Aquatic Therapy for Gait Dysfunction Adult Orthopedic and Geriatric Populations

Terapia acuática Intervenciones para la disfunción de la marcha

Poblaciones adultas de ortopédicas y geriátricas

Emily Dunlap, PT

Central Texas Rehabilitation, USA

Comprehensive Aquatic Therapy put into Practice October 29-31, 2016 Querétaro, Mexico

Wealth of knowledge / Riqueza de conocimientos

Gait gives clues about multiple body systems

Marcha da pistas sobre múltiples sistemas del cuerpo

• Cardiovascular system / Cardiovasculares

• Pulmonary system / Pulmonar

• Musculoskeletal system / Músculo-esquelético

• Strength/ Fuerza

• ROM / Rango de movimiento

• Neurological system/ Neurológica

• Hyper/hypo tonicity / hiper/hypor tonicidad

• Pain/ Dolor

• Coordination / Coordinación

• Balance / Balance

• Cognitive processing / Procesamiento cognitivo

Gait speed: The functional vital sign Velocidad de la marcha: Signo vital funcional

(Fritz 2009, Middleton 2015 – older adults)

• “…almost the perfect measure” “Casi la medida perfecta” (Wade 1992)

• Reliable / Confiable (Richards 1996)

• Valid / Válido (Steffen 2002)

• Sensitive/ Sensible (van Iersel 2008)

• Specific / Específicos (Harada1995)

• Correlates with/ Se correlaciona con

• Functional ability / Capacidad funcional (Perry1995)

• Balance confidence / Equilibrio de confianza (Mangione2007)

Gait speed as a predictor of

function Velocidad de la

marcha como un predictor de la

función (Middleton, Fritz,

Lusardi 2015)

Chart used with permission from Stacy Fritz, PhD, PT

< 0.6 m/s DANGER PELIGRO

0.6 -1.0 m/s WARNING ADVERTENCIA

1.0 m/s Functional Community Ambulator Ambulator comunidad funcional

Ways to measure gait speed Formas de medir la velocidad de la marcha

• 5 - 10 meter walk test – quick and easy – good for those with slow walking speeds.

• Timed Up and Go (TUG) – quick and easy – more functional with rise/lower into chair and turning as well as walking.

• 6 minute walk test – when longer test is needed to view dysfunction (greater than 1.0 m/s gait speed does well in this category)

What is normal? ¿Qué es normal? What is the Minimal Clinically Important Difference?

Rehabmeasures.org

Gait in Water vs land La marcha en tierra del vs agua

• Lower self selected speeds and vertical ground forces in water (Heywood 2016)

• Inter-joint coordination of hip, knee and ankle was changed when walking in water (Miyoshi 2003 – healthy , Barela 2006- healthy , Cadenas-Sanchez 2015 - healthy)

• Reduced BP during water walking (Lambert 2014 – sedentary adults)

Assess gait outcome on land Evaluar resultado de andar en la tierra

Treat gait dysfunction in the pool Tratamiento de la disfunción de la marcha en la piscina

Research to support improved land gait with aquatic interventions

Investigación para apoyar la marcha de tierra mejorado con intervenciones acuáticas

• Improved gait speed Velocidad de la marcha mejorada

(Zhang 2014 – spastic paraparesis, Getz 2012 – Cerebral Palsy , Marinho-Buzelli 2014 – neurological disease)

• Improved TUG Mejorado TUG

(Foley 2003 - OA, Katsura 2010 – older adults, Pompeu 2013 – older adults, Araujo 2015 –post menopausal , Covill 2016- balance)

• Improved gait stability Estabilidad de marcha mejorada

(Lim 2013 – older adults)

Strong indicators for aquatic therapy Fuertes indicadores para terapia acuática

Gait speed <.8 m/s

Velocidad de la marcha <.8 m/s

Walks with assistive device

Unable to single leg stand

Fear Response

Strength less than 3/5 (commonly core, gluteals and gastrosoleus)

Walks with assistive device Fearful to move knee due to pain

Improved knee mobility and less fear of pain with movement.

Unable to single leg stand on land but look at him in the pool!

Rock star

Importance of Gluteals in Gait Importancia de las glúteos en la marcha

• Glut med greatest intermuscular adipose tissue higher

gait variability (Addison 2015 – Older adults)

• Glut max and glut med weakness higher incidents of falls (Inacio 2013- older adults)

• Higher glut med activation noted with stepping tasks (Dwyer 2013- hip OA )

• Early Stance muscles Vasti, adductor magnus, glut med (Neptune 2016 - )

• Aquatic exercise Improved strength glut med with aquatic exercise (Rahmann 2009- THA, TKA)

Importance of calf musculature Importancia de la musculatura de la pantorrilla

• Late Stance muscles glut med, soleus, gastrocnemius (Neptune 2016)

• Flexor hallicus longus strength contributes to push off in gait (Peter 2015)

• Triceps surae (med/lat gastroc and soleus) work dependently (Akasaka 2004)

• Adipose tissue in calf of elderly poor balance and mobility. (Scott 2015- older adults)

• Plyometric training plantar flexion strengthening (Markovic 2010) • Aquatic exercise Improved strength plantarflexors with aquatic exercise + improved TUG

(Katsura 2010- older adults)

• Underwater treadmill walking less intense gastroc work (Shono 2007- older adult women)

< 3/5 strength does well in pool <fuerza 3/5 hace bien en la piscina

Functional activity through FULL range of motion Actividad funcional a través del rango COMPLETO de movimiento

Aquatic Plyometric training Entrenamiento pliométrico acuático

• Aquatic plyometric exercises reduced peak impact forces (Donoghue 2011)

• Aquatic plyometric jumping greater mechanical peak power (Louder 2016)

• Aquatic plyometric training compared to land plyometric training (Stemm 2007 – same; Jurado-Lavanant 2015 - land better outcomes )

You know it’s all about that Bass (I mean …Stance)

Todo sobre Control de postura

Take advantage of the pool. People can practice stance skills without UE support much easier in the pool forcing them to build CENTRAL strength and motor planning strategies during stance control.

Disfruta de la piscina. Personas pueden practicar habilidades de postura sin apoyo de la UE mucho más fácil en la piscina obligándoles a construir fuerza CENTRAL y motor de planificación de estrategias durante el control de la postura.

Deep water running to improve Walking? ¿Corriente de aguas profundas para mejorar caminar?

• Deep water running less postural sway + increase tandem walking speed (Kaneda 2008 – older adults)

Rhythm and Timing is essential Ritmo y la sincronización es esencial

Rhythmic auditory cueing improve stride length, cadence and gait speed (Yu 2015) Music salience effects gait cadence and stride length (de Bruin 2015) Rhythmic sound training activates area of brain involved with motor planning and sequencing (Bengtsson 2009, Ivry 2004) Increase in Musical Cadence increase in physiologic response with aquatic exercise (Bartolomeu 2016 – younger vs older women, Barbosa 2010)

Feel the Rhythm Siente el ritmo

How to improve gait with aquatic therapy Cómo mejorar la marcha con terapia acuática

Missing Component / Componente que falta

Find and work on missing component with aquatic intervention.

Then re-assess, re-assess, re-assess. Encontrar y trabajar en falta componente intervención acuática.

A continuación, vuelva a evaluar, evaluar de nuevo, volver a evaluar.

• Motor planning (coordination, speed modulation, rhythm) / Planeamiento motor

• Strength (big culprits - gluts and GS) / Fuerza

• Pain (antalgic response) / Dolor

• Endurance (cardiovascular exercise) / Resistencia

• Flexibility (big culprits - spine, hip flexors, knee, ankle) / Flexibilidad

• Balance (fall risk) / Balance

1. Select missing component that

impedes function

Seleccione el componente que falta que impida la función

3. Check frequently for

progress

Verifique con frecuencia para el progreso

2. Work on the missing component

with aquatic intervention.

Trabajo en el componente que falta con intervención acuática.

Easy as 1-2-3 Fácil como 1-2-3

Eval – 5 meter walk - .48 m/s

Lack of hip and spinal ROM Falta de ROM de cadera y columna

vertebral

Lack of hip extension during late stance Falta de extensión de cadera en posición

final

Poor Lumbar/pelvic control Pobre control pélvico/Lumbar

Addressing Hip and spinal ROM

Abordar la cadera y columna vertebral ROM

Assess after

intervention for improvement in ROM Evaluación

Addressing Lumbar/pelvic control

Abordar el control pélvico/Lumbar

Assess if lumbar/pelvic control improved with aquatic therapeutic exercise

Evaluación

1 month follow up – 5 meter walk 1.05 m/s Seguimiento 1 mes – 5 metros a pie 1.05 m/s

Assessing gait outcome on land

Evaluar el resultado de andar en la tierra

BEFORE ANTES DE

AFTER 3 WEEKS DESPUÉS DE 3

SEMANAS

Dissociation of Cervical spine movement Disociación de movimiento

de la columna Cervical

Vestibular response Respuesta vestibular

Just off crutches - No pain with gait Justo al lado de muletas - No hay dolor

con la marcha

Poor left stance control Control de la mala postura izquierda Weak gluteus med strength Fuerza med glúteo débil Lack of left hip extension ROM Falta de extensión de cadera izquierda ROM

Poor left stance control and Weak glut med strength Mala postura izquierda control y fuerza de medius del glúteo débil

Lack of left hip extension ROM Falta de extensión de cadera izquierda ROM

3 weeks later 3 semanas después

Specific Gait training – Aquatic Intervention Ideas

Entrenamiento específico de marcha – Ideas de intervención acuática