Water therapy.
It is not just water!!! It is medicine.
Aquatic Therapy
Water the miraculous healer.
“Water - the elixir of life”, Water as we all know is important for life, our planet earth is also unique and called the Living Planet because of the presence of water. Even in our body about 60% (approx.) of the mass is filled with water. Water plays an important role in the day to day life of every living being. Water not only helps for daily living but also helps in curing various ailments.
Water is a “miraculous healer”. The use of water for healing has been dated thousand years ago; it is called the Aquatic therapy, also known as Hydrotherapy, water therapy, pool therapy or aqua therapy, formerly also called hydropathy, is a part of medicine, in particular of Naturopathy, Physiotherapy and Occupational therapy , that involves the use of water for pain relief and treatment. Hydrotherapy when applied externally, either by immersion of the whole body or of parts of the body in water, or without immersion by spraying or pouring water onto the body. The effects of whole body immersion therapy are discussed here.
Aquatic therapy is used as a part of Physiotherapy, in which it helps in Physical rehabilitation, fitness, relaxation, movement-based therapy in water (hydrokinesiotherapy) and treating neurological, orthopedics, pediatrics, cardio-pulmonary, sports injuries and various other specialties in treating injuries, diseases and curing certain illness. Hydrotherapy is also used in pregnant women and obese people.
The unique properties of the aquatic environment and with varied depths of immersion provide various treatment options that are impossible or difficult to implent on land. Physical properties of water such as buoyancy, viscosity, surface tension, temperature and pressure and hydromechanics, etc. are used for therapeutic purposes.
Aquatic rehabilitation has been more beneficial since there is no act of gravity when immersed in water. The Physical properties of water assist and resist in doing exercise which makes it unique and more efficient than in land. The Properties provided by buoyancy, hydrostatic pressure, viscosity, temperature and surface tension have a direct effect on the body in the aquatic environment. Few physical proprieties in brief as its play a vital role during therapy.
Buoyancy is the upward force that acts opposite to gravity, it provides the patient with relative weightlessness and joint unloading, allowing performance of active motion with increased ease, it provides therapist with a three dimensional access to the patient.
Hydrostatic Pressure is the pressure exerted on the immersed objects, as the density of water and depth of immersion increase, so does the hydrostatic pressure.
Increased pressure reduces or limits effusion, assists venous return, induces bradycardia and centralizes peripheral blood flow. The proportionality of depth and pressure allows patients to perform exercise more easily when closer to the surface.
Viscosity is the friction occurring between molecules of liquid resulting in resistance to flow. Water’s viscosity creates resistance with all active movements. Increasing the surface area moving through water increases resistance.
Surface tension, the surface of a fluid acts as a membrane under tension. The resistive force of surface tension changes proportionally to the size of the object moving through the fluid surface. An extremity that moves through the surface performs more work than if kept under water. Using equipment at the surface of the water increases the resistance.
Center of Buoyancy is the reference point of an immersed object on which buoyant (vertical) forces of fluid predictably act. In vertical position, the human center is located at the sternum.
In the vertical position, posteriorly placed buoyancy devices cause the patient to lean forward, anterior buoyancy causes the patient to lean back.
Temperature of water plays an important role in the therapy, because of alterations in temperature conduction and the body’s ability to dissipate heat. Warm water gives more vasodilation for general relaxation and cold water can give more vasoconstriction commonly used to reduce muscle soreness after hard training in sports. It is the responsibility of the therapist to decide the appropriate temperature of the water for the patients
Knowledge of physical proprieties is important to utilize aquatics efficiently, the therapist should understand clinical significance of static and dynamic properties of water as they have influence on the human immersion and exercise, also benefit from the maximum using these properties.
Aquatic exercise helps to
Improve Range of motion of joints.
To improve muscle strength and flexibility.
To enhance gait, balance and coordination training.
Rehabilitation for neurological, geriatric, pediatric, orthopedics and musculoskeletal conditions.
For pre-habilitation, rehabilitation and fitness in sports.
For obese people to do exercise and rehabilitation with ease.
Assist and resist movements.
For pregnant women during pregnancy and labor to ease and reduce discomfort.
Facilitate weight bearing activities.
Post-operative rehabilitation.
Facilitate cardiovascular endurance.
Enhance relaxation.
Technique of application
Before starting the therapy it is mandatory that the therapist does a thorough screening and assessment of the patient, condition, about the assistive aids used by the patient, precautions to be taken during the session in case of Geriatrics, Pediatrics, patients with neurological problems any medical instability or impairment (visual impairment, deafness), fear for water, post-operative conditions, for women about their menstrual cycle and pregnancy. To rule out the contraindication like bowel or urinary incontinence, seizure/ epilepsy, any recent contagious disease, skin diseases, any open wounds, allergy to chlorine, any kidney or cardio-pulmonary conditions, mental illness. The assessment will also be helpful for further prognosis of the condition.
After assessing the therapist should plan the exercise program. The therapist should understand the condition and the requirements of the patient and design a tailored made exercise program for the patient. Therapist should select appropriate form of therapy, the therapist should also prepare the required buoyant devices or any other assistive aids required for the patient based on the condition. The therapist should get the medical consent from the patient or the family members or the guardian prior to therapy, it is essential that the therapist gives a detailed explanation about the therapy and its benefits to avoid fear and anxiety caused to the patient. This will also give confidence and motivation to the patient. If it is a child then this must be explained to the guardian or the family members.
If it is an individual session then the therapist can be with the patient throughout the session inside the water. If it is a group therapy then the therapist can give a brief introduction before the session so that the there is less confusion and the therapist saves time to focus on all patients. Also while in group therapy it is better to categories and divide into upper and lower limb to make it easier for the therapist. Group therapy is beneficial in creating motivation to each other.
Warm up
It is better to begin with the general warm up and also let the patient to feel the aquatic environment before starting the exercise program, this also gains the confidence of the patient.
In case of normal person and athletes it is good to begin with some warm up exercises and stretches.
It is important to hydrate the patient during the session to avoid cramps.
Exercise program
Aquatic exercise can be stretching, strengthening, gait and balance training etc. The duration of therapy is planned by the therapist depending upon the prognosis of the patient.
Stretching
Stretching can either be passive or self-stretching with or without equipment. Manual (passive) stretching can be done in supine, with the help of buoyant devices with a three dimensional access by the therapist. The buoyancy- supported supine position improves (versus land techniques) both access to the patient and control by the therapist, as well as the position of the patient
Fig 1: Manual or passive stretch for trunk to improve lateral flexion
Fig2: Manual or passive stretching to increase cervical lateral flexion
Strengthening
By reducing joint compression, providing three dimensional resistance, and dampening perceived pain, immersed strengthening exercise may be safely initiated earlier in the rehabilitation program than traditional land based strengthening exercise.
The types of exercises performed in water must be carefully designed and selected to address different conditions and to avoid exacerbating existing problems or causing new ones. The patient can perform either closed-chain or open-chain exercises in water. The faster the water moves toward the patient, against the patient’s direction of movement, or the faster the patient moves in the water, the greater the resistance against the patient’s direction of movement, or the faster the patient moves in the water, the greater the resistance against the patient’s movement and thus the greater the strengthening or endurance-building effect of the activity. Buoyancy can also be particularly helpful for obese patients for whom land-based exercise places extreme stresses on the weight-bearing joints, they have greatly reduced joint loading with water based activities.
Like previously mentioned, the therapist designs a tailor made exercise program for each individual. There are few common exercises for the general relaxation exercises like forward walk, side walk, back walk, heel walk toe walk, arm rotation, forward movement, side raise, elbow flexion and extension.
Aquatic equipment /Buoyancy equipment:
There are different varieties of equipment for aquatic exercises. Aquatic equipment is used to provide buoyant support to the body or an extremity, to assist, resist the movement, to assist balance. By adding or removing the equipment, the therapist can increase the intensity of exercise.
Some of the equipment is buoyancy collars, rings, belts and vests. Swim bars (buoyant dumbbells, noodles, gloves, hand paddles, hydro-tone bells, fins and hydro tone boots, kickboards, aquatic resistance swim belt, water fan paddles, aqua cuffs. Few of aerobic conditioning equipment are immersed treadmill, immersed cycle or upper body ergometer. (For normal to athletic population).
Strengthening exercise equipment-assisted are called buoyancy assisted, buoyancy resisted, buoyancy supported, and buoyancy super resisted.
Buoyancy assisted: Vertical movement directed parallel to vertical forces of buoyancy that assist motion (patient may use buoyant equipment to assist with motion).
Buoyancy supported (BS): Horizontal movement with vertical forces of buoyancy eliminating or minimizing the need to support an extremity against gravity (patient may use buoyant equipment to assist with motion).
Buoyancy resisted (BR): Movement directed against or perpendicular to vertical forces of buoyancy, creating drag (performed without equipment).
Buoyancy super-resisted (BSR): Use of equipment generates resistance by increasing the total surface area moving through water by creating greater drag. Increasing the speed of motion through water generates further drag.
Techniques for aquatic therapy include the following:
Ai Chi: Ai chi, developed in 1993 by Jun Konno, uses diaphragmatic breathing and active progressive resistance training in water to relax and strengthen the body, based on elements of qigong and Tai chi chuan.
Aqua running: Aqua Running (Deep Water Running or Aqua jogging) is a form of cardiovascular conditioning, involving running or jogging in water, useful for injured athletes and those who desire a low-impact aerobic workout. Aqua running is performed in deep water using a floatation device (vest or belt) to support the head above water.
Bad Ragaz Ring Method: The Bad Ragaz Ring Method (BRRM) focuses on rehabilitation of neuromuscular function using patterns of therapist-assisted exercise performed while the patient lies horizontal in water, with support provided by rings or floats around the neck, arms, pelvis, and knees. BRRM is an aquatic version of Proprioceptive Neuromuscular Facilitation (PNF) developed by physiotherapists at Bad Ragaz, Switzerland, as a synthesis of aquatic exercises designed by a German physician in the 1930s and land-based PNF developed by American physiotherapists in the 1950s and 1960s.
Burdenko Method: The Burdenko Method, originally developed by Soviet professor of sports medicine Igor Burdenko, is an integrated land-water therapy approach that develops balance, coordination, flexibility, endurance, speed and strength using the same methods as professional athletes. The water-based therapy uses buoyant equipment to challenge the center of buoyancy in vertical positions, exercising with movement in multiple directions, and at multiple speeds ranging from slow to fast.
Halliwick Concept: The Halliwick Concept, originally developed by fluid mechanics engineer James McMillan in the late 1940s and 1950s at the Halliwick School for Girls with Disabilities in London, focuses on biophysical principles of motor control in water, in particular developing sense of balance (equilibrioception) and core stability. The Halliwick Ten-Point-Program implements the concept in a progressive program of mental adjustment, disengagement, and development of motor control, with an emphasis on rotational control, and applies the program to teach physically disabled people balance, control, swimming and independence. Halliwick Aquatic Therapy (also known as Water Specific Therapy, WST), implements the concept in patient-specific aquatic therapy.
Watsu: Watsu is a form of aquatic bodywork, originally developed in the early 1980s by Harold Dull at Harbin Hot Springs, California, in which an aquatic therapist continuously supports and guides the person receiving treatment through a series of flowing movements and stretches that induce deep relaxation and provide therapeutic benefit. In the late 1980s and early 1990s. physiotherapists began to use Watsu for a wide range of orthopedic and neurologic conditions, and to adapt the techniques for use with injury and disability
Aquatic therapy pools are practiced where the temperature, agitation and vibration of water can be controlled and maintained. There must be adequate facilities for patients with wheel chair and other assistive aids. Some of the forms of aquatic therapy are Whirlpool tank, Hubbard tank contrast bath, Non immersion irrigation device, pool, where there is complete immersion and local immersion in water.
Documentation: The patient therapy session and prognosis are documented; the documentation involves the form and type of therapy given, the position and other form of resistance used during therapy. When therapy is completed, the outcomes(s) of the therapy are recorded and compared with the progress relative to the initial evaluation.
Aquatic environment is like a second womb, similar environment which as babies, everybody has moved, played and enjoyed in their mother’s womb.
Aquatic exercise as a therapy by itself or as an augmenting therapy is effective and safe. As a Physiotherapist it is our duty and responsibility to use Aquatic therapy and benefit our patients. 
