aquatic therapy exercise...alison bonnyman, pt cpa healthy aging forum, june 2019 promoting healthy...

+Aquatic Therapy

& Exercise

Alison Bonnyman, PT CPA Healthy Aging Forum, June 2019

Promoting Healthy Aging

+Healthy Aging

§ 66% of 45-64 years old individuals reported walking 3 or more days per week; slight drop in reported activity in those 65-85 years of age. Healthy Aging UK

§ 38% of Britains expect to be fit and healthy in their old age

§ 25% of older adults in Canada reach the recommended amounts of aerobic and resistance type physical activity§ self-reported CLSA survey, 2018 published findings

§ 47,841 participants using the Physical Activity Scale for the Elderly.

Did you know that…

CPA Healthy Aging Forum, June 2019

+Active Adult Living

Prince Edward Island ranked top place to retire§ According to The Guardian (December 6, 2012),

MoneySense magazine ranked Prince Edward Island (PEI) as one of the top 11 least expensive places in the world to retire, where you can retire for less than $30, 000 per year.

However… when searched for community pools/aquatics... Only the Bell Aliant Centre

Did you know that…


+Objectives1. Why Water? Outline the physiological effects of

immersion.1. Aging and immersion, 2. Barriers/Facilitators, Risks/Benefits

2. Advantages of Exercising in Water1. Optimizing hydrodynamics2. Evidence to offer aquatic programs

3. Community Aquatic Opportunities – Let’s Do More1. Access for all2. Optimizing community programming


+Please write 1 barrier to participation in aquatic exercise…

CPA Aging Forum 2019

+Why Water?

Buoyancy

Upthrust

Offloads

Assists Erect Posture

Balance is quietly challenged

Buoyancy, Hydrostatic Pressure, Turbulence & Drag

H Pressure

22 mmgHg/ft

Graduated

>Jobst

Effects in vertical

Slows movement

Turbulence/Drag

Isokinetic and multiplanarmovement

Speed, surface area easily manipulated

Resist or assist (like drafting)

+Hydrodynamics

50%

90%

Buoyancy Torque Hydrostatic Pressure Buoyancy-off loading

+Physiology of Immersion

n Cardiac

n Pulmonary

n Vascular

n Immune

n Cognition

n Lymphatic

n Insulin

n Mood

+Positive Impact of Water Immersion Cardiac

§ Increased stroke volume

§ Lowers blood pressure

§ THR 10-15 bpm lower

Hydrostatic Pressure

§ Fluid moved to core (700 ml in first 10 minutes)

Warmth

§ Dilates peripheral vessels


How:

+Positive Impact of Water Immersion Vascular

§ Peripheral vessels dilate

§ Increased Carotid Artery compliance Increased Cerebral Artery velocity (Carter, 2013)

§ Reduced muscle tone

Warmth■ Vasodilation

periphery


■ Graduated pressureà venous return

Turbulence

■ Wave massage


How:

+Positive Impact of Water Immersion Pulmonary

§ Lung compliance reduced 45% with full body immersion

§ FRC decreases 50% with immersion to xiphoid

§ *60% increased work of breathing


■ Increased thoracic blood volume

■ Compression on chest wall


How:

+Positive Impact of Water Immersion Hormonal

§ Decreased Epinephrine so decreased Sympathetic Nervous System

§ Immersion increases ANP release through atrial stretch receptors

§ Immersion reduces resting catchecolamine levels

§ Increase in Sodium secretion thru ANP


§ Venous and lymphatic compression

§ Changing the central blood volume


How:

+Positive Impact of Water Immersion Lymphatics

§ Improved lymphatic return

§ Reduced peripheral oedema

§ Control swelling

Hydrostatic Pressure■ 22mmHg per foot

of water

■ Graduated

Turbulence■ Gentle wave

massage


How:

+Positive Impact of Water Immersion Complex Physiology

§ Immune - cytokines increase

§ Insulin receptors improve efficiency

§ Lypolysis activated, ANP increase

§ Organ distention (bladder, right atrium) à hormonal activation


§ Fluid movement

Turbulence

§ Sensory-Motor Cortex primed


How:

+Positive Impact of Water Immersion Healthy Elderly

§ Bergamin 2013 – TUGT > aquatic group

§ Graff 2010 – periodized program of aquatic resistance> non periodized

§ Werner, 2019 – Aerobic>Resistance improves telomerase cellular senescence, regenerative capacity, and thus, healthy aging

Buoyancy■ Joint off-loading

Hydrostatic Pressure§ Fluid movement

Turbulence



How:

+Positive Impact of Water Immersion Healthy Impact

§ Carter, 2013 – Healthy men, submerged 10’, carotid diameter and cerebral flow

§ Schaeffer, 2015 – 20-30y.o.+ 1 73 y.o. –dual task memory better immersed


Hydrostatic Pressure§ Fluid movement

Turbulence



How:

§ Sato, 2013 – young men,TMS, mapped brain to

water’s thermal and mechanical effects –primed motor cortex

+Positive Impact of Water Immersion Aquatic exercise has equal effects of land-based with added advantages of:

■ Primary trunk mm engagement

■ Offloading of joints (knees, spine, …)

■ Comorbidities addressed, Pain control

■ Low fall impact

Studies: Systematic Reviews on populations with LBP, Neurological Conditions, Fibromyalgia, OsteoArthritis, COPD



● Fluid movement, dilation

Turbulence

● Sensory-Motor Cortex primed


How:

+Write one facilitator to participation in aquatic exercise…


+Barriers & Facilitators to APT

■ Fear of Water

■ Accessibility

■ Self-confidence

■ Bathing Suit

■ “It’s too cold outside”

■ Other…

■ Education

■ Know when benefits outweigh risk

■ Gait speed: 0.8m/s, SLS <1”, gait aid

■ Tailored Exercise Programs

■ Modifiable – ie depth, temperature

■ ‘Bridging’ to post-rehab

Barriers Facilitators


+Study of Perceived BarriersI enjoyed the water-based exercise program 10 (10,10) +I felt confident exercising in the hospital pool 10 (10,10) +I felt safe to exercise in the hospital pool 10 (10,10) Exercising in water improved my balance 7 (5,10) Exercising in the water eased my muscle and joint pain 7 (1,10) Exercising in the pool gave me chest pain + 1 (1,1) Exercising in the water made me more breathless + 1 (1,1) Exercising in the water made me dizzy + 1 (1,1) Exercising in water made me feel tired and fatigued + 2 (1,5.3) I felt nervous about wearing a swimsuit in front of other people + 1 (1,1) The temperature of the water was neither too warm nor too cool 10 (8,10) The change rooms were too cold + 1 (1,1) I didn't like getting my hair wet + 1 (1,1)

+ denotes reverse. 10-point Likert scale, 1 = “not at all true” and 10 = “Very true”.

+Risks and Benefits

■ Slippery deck, change room risks

■ Drowning

■ Contraindicated for uncontrolled cardiac, pulmonary, open wounds, chlorine intolerance; bowel incontinence

■ Facility risks/liability managed. Low Falls Risk when exercising in pool

■ Lifeguards on deck; education, adaptation

■ Systemic effects positive on oedema, cardiac efficiency, works breathing mm, trunk mm; better vascular perfusion

RISKS BENEFITS


+Aquatic Program – A ‘Falls’ Start!Why Water?

Slows fall so increased time to react. Safely work out of BOSTrunk mm activation++If fall – drink the water/ hair ruined!

■ Devereaux, 2005 – OP, Ex –no change in Fear of Falling – 62-86 y.o.; 10wks, 2x/wk

■ Skinner, 2016,Ai Chi, 45’,1x/wk, 8 wks. Improved TUGT, falls report

■ Guillomon, 2019, SR. AE improved key predisposing physical fitness components


+Aquatic Falls ProgramChallenge out of Base of Support

Include aerobic component

Stop-Start challenge

Obstacle course

Play ball

Bounding – mimic life

Distraction with walking (silly walks)

Anchor feet – swaying arms create isometric trunk work

Ai Chi

Program includes: Warm-up (walking), stretches, aerobic, Ai Chi, strength, posture, gait, vestibular, proprioception, balance activities and education

+Ai Chi

Part 1https://www.youtube.com/watch?v=Wje4Y4E1CXA

Part 2https://www.youtube.com/watch?v=anplxTKNIHI

https://www.youtube.com/watch?v=Wje4Y4E1CXA

https://www.youtube.com/watch?v=Wje4Y4E1CXA

https://www.youtube.com/watch?v=anplxTKNIHI

https://www.youtube.com/watch?v=anplxTKNIHI

+What can it look like?

§ Programs should offer different levels of intensity

§ Educate- adapting to water, what it does for you, sit after out

§ Specific classes on balance, spinal health, post TJA…VARIETY!

§ Educate PRE – self select cadence, postural cueing, position options

§ Consider deep water work - CV

+What can it look like?

§ Power – surface area & speed –music, cadence and task…

§ Functional moves

§ Out of base of support

§ High Intensity Interval Training

§ 70%-80% THR; 1RM

+Bridging Rehab to Community

Therapeutic Aquatic Programs

■ PAR-Q – modify, set goal

■ Social groups are motivating àadherence+

■ Turbulence in groups àbalance!

■ Support of personnel – trained aquafit instructor, aquatic personal trainer

“Oh My Aching Body”

“BackHab”

“Stroke Breakers”

+The Aquatic ‘Fit”

■ What programs are there? Demand? Cost? Accessibility?

■ Clinics, groups rent pool time locally (ie. Arthritis Society)

■ Independent practitioner treats 1:1, in private and public pools with goal to bridge client to community

■ PTAs/OTAs, Rec Therapists, Kins, Ats, Rehab Therapists… team members to work with in community


PEI’s Bell Aliant Centre:AquaFitOpen Time – everyday; always warmMain Pool and Warm Pool

Accessible with beach entry.

No modified levels of AquaFit; trainedInstructors (AQX); Next step: Aquability

*Clinic to Community Opportunity:

Clinics/Clinicians can refer clients to theAquatic programming at Bell Aliant Centrewhere they have free access for2 weeks! “Come and try it!”

City of Mississauga Therapeutic Aquatics Programs


+Mississauga Therapeutic Aquatics

Pools are 92°F

Pre-Hab & Post-Rehab

Open Therapy Time – stay for 2+ hours

Classes are ~$10 per hour;

Aquatic Personal Trainers are ~$50 per hour

Assistants free admission

++ Equipment available

Social time

Ramp Access, Wide steps, sloped floor, from 0.5m to 2.0m

A WELLNESS STORY…


+Healthy Active Aging

■ Physiotherapist’s (PT) promote healthy, active living and thus facilitate participation in lifelong, community-based physical activity.

■ Aquatic exercise provides a safe falls environment, with low joint load, assists upright mobility and addresses multi-morbidities.

■ As experts in mobility, PT’s can optimize effective pool use, influence community programming and ensure that aging adults can pursue lifelong activities of their choice.


+ It’s about Fun & Fitness

+Have I convinced you?…


+Case Client: 70 y.o., 2 weeks post-op double TKR; Use of cane;

goal is endurance.Clinical Impression: poor endurance, deconditioned,

functional goals include stairs; TUGT low score; indep ADL; not with iADL

GOAL #1:Endurance & Strength

GOAL #2:Balance & Coordination

How would you do this using Buoyancy, Turbulence, and Drag?


+70 y.o. 2 weeks post TKR

■ ? incision

■ CV…Target heart rate?

■ Gait aid in pool?

■ Are squats in pool appropriate?

+MCQ #1 – Wounds

There are protocols in place to protect incisional wounds. What is the accepted practice in Canada?

A. 4 weeks post-op TKR

B. 8 weeks post-op TKR

C. 12 weeks post-op TKR

D. 3 days post-op TKR

+MCQ #2

Cardiopulmonary effects, when immersed in chest deep water include:

A. Increased ventricular fibrillation

B. Increased lung volume

C. Increased heart stroke volume

D. Increased muscle tone

+MCQ #2

Cardiopulmonary effects, when immersed in chest deep water include:

A. Increased ventricular fibrillation

B. Increased lung volume

C. Increased stroke volume

D. Increased muscle tone

+MCQ #3

In aquatic rehabilitation an individual, 2 weeks post total knee replacement should include:

A. Gait and balance retraining

B. Aerobic conditioning

C. Unilateral squats

D. Deep water proprioception exercises

+MCQ #4

The use of buoyancy will help offset the body weight by what percentage when chest deep?

A. 30%

B. 50%

C. 70%

D. 90%

+MCQ #4

The use of buoyancy will help offset the body weight by what percentage when chest deep?

A. 30%

B. 50%

C. 70%

D. 90%

50%

90%

+70 y.o. 2 weeks post TKR

■ ? Incision

■ Villalta, 2012

■ Leib, 2015

■ Bloccs, Tagaderm

■ CV…Target heart rate?

■ Include cardiovascular

■ THR 12 beats lower

■ PRE/ “talk but not sing

■ Gait aid in pool?■ No need■ Noodles – 1 as a walker, 2

promote reciprocal gait but demonstrate lean

■ Are squats in pool appropriate?■ They are grade 2 – assisted

by buoyancy■ Quickly advance to unilat,

stairs, deep, boundCPA Healthy Aging Forum, June 2019

+Goal #1-Endurance

Buoyancy

■ 50% off-loaded- could jog, THR 70 bpm

Goal #2 -Balance

Turbulence

■ Do 4-square = stop/start; create self-turbulence

Drag

■ Jungle walk through the water – arms+legs

Buoyancy

■ Walk tandem, chest deep, one arm out

Turbulence

■ Anchor feet and stir arms in front

Drag■ Drag a towel through the

water, bkwds, sides, shapes

Personaldeterminants

Behaviouraldeterminants

Active Aging

Economicdeterminants

Culture

Gender

Health andsocial services

Physicalenvironment

Socialdeterminants

WHO, 2002

The Determinants of Active Ageing

+Take-Home Message

■ Activity Choices, Social component

■ Low Falls Risk, amazing balance workout – trunk mm+

■ Immersion physiology supports body & brain health

■ MultiSystem benefits, safe for comorbidities

■ Common conditions & research supporting Aquatic Exercise■ Total joint arthoplasty pre-hab and post-rehab

■ Arthritis, OA, RA, Fibromyalgia

■ Multiple Sclerosis, Parkinsons, Stroke, Dementia, LymphedemaCPA Healthy Aging Forum, June 2019

+Active Aging Week, Oct 1-7, 2019

■ “Redefining Active” - so much more than just exercise!

■ It’s about the broader engagement—physically, socially, cognitively, spiritually, professionally and civically.

FamilyFriends

CommunityLearning

VolunteeringMentoring Travel Entrepreneurial

SpiritualNutrition Exercise/Movement

Mindfulness

+

Comments?

Questions?


+References/Resources1. Embodia course – APT Foundational course; http://bit.ly/2Te2ezB

2. For pool/Aquatic Therapist List/Canadian courses - www.aquaticrehab.ca

3. Becker & Cole. 2009. Comprehensive Aquatic Therapy.

4. Carter HH, Spence AL, Pugh CJA, Ainslie P, Naylor LH, Green DJ. 2014. Cardiovascular responses to water immersion in humans: impact on cerebral perfusion. Am J Physiol Regul Integr Comp Physiol 306: R636-40.

5. Cider A1, Schaufelberger M, Sunnerhagen KS, Andersson B. 2003. Hydrotherapy--a new approach to improve function in the older patient with chronic heart failure. Eur J Heart Fail. 5(4):527-35.

6. Devereux K, Robertson D and Briffa NK (2005): Effects of a water-based program on women 65 years and over: A randomised controlled trial. Australian Journal of Physiotherapy 51:102–8.

http://bit.ly/2Te2ezB

http://www.aquaticrehab.ca

https://www-ncbi-nlm-nih-gov.myaccess.library.utoronto.ca/pubmed/?term=Cider%20A%5BAuthor%5D&cauthor=true&cauthor_uid=12921815

https://www-ncbi-nlm-nih-gov.myaccess.library.utoronto.ca/pubmed/?term=Schaufelberger%20M%5BAuthor%5D&cauthor=true&cauthor_uid=12921815

https://www-ncbi-nlm-nih-gov.myaccess.library.utoronto.ca/pubmed/?term=Sunnerhagen%20KS%5BAuthor%5D&cauthor=true&cauthor_uid=12921815

https://www-ncbi-nlm-nih-gov.myaccess.library.utoronto.ca/pubmed/?term=Andersson%20B%5BAuthor%5D&cauthor=true&cauthor_uid=12921815

https://www-ncbi-nlm-nih-gov.myaccess.library.utoronto.ca/pubmed/?term=Cider+2003+hydrotherapy

+References/Resources

6. Marti nez-Carbonell Guillamon et al. Does aquatic exercise improve commonly reported predisposing risk factors to falls within the elderly? A systematic review BMC Geriatrics (2019) 19:52

7. Adsett JA et al. 2018.Motivators and barriers for participation in aquatic and land-based exercise training programs for people with stable heart failure: A mixed methods approach. Heart Lung

8. Sato D, et al. 2013. Effects of water immersion on short- and long-latency afferent inhibition, short-interval intracortical inhibition, and intracortical facilitation . Clin Neurophys 124 (2013) 1846–1852

9. Schaeffer S, Louder TJ, Foster S, Bressel E. 2015. Effect of Water Immersion on Dual-task Performance: Implications for Aquatic Therapy. Physiother Res Int. DOI.10.1002/pri-1628.

10. Skinner EH, Dinh T, Hewitt M, Piper R, Thwaites C. 2016. An Ai Chi-based aquatic group improves balance and reduces falls in community-dwelling adults: A pilot observational cohort study. Physiother Theory Pract. 32(8):581-590.


https://www-ncbi-nlm-nih-gov.myaccess.library.utoronto.ca/pubmed/30528166

https://www-ncbi-nlm-nih-gov.myaccess.library.utoronto.ca/pubmed/?term=Skinner%20EH%5BAuthor%5D&cauthor=true&cauthor_uid=27710164




https://www-ncbi-nlm-nih-gov.myaccess.library.utoronto.ca/pubmed/?term=Dinh%20T%5BAuthor%5D&cauthor=true&cauthor_uid=27710164

https://www-ncbi-nlm-nih-gov.myaccess.library.utoronto.ca/pubmed/?term=Hewitt%20M%5BAuthor%5D&cauthor=true&cauthor_uid=27710164

https://www-ncbi-nlm-nih-gov.myaccess.library.utoronto.ca/pubmed/?term=Piper%20R%5BAuthor%5D&cauthor=true&cauthor_uid=27710164

https://www-ncbi-nlm-nih-gov.myaccess.library.utoronto.ca/pubmed/?term=Thwaites%20C%5BAuthor%5D&cauthor=true&cauthor_uid=27710164

https://www-ncbi-nlm-nih-gov.myaccess.library.utoronto.ca/pubmed/27710164

aquatic therapy exercise...alison bonnyman, pt cpa healthy aging forum, june 2019 promoting healthy...

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