Saturday, April 20, 2013

Using Effective Aquatic Therapy Techniques Can "Take A Load Off"

Repetitive pounding from weight bearing activities is a mechanism of injury for many sport related maladies.  Lower extremity overuse injuries plague the athletics world and occur from many factors (stay tuned for a later blog on this, it is quite interesting).  Tibial stress fractures, femoral stress fractures, metatarsal stress fractures, achilles tendonitis, chondromalacia, and patellar tendonitis are all common injuries that are impacted by repetitive loading of the lower extremity. 

Typically, patients with chronic stress related injuries will be instructed to remain active (but reduce or eliminate weight bearing activities), receive appropriate therapy on the injury, strengthen the affected area, and once healed, "gradually" move back into activity. Most Type A personality athletes take this as "get back to training as soon as I start to get a little relief from rest and therapy".  This is a natural response for competitive people but certainly not the best course of action to return from a significant stress related inevitably occurs. Elite athletes with stress related injuries try to avoid this mistake by incorporating specific methods of training during their recovery and rehabilitation.  By utilizing aquatic therapy as part of the rehabilitation program, top athletic health care professionals are able to manage injury restrictions, yet maintain or improve conditioning, strengthen the injured area, and formulate a measurable graduated return to full weight bearing to avoid re-injury after the athlete returns to competition. 

Gradual Return to Full Weight Bearing
For many stress related lower extremity injuries, reduction of weight bearing is necessary for the injury to heal, but total non-weight bearing is rarely prescribed.  Partial or restricted weight bearing is often chosen because the body needs this stimulation to propagate the healing process.  The effects of buoyancy in water allows performance of sport related activities in various levels of "measurable" weight bearing.  To estimate the percentage of weight bearing while in the water, there is a simple rule of thumb:

 0% Weight Bearing = Submerged but unable to touch the floor of the pool
10% Weight Bearing = Submerged in water up to the sternoclavicular joint (base of the neck)
25% Weight Bearing = Submerged in water up to the xiphoid process (just below the chest)
50% Weight Bearing = Submerged in water up to the ASIS (bones on the front of the hips)
(These are guidelines, exact weight bearing numbers depend on sex, body type, and body composition)

If needed, non-weight bearing activities can be performed in water deep enough the bottom of the pool can't be contacted.  The use of flotation devices on the torso allows the athlete to perform physical activities in the water in a non-weight bearing capacity. Commonly used flotation devices by top professionals are the AquaJogger, the Zero G Flotation Suits, and the WetVest.  Whatever device is chosen should provide enough buoyancy to allow the athlete to float neck deep in the water but maintain an upright running position.  All are effective and can be purchased online and are a great investment for the athlete relegated to water workouts for any extended period of time.

For those that don't have the luxury of elite athletes' access to a custom pool, there is no need to worry.  Utilization of  various depths of water in any pool can be performed to achieve these gradual increases in weight bearing.  Once cleared by an athletic health care professional to resume gradual weight bearing, start at the appropriately prescribed level in the pool and perform running activities at that depth.  As exercises are tolerated without exacerbation of symptoms, gradual movements into more shallow areas of the pool can occur to add more weight bearing.  As the level of weight bearing increases, steps must be taken to monitor for the return of any symptoms. Return of symptoms may indicate that progression has occurred too quickly, and a return to previously used deeper depths until the body has time to respond and adapt may be warranted.  Once running is performed at 50% weight bearing with no increase in symptoms, the athlete is normally ready to resume land based training (again increasing the workouts in a logical graded fashion over time).

Keeping the Pressure on the Injury
Hydrostatic pressure is the amount of pressure applied to the body while submerged in water.  The deeper the body, the more pressure is exerted.  (This is the cause of the sensation of the ears needing to "pop" when diving in deep water and the cause of some dangerous conditions in individuals who deep sea dive.)  What does this have to do with treating injuries?  Hydrostatic pressure can be utilized to control and reduce swelling at appropriate depths.  For every foot of depth in the water, 22.4 mmHg is equally exerted around the body part (remember mmHg are the units of pressure used in determining blood pressure). For the normal athlete standing in 5 feet of water, there will be 112 mmHg pressure exerted on the feet with gradually less pressure exerted on the legs as you approach the surface of the water. The average person's diastolic blood pressure is 80mmHg, so even if the water is warm at that depth, swelling will not occur.  In fact, hydrostatic pressure is significant enough that swelling will reduce due to the pressure and move upward into the body and removed through the lymph system.  This effect can be further enhanced with movement in the water since muscular contractions also assist in the movement of swelling.  Taking advantage of hydrostatic pressure is one of the "secrets" used to manage injuries of the foot, ankle, and knee by top level athletic health care professionals.

Something to Consider
Hydrostatic pressure at 5 feet of depth exceeds the pressure exerted by many popular compression and recovery devices, leading to the conclusion that walking in deep water may be a means to promote recovery after hard workouts (especially if the water is cool). Try it some time.  If you think it doesn't work consider this: have you ever noticed that after a long swim workout your clothes fit a little looser initially?  Fluid shifts cause minor changes in limb girth until gravity reverses its effects. So the consumer tip for the day is -- don't go shopping for pants immediately after swimming or you might be likely to go home a few days later to find they don't fit quite like they did in the store!

Are There Contraindications To Using Aquatic Therapy?
Aquatic therapy is not recommended in some instances including but not limited to:
1. Untreated infectious disease (the patient has a temperature/fever)
2. Open wounds or unhealed surgical incisions
3. Contagious skin diseases
4. Serious cardiac conditions (due to the centralization of blood flow caused by hydrostatic pressure)
Athletes with pulmonary conditions should not be submersed more than 85% due to the resistance of chest wall expansion by the water creating subsequent complications.  It is always wise to check with an athletic health care professional before commencing a program including aquatic therapy.

Helpful Hints and Tips to Make Aquatic Therapy Effective
1. For individuals who are going to be performing partial weight bearing water running activities in the pool for extended periods of time, footwear should be worn in the water.  Without footwear, blisters on the bottom of the feet will likely occur as the skin weakens and slippage on the bottom of the pool occurs.  An older pair of running shoes will suffice (make sure they are cleaned and free of dirt, etc).  Specialized water running shoes (AQx shoes) are available are very effective in protective the feet during water running.

 2. Weight bearing estimations assume a normal body position with the hands in the water at depths above the waist.  Moving the arms out of the water will increase weight bearing (many people will do this to move faster in the water due to better traction on the bottom of the pool from the increase in weight bearing) and will affect the amount of impact experienced during activity.

3. Exercise must be performed at an appropriate intensity to elicit the desired conditioning effect.  Specific guidelines for how to maintain conditioning levels, isolated injury strengthening, increasing core strength, and other hidden gems of aquatic therapy is the topic for the next blog!

Be well. Be informed. Be Active!

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