Back to menu  Reinhard R. Bergel, Ph.D.H.E.A.T., Inc. Spa Therapy Development International Training Institute for Spa Therapy P.O. Box 1177 Calistoga, CA 94515 phone: (707) 942-6633 fax (707) 942-0734 email: heat@vom.com  Exercises in water differ considerably from apparently similar exercises in air because of the differences in the physical properties of the two environments. As with other forms of therapeutic exercises, water exercises increase muscle power and endurance and helps mobilize joints and muscles. In addition, it recreation. The presentation will discuss the physical properties of water that are primarily concerned, namely buoyancy, cohesion, and viscosity. The application of general principles of water exercises, step-wise water exercises progressions in fixed and free floating positions and the use of apparatus will be illustrated and demonstrated. Water is especially beneficial in the treatment of muscle weakness because of its properties (buoyancy, pressure transmission, heat capacity, and resistance), which allow earlier movements of limbs, muscle relaxation, reduction in spasm and pain, and increased range of painless motion. It is in the convalescent and chronic stages that water assumes its considerable importance in the rehabilitation program. In the chronically ill of disabled patients, it is one of the most practical means of maintaining activity and preventing further physical deterioration in conjunction with other physical methods. Illustrated will be the role of apparatus aids and the role of a skilled therapist in the water, providing hands-on therapy. I have applied water exercises and swimming clinically for more than ten years with a variety of impairments and disabilities. There has been little needed research that in lieu of scientific evidence I feel justified in presenting some of the advantages that I have witnessed patients gain from swimming. For these physicians who wish to prescribe swimming specifically, that is, for the strengthening of muscles, an analysis of muscles required in the execution of the different swimming strokes will be made available (backstroke, crawl, breast stroke, side stroke, and treading water).  Exercises in Water Exercises in Water differ considerably from apparently similar exercises in air because of the difference in the physical properties of the two fluids. As with other forms of therapeutic exercises, hydro-gymnastics increases muscle power and endurance and helps mobilize joints and muscle. In addition, it helps to relax muscles, improve coordination, and afford recreation. the physical properties of water that are primarily concerned are its buoyancy and its cohesion. Buoancy Archmides found that a body which is wholly or partially immersed in a fluid at rest experiences an upthrust that is equal to the weight of the fluid displaced. Such a body has the following forces acting upon it: its own weight, W, vertically downward, and another force, B, equal to the weight of the fluid displaced acting vertically upward. When W = B, the body will float: when W < B the body will sink; and when W > B the body will float, partially submerged. Since the specific gravity of water is 1.0, any body with a specific gravity of less than 1.0 will float in it (cork or inflated rubber objects). The specific gravity of the human body with air in the lungs averages 0.974; most humans will float. The specific gravity of the human limb averages 1.0; depending upon the ratio of fat (low) to bone (high), a limb may or may not float. If the specific gravity of a part exceeds 1.0, buoyancy can be achieved by attaching to it an inflated rubber container. The upward thrust, force B, can be used to exercise in assisted, supported, and resisted movements. Assisted movements. The upthrust is used to assist limb or trunk movement. The part is first held below buoyant level, and the upthrust on the part toward the surface will assist movement in that direction. During the movement, the muscles concerned must be palpated to be sure that the patient is performing a voluntary contraction, that is, that the movement is truly assisted rather than passive. Supported movements. When the limb at buoyant level is moved parallel to the surface of the water, the upthrust supports the limb, as in a series of slings. This is an ideal position for testing and assessing joint movement and muscle power since minimal movement can be detected. Considerable experience is needed to differentiate ''trick movements'' in this position. Resisted movements. Pulling the limb vertically downward from the buoyant level uses the upthrust of the water as a resistance. In all the preceding situations, the muscles are used concentrically, but, if the limb is held below the buoyant level, the muscles will work statically, while, if the movement is controlled from below up toward the surface, the muscles will work eccentrically. In addition to these basic progressions, further work can be achieved by increasing the speed of movement, increasing the number of repetitions of the exercise, increasing the range of motion, altering starting positions and fixations, altering leverage, or using apparatus. Cohesion and Viscosity Cohesion in a liquid is the attractive force exerted by each molecule on those surrounding it, which results in a resistance of any object passing through the liquid. Viscosity (internal friction) is the property of a liquid to resist relative motion within it. The greater the cohesion, the greater the viscosity. All movements in all directions in water are resisted by cohesion and viscosity. The degree of resistance will depend upon the movement and on the shape of the moving body. The greater the speed, the greater will be the resistance. An exercise in water is first given slowly; progression is accomplished by increasing the speed of exercise performance. Water offers less resistance to a streamlined body than it does to a flat, angular, or irregular surface. This fact can be useful in designing underwater exercises, particularly those of the upper extremity. The arm can be moved through the water with the fingers or edge of the hand leading, and movement can be made more difficult by altering the impinging surface to the palm or back of the hand. The flow of water around the body is not uniform. A pressure difference is set up between the impinging surface and its rear, where there will be a ''wake'' or zone of reduced pressure, which, naturally ''fills'' rapidly as might a vacuum. A sudden reversal of body movement will be opposed by water moving into the reduced pressure area. If there is repeated change of directions, waves and turbulence will be created with further resistance to movement. A further progression of resistance can be achieved by utilizing the weight of the water. If the patient is buoyant a movement can be performed from below buoyant level toward the surface at a greater speed than that of the upthrust; thus, the muscles must overcome not only cohesion and viscosity but also the weight of the column of water lying above them minus the upthrust. Since one liter of water weighs one kilogram, the load lifted may be considerable. Progression by Initial Positioning When fixed in a stable position, an individual muscle or limb can be isolated, although fixed starting positions are difficult to achieve in a buoyant medium. Apparatus and built-in furniture are helpful but often cannot replace manual fixation. The therapist may stabilize the patient manually either from within the pool or from without. Occasionally, to reach the exercise goal it may be necessary for one therapist to stabilize the patient while another directs the movement. Patients without severe handicaps may achieve stability for themselves by fixing themselves to pool fittings with their hands or feet and by making simultaneous limb movements. The initial fixed positions can be arranged in progressive order: (a) lying on a submerged plinth, fixed, if necessary, by hands or strap; (b) sitting on an underwater chair or stool, fixed as necessary; and (c) standing, holding a handrail or pool fitting. Semifixed positions. An exercise is more difficult to perform in a semifixed or nonfixed position than it is when the patient is stabilized. This form of progression in hydro-gymnastics has been developed into a protocol comparable to that of progressive resistance exercises. Two suitable positions are described. (1) The patient's arms hold the rail while he floats prone or supine, with his head on the therapist's shoulders and with the therapist's hands fixing the patient's waist. The legs and trunk are free to move. (2) The patient's feet are fixed under parallel bars or the handrail; he assumes the straddle position, with his legs on either side of the therapist's waist. The therapist's hands fix the patient's pelvis. The upper trunk and arm are free to move. A horseshoe-shaped neck float is often necessary to give the patient confidence in this position. Free floating. This position usually requires the support of floats under the head and possibly under the feet. This position is not suitable for strong exercises because good concentration is needed to maintain equilibrium and constant adjustments are required to achieve balance. It is useful for relaxation. Use of apparatus. (a) In the buoyancy-assited position, floats are used to increase mobility; the upthrust carries the limb or joint through an increased range of motion. (b) In the buoyancy-supported position, the same floats are used to support and give confidence to the patient. Flippers and fins are used to lengthen the buoyancy-resisted position, the same floats are attached to the limb to make it more buoyant and thus increase the muscle work required to sink the limb with its attached floats. Progression is made by starting with cork or small, inflated rubber floats and progressing to larger and larger ones. Additional apparatus. Other apparatus will be needed for standing, balancing, and walking in water. If the lower extremities are of unequal length, a raised show will compensate for this. In some poliomyelitic patients external fixation of one joint may be needed while working with other joints, for example, fixing a flail knee or elbow while working the shoulder or hip by means of a plastic or other waterproof splint. Knee splints help fix a flail knee when balance or standing re-education is begun. The progression of exercise may be summarized in the following table: Buoancy assisted long lever - - short fixed position - - semifixed slow - - faster Buoyancy supported short level - - long - - add flippers or fins fixed position - - semifixed slow - - faster Buoyancy resisted short level - - long fixed position - - semifixed slow - - faster add small floats - - large floats Lifting up through surface Lift more quickly than water upthrust B; overcome surface tension and gravity as limb leaves water Application Walking re-education. Water is an ideal medium for teaching standing and balance, and where possible such teaching should precede re-education of these functions in air. It should be started with the patient immersed up to neck level in order to reduce weight bearing on the feet to a minimum. With that amount of immersion, a person experiences an apparent loss of nine-tenths of his weight out of water. In other words, the feet of a 70-kilogram man so immersed are called on to support only 7 kilograms. Thus, patients with painful weight-bearing joints will usually find it comfortable to stand in water; those with only poor leg muscles will be able to support such a small weight. Water turbulence can be used to re-educate balance as the patient tries to maintain his equilibrium against the onslaught of water pressure. Progression will result by increasing the pressure or lowering the water depth, forcing the feet to work their muscles harder to stabilize the joints. Once the patient has learned balance in water, walking can commence. It must be conceded that progression in water is not truly walking re-education since the muscle work of walking in water is quite different from that on land. Nevertheless, a correct pattern of walking can be taught, a good posture achieved, and postural hypertension corrected. It is also good for the morale of a patient to find he can walk easily in water. Retraining of standing and sitting can also be started, first in deep water and progressing to shallow water with an underwater chair or stool. Going up and down stairs can be practiced on the steps of the pool. If there are no steps, removable weighted platforms can be used. Mobility. Hydro-gymnastics is valuable for the increase and maintenance of mobility of joints and soft tissues as well as for the strengthening of muscles. In fact, these goals are often complementary. The temperature of the water will help to diminish pain, which may be causing enough muscle spasm to limit joint motion. Further relief of pain may result from an underwater douche played around the affected joint in a circular pattern. This should be given at 6¡C. higher than the pool water at a pressure of 700 grams per cm. If the whole limb is painful, the douche is directed from the distal to the proximal end of the limb much as effleurage is given along the path of venous return. If the patient's limb is buoyant, the upthrust can be utilized to carry the limb through as great a range as possible, and this can be further enhanced by the use of floats, especially where full passive range or active assisted motion is possible in air, but where the muscles are too weak to achieve it without assistance. It may also be possible in the buoyancy-supporting position, because most of the weight of the limb is supported by the water. Manual assistance may also be necessary as the limits of movement are reached. The chief problem encountered in these exercises is in avoiding trick motions by an adequate, fixed starting position. For example, to mobilize the shoulder joint, the therapist must limit movement at the glenohumeral joint by fixing the scapula. To mobilize one hip, the other hip must be fixed in such a position that pelvic motion is prevented; for example, the left hip is held in flexion to achieve right hip extension, and it is held in abduction to gain right hip abduction or bilateral movements are performed. Relaxation. The primary goal of treatment may be to relax spastic muscles or to bring about overall relaxation in generally tense patients. For general relaxation, the floating position is ideal even if supporting floats are required at the hed and feet. Warm water (37¡C) not only enhances relaxation but also may relieve tension by diminishing aches and pains. The feeling of movements can be performed in this position without fear of overbalancing, and these are usually followed by a period of rest and relaxation. Relaxation can be prolonged after immersion by a pack in warm towels, a sheet and blankets. Where local relaxation is desired, a more fixed position is advisable; the method chosen will depend upon the degree of muscle spasms. If the muscles have voluntary power they should be worked as hard as possible against the greatest resistance possible in water until they tire and relax. If there is no voluntary power the opposing muscle groups must be worked to gain physiological relaxation of the spastic group. Abductor spasm of the hips may be helped by resisted exercises of the abductors. Coordination. The best coordination exercises in water are floating and swimming, but it is better to start with slow, controlled movements in one of the fixed positions. It is often possible to achieve a slow, controlled movement in water that is impossible in air because the apparent loss of weight of the limbs in water allows weakened muscles to control a movement successfully. The next step is floating, from which controlled changes of position can be taught, which may lead to the first steps in swimming instruction. The starting movement is a slow, sculling movement of the arms, followed by the back crawl leg kick at first performed slowly and then more rapidly. These two movements can then be combined to give a smooth, coordinated progression. First the arm and then the leg movement of the breast stroke should be practiced separately and then combined. When the patient can do the breast stroke correctly, coordination of arms and legs has become so well established that no further progression in the water is necessary. Recreation. Many patients can achieve more general activity in the water than on land. Even the most severely handicapped can usually be given some modified recreation that will add interest to the treatment; careful planning will also help their disability. The obvious recreation is swimming, the best general exercise that can be given in a pool. For the severely handicapped patient, normal swimming strokes will have to be adapted and stabilizing floats may be required to impart confidence. In most cases it will be possible to teach some method of self-propulsion. We try to teach all our patients some form of swimming, usually starting with floating on the back with an inflated horseshoe-shaped head float. The next step is sculling with the arms and splashing with the legs, from which patients may progress to recognized swimming strokes, concentrating on these which will help their disability most. Once they can regain the upright position from floating positions, recreation can be concentrated on the individual handicap. Recreational activities for the lower extremities. (a) The therapist supports the upper part of the body on a float and makes the patient use the legs for forward propulsion. This is hard work. Competition will make some patients work harder; races can be organized between two or three patients, possibly with the hydrotherapist also participating. (b) The patient jumps in deep water, starting with small jumps and progressing to higher jumps in deeper, then in shallower, water. Interest can be increased by attempting to leapfrog over floats. (c) He hops and runs in water. (d) Holding the rail, feet against the side, he pushes off into a floating position. (e) He kicks floating balls on the surface while floating. Recreational activities for the upper extremities. (a) The patient pushes a ball down into the water and under parallel bars; he starts with a small ball and progresses to a larger one. (b) The lower part of his body is supported on a float; he uses only the arm for propulsion. Races can be organized. (c) Sitting on an inflated rubber float, he rows along. Races may be organized here too. (d) He pulls himself along the handrail in a floating position. (e) Water polo is also useful. Restrictions. Patients with open or infected wounds or who are incontinent are not suitable for treatment in a large pool but may be treated in a small, individual pool. If faulty techniques are employed, certain disadvantages may be encountered (a) Faulty movement patterns, for example, trick movements, may develop. (b) Muscle incoordination may be worsened if there is improper stabilization during exercise. (c) Work in warm water is tiring; prolonged immersion may lead to ''thermal disability'' in patients and staff and should be avoided by careful planning. Exercises 1. Buoyancy-assisted exercises for deltoid muscle. The patient is seated on an underwater chair or stool. The therapist palpates the deltoid to ensure active contraction. (a) Arms are raised sideways up toward the water surface. (b) Arms are carried back and up toward the water surface. (c) Arms are carried forward and up toward the water surface. 2. Buoyancy-assisted exercises. (a) For the hip abductors, the patient is side-lying on an inclined stretcher. The upper leg is carried up toward the surface. the therapist supports the pelvis and palpates the muscles to ensure active contractions of abductors. (b) For the back extensors, the patient is prone-lying on an inclined stretcher. The legs and lower trunk are lifted up toward the water surface. The therapist palpates the extensors to ensure active contraction. 3. Buoyancy-supporting deltoid exercises. (a) For the middle fibers, the patient lies on an underwater plinth, his arms raised sideways, the back of his hand leading, altering the impinging surface. (b) For the middle fibers, the patient lies on an underwater plinth, his arms raised sideways parallel with the water surface, the edge of his hand leading. (c) For the anterior and posterior fibers, the patient is in a reaching position, sitting on an underwater chair or stool. His arms are carried backward parallel to the water surface, the edge of his hand leading, and are then returned to the reaching position in the same manner. (d) The patient is in a reaching position, sitting on an underwater chair or stool. His arms are carried backward parallel to the water surface with the back of his hand leading, and are then returned to the reaching position with the palm of the hand leading. 4. Buoyancy-supporting exercises. For the right hip extensors, the patient is inthe left side-lying position on an underwater plinth, the left hip fully flexed to prevent pelvic movements, the right hip extended parallel to the water surface. 5. Buoyancy-resisting exercises of the deltoid. (a) With the patient in the side-lying position, his head supported on a horseshoe-shaped float and the therapist holding his legs and trunk, the arm is carried downward into the water. (b) The patient is in the prone-lying position, his head supported on a horseshoe-shaped float, the therapist supporting his legs and trunk. The arm is carried forward and down into the water. (c) The patient is in a reaching position, sitting on an underwater chair or stool, and his arms are brought down into the water. For the posterior fibers, the patient is in the straddle position with a horseshoe-shaped head float, the therapist supporting his pelvis. The arms are brought downward into the water. 6. Buoyancy-resisting exercises. (a) For the left hip abductors, the patient is in the left side-floating position over parallel bars or supported by the therapist. His head is on a horseshoe-shaped head float, and his left leg is pressed downward into the water. (b) For the back extensors, the patient is supine, floating with his hands on a rail, his trunk supported by the therapist. His legs and pelvis are pressed downward into the water. (c) For the left hip extensors, the patient is lying on an inclined stretcher, his right knee bent to prevent pelvic movement, while his left leg with a straight knee is pushed downward into the water. Exercises 1. Buoyancy-assisted exercises for deltoid muscles. The patient is seated on an underwater chair or stool. The therapist palpates the deltoid to ensure active contraction. (a) Arms are raised sideways up toward the water surface. (b) Arms are carried back and up toward the water surface. (c) Arms are carried forward and up toward the water surface (Fig. 26). Fig. 26. Buoyancy-assisted exercises for the deltoid muscle. 2. Buoyancy-assisted exercises. (a) For the hip abductors, the patient is side-lying on an inclined stretcher. The upper leg is carried up toward the surface. The therapist supports the pelvis and palpates the muscles to ensure active contractions of abductors. (b) For the back extensors, the patient is prone-lying on an inclined stretcher. The legs and lower trunk are lifted up toward the water surface. The therapist palpates the extensors to ensure active contraction (Fig. 27). Fig. 27. Buoyancy-assisted exercises for the hip and back. 3. Buoyancy-supporting deltoid exercises. (a) For the middle fibers, the patient lies on an underwater plinth, his arms raised sideways, the back of his hand leading, altering the impinging surface. (b) For the middle fibers, the patient lies on an underwater plinth, his arms raised sideways parallel with the water surface, the edge of his hand leading. (c) For the anterior and posterior fibers, the patient is in a reaching position, sitting on an underwater chair or stool. His arms are carried backward parallel to the water surface, the edge of his hand leading, and are then returned to the reaching position in the same manner. (d) The patient is in a reaching position, sitting on an underwater chair or stool. His arms are carried backward parallel to the water surface, with the back of his hand leading, and are then returned to the reaching position with the palm of the hand leading (Fig. 28). Fig. 28. Buoyancy-supporting exercises for the deltoid. 4. Buoyancy-supporting exercises. For the right hip extensors, the patient is in the left side-lying position on an underwater plinth, the left hip fully flexed to prevent pelvic movements, the right hip extended parallel to the water surface (Fig. 29). 5. Buoyancy-resisting exercises of the deltoid. (a) With the patient in the side-lying position, his head supported on a horseshoe-shaped float and the therapist holding his legs and trunk, the arm is carried downward into the water. (b) The patient is in the prone-lying position, his head supported on a horseshoe-shaped float, the therapist supporting his legs and trunk. The arm is carried forward and down into the water. (c) The patient is in a reaching position, sitting on an underwater chair or stool, and his arms are brought down into the water. (d) For the posterior fibers, the patient is in the straddle position with a horseshoe-shaped head float, the therapist supporting his pelvis. The arms are brought downward into the water (Fig. 30). Fig. 29. Buoyancy-supporting exercises for the hip extensors. Fig. 30. Buoyancy-resisting exercises for the deltoid. A Agility and Strengthening Exercises for Trunk and Spine 7) Hip side bends. Move with your hips perpendicular to the wall away from and back to the wall, legs extended. Change left and right side. 8) Push the water away from you. In backlying position tuck your legs and push the water away from you. 9) Squats against the wall. Place your feet flat against the pool wall and push away with both of them. Start over again from the floor. 1) Twist your trunk. Arms to the side, turn trunk, head, and arms to the left and right. 2) Knee bends to your chest. Move your straight arms up and down. Alternate knee bend left and right. 3) Trunk side bend. Move your straight arms, head and trunk to the side. 4) Trunk twists. Move your straight arms and head together to the left and right. 5) Hip-semi circles. Move your hips, with straight legs, to the left and right. 6) Bent hip-side twists. Move with squatted legs from the left to the right across the wall. B Agility and Strengthening Exercises for Shoulder Girdle and Arms 7) Straight arm small circles. Hold your arms sideways and move them in small circles clockwise and counterclockwise. 8) Bent arm-water-push. With your palms, alternately push the water away from you in all directions (resistance exercise). 9) Arm flexion and arm extension. Pull and push your body to and away from the pool wall. 1) Shoulder circles. Circle your shoulders loosly forward and backwards. 2) Straight arms semi circles (horizontal). More your straight arms to the side and in front of your chest. Turn your palms while moving back and forth in order to feel the resistance of the water. Straight arm swings up and down. More your straight arms up and down. Turn your palms while moving up and down in order to feel the resistance of the water. 4) Alternate arm swings up and down. Move your arms alternately up and down alongside the hips. Turn your palms while swinging your arms in order to feel the resistance of the water. 5) Straight arm swings sideways up and down. Move your straight arms up and down sideways. Turn your palms while swinging your arms in order to feel the resistance of the water. 6) Full arm circles. Straight arm circles forward and backwards. General Aquatic Agility and Strengthening Exercises (execute each checked exercise three times)
Vertical Trunk Twist - Begin by twisting your lower body to the left by crossing your right leg over the left and extend it as far as possible. At the same time, twist your upper torso to the right by crossing your left arm over to the right side in front of your body while bringing your right arm behind the body as far as possible. Twist to the opposite side. This is 1 repetition. © SPA MANAGEMENT |