelphia: F. A.
Davis Company, 2007. p. 273
seizures
Incipient cardiac failure and unstable angina.
Respiratory dysfunction; vital capacity of less than 1liter.
Severe peripheral vascular disease.
Danger of bleeding or hemorrhage.
Severe kidney disease
Open wounds, colostomy, and skin infections such as tinea-pedis
and ringworm.

18. METHODS

19. Bad Ragaz Ring Method
• Technique
– The therapist provide stability for the client
– 3 action ways: isometrically, isokinetically, isotonically
aquaticsintl.com
Garret G. Bad Ragaz Ring method. In: Ruoti RG, Morris DM, Cole AJ, editors. Aquatic rehabilitation. Philadelphia: Lippincott;1997. p.
289
• The client wears neck ring float,
body ring at the L5-S2 level and
extremity rings
•The water level should not exceed
axillary (T8-T10) level of therapist
• Minimal pool area 15,8 m2
• Water depth usually 0,9-1,2 m
• Temperature 33,3⁰C – 36,6⁰C

20. Bad Ragaz Ring Method
• Aim:
– Tone reduction
– Relaxation
– Increasing ROM
– Muscle re-education
– Strengthening
– Spinal
traction/elongation
– Improving alignment
and trunk stability
– Preparation of the LE
for weight-bearing
– Restoration of normal
pattern of LE&UE
movement
– Improve general
endurance
– Training the body
functional capacity
Garret G. Bad Ragaz Ring method. In: Ruoti RG, Morris DM, Cole AJ, editors. Aquatic rehabilitation. Philadelphia: Lippincott;1997. p.
289

21. Indication
• Orthopedic &
rheumatologic
conditions
• Neurologic disorders
• Pain syndrome
• Sensory
desensitization
• Developmental delay
symptoms
Contraindication
• Precaution to
excessive fatique
• Vestibular problems
• Acute conditions
Garret G. Bad Ragaz Ring method. In: Ruoti RG, Morris DM, Cole AJ, editors. Aquatic rehabilitation. Philadelphia: Lippincott;1997. p.
289
Bad Ragaz Ring Method

22. • Trunk Pattern
– Stabilization
– Rotation
– Rotation with flexion
– Rotation with
extension
• Arm Pattern
• Leg Pattern
• Isokinetic/Isotonic/Is
ometric
• Bilateral/Unilateral
• Starting Position
• Therapist hold
• Verbal Commands
• Finishing Position
• Progression

23. Halliwick Method
BALANCE
AND
POSTURE
Can be used for patients
with neurologically or
developmental impaired
Focusing on patients
ability in water and
NOT disability on land

24. Mental Adaptation
Maintaining posture and
balance with buoyant force
influence
Overcome breathing
difficulty
Adjustment to therapist
dis-engagement
Balance
Restoration
Use primitive reflex
activities to control
vertical, lateral, and
combined rotation
movement
Inhibition
Teaches clients to hold a
posture when challenges are
applied on body
Facilitation
Controlling movement through
the water
Maintain balanced posture
while being moved passively
Swim stroke
Halliwick
Method

25. AQUATIC REHABILITATION FOR
OSTEOARTHRITIS

26. Aquatic Therapy With Knee
Osteoarthritis
• Purpose  Prevent
atrophy and motion loss
and abnormal movement
pattern development
Aquatic rehabilitation richaed g.ruoti, david m.morris, andrew j.cole. LIPPINCOT Philadhelpia New york 1997
Limitations of Weight
bearing with Buoyancy
effect

27. Aquatic Therapy With Knee
Osteoarthritis
Condition
associated with
weight bearing
limitations
Can use exercise according to
early phase , intermediate
phase and late phase
Limited weight bearing using
buoyancy can be initiated
early to prevent athropy and
motion loss and abnormal
movement pattern
development

28. Primary goal :
Restore normal gait
mechanics
• Proper heelstrike
• Proper weight
transfer
• Proper knee and
hip flexion
• Proper knee
ekstension
Aquatic rehabilitation richaed g.ruoti, david m.morris, andrew j.cole. LIPPINCOT Philadhelpia New york 1997. pg 79-81
Primary goal:
• Increased endurance in
gait
• Restoration of full motion
• Return of muscle
function.
Primary goal:
• Progression to full weight
bearing on ground
• Impact loading, plyometric
exercise and functional
activities in the pool (optional)
Early Phase
Intermediate Phase
Late Phase

29. Special Requirement
• Water temperature 27-30°C
• Depth
– Subacute phase: xyphoid level
– Chronic phase: SIAS level
• Modify:
– Patient’s position
– Lever arm length
– Direction of movement
– Use of flotation or weighted
equipment
Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and
Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.

30. Sample Training Program for
Knee Problem
Trunk
stabilization
Flexion/extension in
floating supine and prone
position
Balance
training
Single leg standing on
heels (up to toes - down to
heels - repeat)
Upper
extremity
training
Straight arm pull
Lower
extremity
training
Walking (forward,
backward, sideways)
Endurance
training Jogging in deep water Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli
LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and
Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.

31. Activities to improve posture
Activities to increase ROM and flexibility
Activities to increase muscular strength and endurance
Cardiovascular training
Musculosceletal Conditions Of The Spine
GOAL :
Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and
Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.

32. Activities To Improve Posture
• Spinal stabilization
exercise
• Forward walking
with a resistance
board
• Trunk strengthening
with paddles
• Advance spinal
stabilization exercise
• Balancing (sitting) on
a kickboard

33. Activities To Increase ROM And Flexibility
• Hamstring strech with use of floatation bouyance
• Forward walking exercise

34. Passive Trunk Flexion And Extension
Flexion
Extension
Wall slide /squats
Supine lap work, holding
kickboard at chest
Hanging in corner, lower
extremity flexed, back to wall
Posterior pelvic tilt with back to
wall, vertical stabilization with
lower extremities flexion

35. Activities To Increase Muscular Strength
And Endurance
Increase the strength and endurance of the
paraspinal and abdominal musculature
(important)

36. Cardiovascular Training
Important in completing the
rehabilitation process and
facilitating the transtition to a
regular fitness regime
1. Walking
2. Jogging
3. Swimming strokes
4. Immersed cycling
5. Immersed treadmill

37. Impairment Oriented Rehabilitation
• Mechanical back pain
• Soft tissue injuries
• Postural dysfunction
• Other imparment
oriented
considerations
Phase :
• Early
• Intermediate
• Late

38. Mechanical Back Pain
• Include :
– discogenic pain,
– facet syndrome ,
– degenerative joint
disease,
– obesity
• Goal : reduction of pain
– Unloading the spine by
means of immersion
into the shallow/deep
end of the pool
– Sensory input from flow
along the body
– Water’s warmth

39. Early Phase
GOALS:
1. Reduction of pain
2. Correction of any
postural faults
(lateral shift, lumbar
spine flexion)
3. The establishment of
normal movement
patterns.
• Variety of positions:
– Bad Ragaz techniques for
passive lateral trunk flexion
– Passive trunk flexion and
extension
– Gentle traction for
lumbar/cervical spine
(supine by stabilizing distally
or proximally at the trunk
then traction force at the
head or hips)
– Vertical traction in deeper
water by using ankle weight
and flotation vest

40. Intermediate Phase
GOAL :
• Increasing the pain-free ROM
• Improving ability to generate torque in the trunk
musculature for extended periods of time
• Increasing the number of activities performed
without pain.

41. Technique
Exercise by resistive trunk rotation :
• Stabilizing the feet on the bottom of the pool and
rotating the trunk
• Stabilizing the trunk by holding on to a stationary
object with the arms and rotating the legs.
Exercise in the pool
allows the person to
increase the exercise
time and repetition
without increasing joint
compression
Patient usually can
demonstrate proper
posture when cued, but
has difficulty
maintaining the posture
for any length of time

42. Late phase
• Pain free ROM
• Dynamic control of posture
• Muscular endurance
Functional
Needs

43. NEUROLOGIC DISORDER

44. Aquatic Rehabilitation Of Clients With
Neurologic Disorder
Neurorehabilitation model
Motor learning
Enchancing motor skill throught
task analysis

45. Balance dysfunction
• Biomechanical aspect
• Motor coordination
• Sensory integration and aquatic solution for
balance dysfuntion
Voluntary movement deficit
• Central mechanism dysfunction
• Periferal mechanism dysfunction
• Aquatic solution for voluntary movement deficit
Gait dysfunction
• stance and swing phase
• aquatic solution to gait dysfunction

46. STROKE

47. Stroke Aquatic Program
GOAL :
Produce a positive influence on participants over all
endurance, strength and flexibility
Provide a convenient, regularly scheduled opportunity
for participant to exercise and socialize in a positive,
fulfilling manner.
Provide effective, worthwhile educational program

48. b) Streching (10’- held @15
“)
with active streches
preferred :
1. Hip flexor
2. Hip adduction
3. Heel cord
4. Back extension
5. Shoulder flexion
6. Shoulder horizontal
abduction
activities
a) warm up (5 ‘ )
for perform increasing blood
circulation :
1. Slow walking
2. Slow marching at wall
3. Slow cycling
c) Movement control (10‘)
Aimed : improving control
of muscular contractions to
enchance smooth, effective
joint movement

49. d) Aerobic activities
(15’)
to increase heart rate
to 50 % to 70 % of
maximum heart rate :
1. Water walking
2. Water running
3. Marching at the
side of the pool
4. Cycling in the
innertube
5. Cycling while held
by a partner
e) Cool down (15’)
to return the heart
rate gently to a
resting level :
1. Slow walking
2. Slow marching at
the wall
3. Slow cycling

50. PEDIATRIC

51. Aquatic Rehabilitation In Pediatric
General Safety
Consideration :
• Oral Motor Control
• Ear Chronic Infection
• Hiponatremi
• Flotation device for
safety
Behavioral
considerations
Age guidelines
Cognitive status
Behavioral concerns
related to diagnosis.
Aquatic rehabilitation richaed g.ruoti, david m.morris, andrew j.cole. LIPPINCOT Philadhelpia New york 1997

52. Using Water To Address Problem Area
Alteration in stiffness:
• Hypotonia
• Hypertonia
• Weakness
ROM
Respiratory problems
Arousal problems
Sensory perseptual difficulties
Aquatic rehabilitation richaed g.ruoti, david m.morris, andrew j.cole. LIPPINCOT Philadhelpia New york 1997

53. Parent/ Guardian/Caregiver Instruction
• Children require more intense supervision
• The assisting enter the water with the child
and therapist to learn the necessary skills
• A demonstration by the therapist followed by
a return demonstration by the learner.

54. Adapted Bad Ragaz
• Requires : the patient respond to a
verbal command by the therapist.
• Modified
 the therapist’s hands become the
vehicle of communication and
slight pressure or traction to
move.
 The therapist’s may be able to
hold the child without using
flotation if she is small enough or
buoyancy enough.

55. Example
• To activate the lateral trunk and legs by
beginning in supported supine, holding at
the shoulders, elbows or rib cage to
provide stability.
• By quickly moving the upper trunk and
shoulders side to side, the child can be
helped to move her lower trunk and legs
to the side.

56. Adapted WATSU
Very useful :
 The severely or profoundly
mentally retarded child
 Child with increased stiffness
Not indication :
 Children who are significantly
hypotonic
• Can be used early in the session
to “loosen up” the child in
preparation for more active
work.

57. Cerebral Palsy, Spastic Diplegia With
Minimal Severity Sesion Plan
1. Enter via jumping off deck from a sitting
position near therapist
2. Turn around to place hands and feet on the
wall, push off the wall with feet and continue
with supine flutter kick
3. Supine recovery to do prone flutter kick back
to the wall
4. Repeat steps 2 and 3 several times for trunk
and lower extremity strengthening.

58. 5. Race across the pool using kickboards for upper
extremity stability and flutter kick in either prone or
supine.
6. Perform an obstacle course with object to retrive
from the pool floor using a surface dive
7. Trunk and lower extremity exercise in suspended
vertical with arms in two kickboards
8. Practice with simple hand stands
9. Handstands with controlled lower extremity
movements into flexion / extension and abduction /
adduction
10. Exit pool via staircase using two rails and assist as
needed

59. ATHLETE

60. Aquatic Rehabilitation Of The Athlete
Benefit of aquatic
programming for the
athlete The Principle of
Unloading
The aquatic medium provide
the athlete with the
opportunities for injury
prevention and for immediate
onset of safe and functional
rehabilitation
Aquatic rehabilitation richaed g.ruoti, david m.morris, andrew j.cole. LIPPINCOT Philadhelpia New york 1997

61. Purpose
Aquatic rehabilitation richaed g.ruoti, david m.morris, andrew j.cole. LIPPINCOT Philadhelpia New york 1997
To negate or lessen any
force that would
interfere with a final
goal
unloaded articular
cartilage and the
cortical and
cancellanous bone
Protection of the
ligaments and muscle-
tendon from excessive
torque or damaging
vibrational forces

62. Exercise prescription

65. The general principle
1. Work in the most shallow water tolerated
2. Functional activities should be practice as a whole
3. Sytematically remove external stabilization provided for
clients
4. Encourage stabilizing contractions in upright positions with
movement of selected body segment
5. Encourage quick, reciprocal movement
6. Encourage active movement problem solving
7. Gradually increase the difficulty of the task.

66. Type training to improve gait
dysfunction
• Standing weight shift
• One leg up
• Marcing
• Kick back
• Side kick
• Straight leg kick
• Walking with front
support
• Walking with side
support

67. Wicker A. Aquatic Rehabilitation. In: Frontera WR, Herring SA, Micheli LJ, Silver JK, editors. Clinical Sports Medicine: Medical Management and
Rehabilitation. 1st ed. Philadelphia: Saunders Elsevier; 2007.

68. Hoogenboom B, Lomax N. Aquatic therapy in rehabilitation. In: Prentice WE, editor. Rehabilitation techniques for sports
medicine and athletic training. 4th ed. New York: McGraw Hill, 2004. p. 326

69. Application

70. Application
Noodle Water