Effects of hydrotherapy in balance and prevention of falls among elderly women

Artigo CientífiCo

ISSN 1413-3555

Rev Bras Fisioter, São Carlos, v. 12, n. 1, p. 57-63, jan./fev. 2008©Revista Brasileira de Fisioterapia

Effects of hydrotherapy in balance and prevention of falls among elderly womenEfeitos da hidroterapia na recuperação do equilíbrio e prevenção de quedas em idosas

Resende SM1, Rassi CM2, Viana FP2

Abstract

Background: Hydrotherapy is used to treat rheumatic, orthopedic and neurological disorders. It has been the subject of investigations

regarding balance recovery in elderly people. Objective: To evaluate the effect of a hydrotherapy program for balance, in relation

to the risk of falls in elderly women. Methods: This was a quasi-experimental before/after study without a control group. Twenty-five

elderly women were evaluated using two scales: the Berg Balance Scale and Timed Up & Go. The subjects underwent, subsequently,

a low to moderate intensity hydrotherapy program for balance, which consisted of three phases: a phase of adaptation to the aquatic

environment, a stretching phase and a phase of static and dynamic balance exercises. The program was applied for 12 weeks, with

two sessions per week, each session lasting 40 minutes. The elderly women were reassessed after the sixth and twelfth weeks of the

hydrotherapy program. The data were analyzed statistically by means of Student’s t test for paired samples and the Wilcoxon test.

Results: Hydrotherapy promoted significant increases in the elderly women’s balance, as assessed using the Berg Balance Scale

(p< 0.001) and the Timed Up & Go test (p< 0.001). There was also a reduction of the scores in a scale of risk of falls (p< 0.001),

according to the model of Shumway-Cook et al. Conclusions: It can be suggested that this hydrotherapy program for balance gave rise

to an increase in balance and a possible reduction in the risk of falls among these aged women.

Key words: hydrotherapy; physical therapy; musculoskeletal equilibrium; accidental falls; aged person.

Resumo

Contexto: A hidroterapia é utilizada para tratar doenças reumáticas, ortopédicas e neurológicas. Na atualidade, é alvo de investigações

na recuperação do equilíbrio em idosos. Objetivo: Avaliar o efeito de um programa de hidroterapia no equilíbrio e no risco de quedas em

idosas. Métodos: Trata-se de um estudo quase-experimental antes/depois sem grupo controle. Foram avaliadas 25 idosas por meio de

duas escalas, a Escala de Equilíbrio de Berg e Timed Up & Go. Posteriormente, foram submetidas a um programa de hidroterapia para

equilíbrio, de baixa a moderada intensidade, que consistiu de três fases: fase de adaptação ao meio aquático, fase de alongamento e

fase de exercícios estáticos e dinâmicos para equilíbrio. O programa foi aplicado durante 12 semanas, sendo duas sessões semanais

com 40 minutos de duração cada sessão. As idosas foram reavaliadas após a sexta e a 12ª semanas do programa de hidroterapia. Os

dados foram analisados estatisticamente pelo teste t, para amostras pareadas, e pelo teste de Wilcoxon. Resultados: A hidroterapia

promoveu aumento significativo do equilíbrio das idosas, avaliado por meio da Escala de Equilíbrio de Berg (p< 0,001) e teste Timed

Up & Go (p< 0,001), e ainda, redução do risco de quedas (p< 0,001), de acordo com o modelo de Shumway-Cook et al. Conclusões:

Pode-se sugerir que este programa de hidroterapia para equilíbrio aumentou o equilíbrio e reduziu o risco de quedas nas idosas.

Palavras-chave: hidroterapia; fisioterapia; equilíbrio musculoesquelético; acidentes por quedas; idoso.

Recebido: 16/4/2007 – Revisado: 16/8/2007 – Aceito: 21/9/2007

1 “Dr. Henrique Santillo” Readaptation and Rehabilitation Center (CRER), Associação de Idosos do Brasil (AIB) – Goiânia (GO), Brazil2 Universidade Católica de Goiás, Goiânia (GO), Brazil

Correspondence to: Selma Mendes Resende, Rua José Del Fiol, 186, Jardim Andréa Ville, CEP 18276-710, Tatuí (SP), Brazil, e-mail: [email protected]

57Rev Bras Fisioter. 2008;12(1):57-63.

Resende SM, Rassi CM, Viana FP


Introduction Nowadays, falls are one of the largest public health problems

among elderly people due to the high morbidity, mortality and costs for the family and society1. The main risk factors for falls in this population are related to functional limitations, history of falls, increasing age1-4, muscle weakness, use of psychotropic drugs, environmental risks1,3,4, the female gender2,5,6 and visual deficits2. Researchers have reported that elderly women have a higher propensity for falls because of less lean body mass and muscle strength, a higher prevalence of chronic-degenerative diseases and exposure to domestic activities2,5,6.

Every year, in Brazil2 and the United States7, 30% of non-institutionalized elderly people suffer falls. Approximately 5% of these cause fractures, especially in the hips2. In the United States, the annual cost of treating hip fractures among elderly people caused by falls is 10 billion dollars8. On the other hand, despite the high rate of fractures in Brazil, R$ 12 million is spent every year9.

To prevent falls, it is necessary to improve the reception conditions for sensory information from the vestibular, visual and somatosensory systems, so that the antigravity muscles are activated and balance is stimulated10. One of the means applied for promoting the stimulation mentioned above is the practice of physical activities11,12.

Thus, it is recognized in the literature that physical activity practiced throughout life can diminish bone and muscle loss, and reduce the risk of fractures by up to 60%1,3. In addition, physical activity promotes increased muscle strength, aerobic conditioning, flexibility and balance, and reduces the risk of falls and improves quality of life3,13.

Since long ago, hydrotherapy has been used as a resource for treating rheumatic, orthopedic and neurological diseases; however, it has only recently become the target of scientific studies. The physical proprieties of water, together with the exercises, can fulfill most of the physical objectives that are proposed in a rehabilitation program. The aquatic environment is considered safe and efficient for the rehabilitation of elderly people, because water acts simultaneously on musculoskeletal disorders and balance improvements14,15.

The multiplicity of symptoms such as pain, muscle weak-ness, balance defi cits, obesity, arthritic diseases and gait dis-balance deficits, obesity, arthritic diseases and gait dis- arthritic diseases and gait dis-orders, among others, make it difficult for elderly people to perform exercises on the ground. The situation is different with exercises in an aquatic environment, where there is a reduction in joint overload and less risk of falls and lesions. In addition, floating allows individuals to perform exercises and move-ments that cannot be done on the ground10,14,16.

Although few studies have reported the effects of hydro-therapy on balance and the reduction of falls, all of them have

shown benefits, for example, of reduced postural oscillations17, increased functional reach16 and greater independence in activities of daily living (ADLs)18. Given the relevance of this subject, the objective of the present study was to evaluate the effects of a hydrotherapy program on balance and risk of falls among elderly women.

Methods This was a quasi-experimental pre/post study without a

control group, carried out at the Elderly People’s Association of Brazil, in Goiânia, State of Goiás. It was carried out following the ethical principles for research involving human beings, in accordance with Resolution 196/96 from the National Health Council. The study was approved by the Research Ethics Com-mittee of the Universidade Católica de Goiás, under procedure number 0065.0.168.000-05.

Individuals

To develop the study, 50 elderly people (49 women and one man) were selected. The volunteers were recruited by means of posters in the association itself and subsequently selected in accordance with the inclusion and exclusion criteria.

The inclusion criteria were: over 60 years of age, indepen-dence in walking, independence in activities of daily living, the absence of medical contraindications for exercise, cardiologi-cal and dermatological medical certificate, 80% participation in the treatment and signature of the free and informed con-sent statement. The exclusion criteria were: urinary or fecal incontinence, renal insufficiency, open wounds, contagious skin diseases, infectious diseases, catheters, vascular thrombi, cardiac insufficiency, uncontrolled arterial pressure, dyspnea upon minimal effort, use of psychotropic drugs (benzodiazepi-nes) or participation in any other physical activity or physical therapy program.

After the selection, 40 elderly women fit the inclusion cri-teria. Fifteen of them did not complete the study for reasons such as travel and health problems. Thus, 25 elderly women with a mean age of 72.60 ± 7.11 years composed the sample that was investigated.

Materials

The materials consisted of the following: a questio-nnaire for interview, the Berg Balance Scale – Brazilian version19, the Timed Up & Go test20, a chronometer (Sport Timer), a 20-centimeter (cm) graduated ruler, two chairs of 45 cm in height (one of them with arms), a measuring

tape, stethoscope and sphygmomanometer of the Becton Dickinson brand, and a rectangular-shaped swimming pool measuring 7.5 by 11.1 meters, with a sloping bottom with the depth going from 0.8 to 1.2 meters, and with a mean temperature of 30ºC.

Procedures

The evaluation started with an interview to collect infor-mation such as age, marital status, number of people living in the home, reports of diseases, use of medications and history of falls and fractures. After the interview, the elderly women underwent balance evaluation using the Berg Balance Scale19 – Brazilian version, and the Timed Up & Go20 test. In addition, the prognosis for the risk of falls, in relation to the Berg Ba-lance Scale score, was evaluated in accordance with the model of Shumway-Cook et al.21. These tests were chosen because they are functional, validated, internationally accepted, easy to apply and low-cost19,20.

The Berg Balance Scale serves various purposes, such as quantitative description of functional balance ability, determina-tion of risk factors for loss of independence and falls among el-derly people, and evaluation of the effectiveness of interventions both in clinical practice and research. The scale evaluates static and dynamic balance based in 14 common items in daily life, such as reaching, turning around, moving away, standing up and getting up. The maximum score that can be attained is 56 points. It was applied in accordance with the procedures described by the authors who translated and adapted it for Brazil19.

The model for quantitative prediction of the risk of falls among elderly people, which establishes the relationship between the Berg Balance Scale and the risk of falls (10 – 100%), was also used as developed by Shumway-Cook et al.21. In this model, the sensitivity of the scale was 91% and the specificity was 82%. The likelihood of falls increases with decreasing scores on the Berg Balance Scale in a nonlinear relationship. For amplitudes from 56 to 54, each point lost is associated with an increase in the risk of falls of 3 to 4%.

From 54 to 46, each one-point decrease is associated with an increase of 6 to 8%. Below 36 points, the risk of falls is nearly 100%21.

The Time Up & Go test provides rapid monitoring to detect balance problems that affect elderly people’s ADLs. The shorter the time used to complete the test, the better the balance is. The time it took for the elderly women to get up from a chair, walk a distance of 3 meters, turn around, walk back to the chair and sit down again was measured in seconds20. The elderly wo-men did the test once to become familiarized with it and, on the second attempt, the time was recorded.

The scales were applied before the treatment (pre-test) and after six weeks (post-test 6) and 12 weeks (post-test 12) of hydrotherapy. The arterial pressure (AP) was measured before and after the treatment sessions, with the aim of checking the individuals’ conditions for performing the aquatic activities, without statistical intentions.

The study lasted 12 weeks, with 40-minute sessions, twice a week (on Mondays and Wednesdays). The hydrotherapy for balance program was carried out with six elderly women per group and included adaptation to the aquatic environment, hydrokinesio-therapy and inclusion of aquatic exercises from other studies16,22,23 that challenge balance. Each session was divided into three phases: aquatic environment adaptation phase, stretching phase and a phase of static and dynamic exercises for balance. The intensity was low to moderate, with constant intensity, frequency and speed, for 12 weeks. Each series was performed continuously and between each one there was a one-minute rest. The program is described in the following and can be observed in Figures 1, 2 and 3.

Phase I – Aquatic environment adaptation.Exercise 1: Respiratory control.

• Positioning: Semi-seated position without posterior sup-port, with immersion to the shoulder level. Shoulders at 90º flexion and with extended elbows.

• Activity:Slow and prolonged expiration through the mouth over the water, then with the mouth immersed, and subse-quently with both mouth and nose immersed (2’).

Exercise 1

Figure 1. Hydrotherapy program for balance. Phase I – aquatic environment adaptation.

Exercise 2 Exercise 3

Figure 2. Hydrotherapy program for balance. Phase II – stretching.

Hydrotherapy for balance and prevention of falls among elderly women


Phase II – Stretching. Each stretching exercise was maintained for 30 seconds.Exercise 2: Stretching of the hamstring muscles

• Positioning: Orthostatic position with back supported against the wall.

• Activity:Elevation of one of the lower limbs, maintaining knee extension and ankle dorsal flexion.

Exercise 3: Stretching of the triceps surae and iliopsoas muscles• Positioning:Orthostaticpositionwithhandsontheedgeof

the pool. • Activity:Takingalargestepforward,whilemaintainingthe

anterior knee in flexion, the posterior knee in extension, and feet in contact with the bottom of the pool.

Phase III – Static and dynamic exercises for balance. The speeds and frequencies indicated were approximate averages.

Exercise 4: Walking in circles hand-in-hand with sporadic changes of direction• Activity:Walkingsideways,facingforwardsandbackwards,alter-

nating the direction from clockwise to anticlockwise, three times in each kind of walk (once for each kind of walk, speed: 0.40 m/s).

Exercise 5: Walking in line• Positioning:Handssupportedonthewaistoftheindividual

in front. • Activity:Movinginthepoolmakingcirclesandchangesin

direction. The activity was conducted by the physical thera-pist (Three times, speed: 0.40 m/s).

Exercise 6: Walking forward pushing lower members vigorously • Activity:Walkingwithhigherspeedandpropulsion(45me-

ters, speed: 0.50 m/s).

Exercise 7: Walking backwards. (45 meters, speed: 0.50 m/s)

Exercise 8: Lateral walk with large steps. (45 meters, speed: 0.55 m/s)

Exercise 9: Walking with one foot in front of the other• Activity:Walkingsupportingonefootimmediatelyinfrontof

the other, and so on successively (45 meters, speed: 0.20 m/s).

Exercise 10: Walking with trunk rotation• Activity:Walkingforwardstakinghandtooppositekneein

flexion, alternately (45 meters, speed: 0.30 m/s).

Exercise 11: Walking with one-leg support pauses• Activity: Walking and, at the physical therapist’s com-

mand, maintaining one-leg support with the opposite knee in flexion for 10 seconds (12 pauses in 45 meters, speed: 0.50 m/s).

Exercise 12: Bilateral shoulder flexion-extension• Positioning:Semi-seatedposition.• Activity:Performingshoulderflexionandextension,while

keeping the elbows in extension. Starting with maximum



Exercise 4

Exercise 8

Exercise 12

Exercise 7 Exercise 6 Exercise 5

Exercise 11 Exercise 10 Exercise 9

Exercise 14 Exercise 13

Figure 3. Hydrotherapy program for balance. Phase III – static and dynamic exercises for balance.

shoulder hyperextension and going until 90º flexion (10 repetitions, frequency: 12 repetitions per minute).

Exercise 13: Bilateral horizontal shoulder abduction-adduction• Positioning:Semi-seatedposition,shouldersflexedat90º,

extended elbows. • Activity:Startinginadductionandgoinguntil90ºofhori-

zontal abduction (10 repetitions, frequency: 12 repetitions per minute).

Exercise 14: Ankle pumping• Positioning:Orthostaticposition,withimmersionuptothe

xiphoid process level. • Activity: Extension of the knees associated with plantar

flexion, maintaining this position for 5 s, and then knee flexion associated with dorsiflexion, also maintaining this for 5 s (10 repetitions, frequency: 3 repetitions per minute).

Statistical Analyses

For comparisons over the course of time for the mea-surable variables, the Student t test for paired data and the Wilcoxon test were used, by means of comparing scores or times after the treatment with corresponding results for the same individual from the preceding evaluation. The data have been shown as mean differences and standard devia-tions of the difference. The analysis was carried out with the aid of the “Minitab” software. The significance level adopted was α= 0.01.

Results According to the initial interviews, the elderly women de-

monstrated the following characteristics: predominant age group between 70 and 79 years (64%), 28% were married and 28% lived alone. The mean number of diseases reported per individual was 2.2: predominantly controlled arterial hypertension (60%) and osteoporosis (28%). The mean number of regularly used medica-tions was 1.76 per individual. Twenty% of the elderly women had already experienced fractures as a consequence from falls, and 76% had history of falls. Regarding arterial pressure, there were no variations from before to after the sessions.

According to the obtained results, the hydrotherapy program promoted significant increases in the elderly womens’ balance, as observed by means of the Berg Balance Scale. The increase occur-red after the sixth week (p< 0.001), after the twelfth week (p< 0.001) and between the sixth and twelfth weeks (p< 0.001) (Table 1).

Likewise, the Timed Up & Go test showed that there was a significant decrease in the elderly women’s times taken to per-form the tests after the hydrotherapy program, after the sixth week (p< 0.001), after the twelfth week (p< 0.001) and between the sixth and twelfth weeks (p< 0.001), which indicated an in-crease in their balance (Tables 2 and 3).

The results show that the hydrotherapy program promoted a significant reduction in the risk of falls among these elderly women, after the sixth week (p< 0.001), after the twelfth week (p< 0.001), and between the sixth and twelfth weeks (p< 0.001). These results are in agreement with the prediction given by the model of Shumway-Cook et al.21 applied to the Berg Balance Scale scores (Table 4).

Table 1. Mean differences and standard deviations of the differences, in points on the Berg Balance Scale, among elderly women before and after the program of hydrotherapy for balance, for the periods from Pre-test (before treatment) to Post-test6 (after 6 weeks), from Post-test6 to Post-test12 (after 12 weeks) and from Pre-test to Post-test12. p values were obtained by means of the Student t test for paired data.

Mean difference ± standard deviation 99% confidence interval p-valuePre-test – Post-test6 6.36 ± 3.49 4.41 to 8.31 <0.001Post-test6 – Post-test12 1.24 ± 0.97 0.70 to 1.78 <0.001Pre-test – Post-test12 7.60 ± 3.77 5.49 to 9.71 <0.001

Table 2. Mean differences and standard deviations of the time differences in seconds in the Timed Up & Go test, among elderly women before and after the program of hydrotherapy for balance, for the periods from Pre-test (before treatment) to Post-test6 (after 6 weeks) and from Pre-test to Post-test12 (after 12 weeks). p values were obtained by means of the Student t test for paired data.

Mean difference ± standard deviation 99% confidence interval p-valuePre-test – Post-test6 -3.68 ± 2.58s -5.12 to -2.24s <0.001Pre-test – Post-test12 -5.08 ± 2.78s -6.64 to -3.52s <0.001

Table 3. Median differences in time taken in seconds in the Timed Up & Go test, among elderly women before and after the program of hydrotherapy for balance, for the period from Post-test6 (after 6 weeks) to Post-test12 (after 12 weeks). The p value was obtained by means of the Wilcoxon test.

Median Difference n for test 99% confidence interval p-value

Post-test6 – Post-test12 -1.50s 20 -2.00 to -1.00s <0.001



Discussion According to the obtained results, balance increased signifi-

cantly after conducting the hydrotherapy program, according to the Berg Balance Scale and the Timed Up & Go test. This was similar to the results obtained by many other authors14,16,17,22-24, in which the application of a hydrotherapy program increased balance among elderly people. However, the functional tests and treatment programs used in these studies were different, making it difficult to make quantitative comparisons.

In the present study, the risk of falls among elderly women, evaluated quantitatively, underwent a significant reduction after the treatment. Studies that have found increased balance after hydrotherapy programs have also suggested that there is a reduction in the risk of falls, since balance has a direct relation with these risks14,16,22. These authors did not use a model with scoring that predicted the risk of falls, but was evaluated indi-rectly. That is, they classified the elderly people as having a low, medium or high risk of falls according to the score obtained in the balance tests. Thus, it can be suggested that subsequent studies should use scales for scoring the risk of falls, in order to directly obtain results.

Other authors are unanimous regarding the indication of aquatic exercises for individuals with fear of falling who are at risk of falls14,16,22,24. Water is viscous: it decelerates movement and retards falls, which prolongs the time available for regaining posture when the body gets out of balance. Floating acts as a support, which increases individuals’ confidence and reduces the fear of falling. In this way, individuals can be challenged beyond their limits of stability without being afraid of the con-sequences of falls that would occur on the ground10,25.

This hydrotherapy program was effective in reducing the risk of falls among elderly women, thus, undesirable effects resulting from falls could be prevented. These can vary from small injuries, mobility restrictions, limitations in ADLs and loss of functional independence, up to social isolation, can create a vicious circle of voluntary restriction of activities and, thus severely compromises the quality of life2,26.

When analyzing the time intervals between the evaluations according to the scales, it was observed that there was a grea-ter gain in balance during the first stage of the program (up to

the sixth week), as was seen by Simmons and Hansen16. These results possibly occurred because the responses to physical exercise are more evident during the first weeks of treatment. In the initial phase, neural changes predominate, and in the in-termediate phase muscle adaptations predominate. In elderly people, the muscle strength increases are mainly due to neural adaptations, which occur with greater magnitude during the first six to eight weeks of training27,28.

In the present study, the same program was applied throughout the whole period. It is possible that modifying the program during the treatment, with progressive exercises (in-creasing intensity, frequency and duration) would allow results of greater magnitude.

Another possible hypothesis which may explain this result relates to the limitations of the scales that were used. This meant that there was no possibility of measuring new abilities in the next period. The Berg Balance Scale has a maximum score of 56 points, and many of the elderly women came very close to this value after the sixth week; and the Timed Up & Go test cannot indefinitely show reducing times. As a reference, 10 s is the time considered normal for healthy and independent elderly people20. Furthermore, other functional tests that were used to evaluate balance, such as functional reach, Tinetti gait and balance scale and the dynamic gait index resulted in similar limitations.

The proposal of this hydrotherapy program consisted of stimulating balance reactions, in order to promote increa-sed balance and prevent falls among elderly women. It also sought to create a program that would be easy to replicate, since each exercise and its frequency, intensity and duration were described, differently from most studies on this same theme, in which the descriptions of the programs are simple and general14,16,17,22-24. Well defined programs are fundamen-tal for reproducing new research, and for confirmation of the results.

One possible limitation for this study regarding prediction of the risk of falls may come from the low sensitivity of the Berg Balance Scale. Thorbahn and Newton29 compared elderly people’s self-reports of falls with the scale scores and obser-ved that the specificity of the test was high, but the sensitivity was only 53%. Due to the scarcity of tests for quantifying the

Table 4. Mean differences and standard deviations of the differences, in percentage points, of the risk of falls based on the model by Shumway-Cook et al.21 applied to the Berg Balance Scale scores, among elderly women before and after the program of hydrotherapy for balance, for the periods from Pre-test (before treatment) to Post-test6 (after 6 weeks), from Post-test6 to Post-test12 (after 12 weeks) and from Pre-test to Post-test12. p values were obtained by means of the Student t test for paired data.

Mean difference ± standard deviation 99% confidence interval p-valuePre-test – Post-test6 -35.2 ± 19.4 -46.0 to -24.4 <0.001Post-test6 – Post-test12 -6.1 ± 5.8 -9.4 to -2.9 <0.001Pre-test – Post-test12 -41.3 ± 21.0 -53.1 to -29.6 <0.001



Stevens JA, Olson S. Reducing falls and resulting hip fractures among 1. older women. MMWR Morb Mortal Wkly Rep. 2000;49:1-12.

Perracini MR, Ramos LR. Fatores associados a quedas em uma coorte de 2. idosos residentes na comunidade. Rev Saúde Pública. 2002;36(6):709-16.

Gregg EW, Pereira MA, Caspersen CJ. Physical activity, falls, and fractures 3. among older adults: A review of the epidemiologic evidence. J Am Geriatr Soc. 2000;48:883-93.

Newton RA. Standing balance abilities of elderly subjects under altered 4. visual and support surfaces. Phys Can. 1995;47:25-9.

Fried LP, Tangen CM, Walston J, Newman AB, Hirsh C, Gottdiener J, et al5. . Frailty in older adults. J Gerontol A Biol Sci Med Sci. 2001;56:146-57.

Foldavari M, Clarck M, Laviolette LC, Bernstein MA, Kaliton D, Castaneda 6. C, et al. Association of muscle power with functional status in community-dwelling women. J Gerontol A Biol Sci Med Sci. 2000;55:192-9.

Fuller GF. Falls in the elderly. Am Family Fhysician. 2000;61:2159-68.7.

Carter ND, Kannus P, Khan KM. Exercise in the prevention of falls in older 8. people: a systematic literature review examining the rationale and the evidence. Sports Med. 2001;31(6):427-38.

Araújo DV, Oliveira JHA, Bracco OL. Custo da fratura osteoporótica de 9. fêmur no sistema suplementar de saúde brasileiro. Arq Bras Endocrinol Metab. 2005;49(6):897-901.

Geigle PR, Cheek WL, Gould ML, Hunt HC, Shafiq B. Aquatic physical 10. therapy for balance: the interaction of somatosensory and hydrodynamic principles. The Journal of Aquatic Physical Therapy. 1997;5(1):4-10.

Masud T, Morris RO. Epidemiology of falls. Age Ageing. 2001; 11. 30(S4):3-7.

Province MA, Hadley EC, Hornbrook MC, Lipsitz LA, Miller JP, Mulrow 12. CD, et al. The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty and Injuries: Cooperative Studies of Intervention Techniques. JAMA. 1995;273:1341-7.

Barnett A, Smith B, Lord SR, Williams M, Baumand A. Community-based 13. group exercises improves balance and reduces falls in at-risk older people: a randomised controlled trial. Age Aging. 2003;32:407-14.

Booth CE. Water exercise and its effects on balance and gait to reduce the risk 14. of falling in older adults. Activities, Adaptation Aging. 2004;28(4):45-57.

Caromano FA, Candeloro JM. Fundamentos da hidroterapia para idosos. 15. Arq Ciênc Saúde Unipar. 2001;5(2):187-95.

risk of falls, it is suggested that the existing ones should be improved and new tests should be created.

Although the sample size was small, and there was no control group, the results indicated that the hydrotherapy

exercise program promoted increases in balance and, possi-bly, a reduction in the risk of falls among elderly women. Thus, hydrotherapy is a possible physical therapeutic resource to be recommended for preventing falls among elderly people.

Simmons V, Hansen PD. Effectiveness of water exercise on postural 16. mobility in the well elderly: an experimental study on balance enhancement. J Gerontol. 1996;51A(5):M233-8.

Lord S, Mitchell D, Willians P. Effect of water exercise on balance and 17. related factors in older people. Aust Physio. 1993;39(3):217-22.

Rissel C. Water exercises for the frail elderly: a pilot programme. Aust J 18. Physiother. 1987;33(4):226-32.

Miyamoto ST, Lombardi Junior I, Berg KO, Ramos LR, Natour J. Brazilian 19. version of the Berg balance scale. Braz J Med Biol Res. 2004;37:1411-21.

Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional 20. mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142-8.

Shumway-Cook A, Baldwin M, Polissar NL, Gruber W. Predicting the 21. probability for falls in community-dwelling older adults. Phys Ther. 1997;77(8):812-9.

Douris P, Southard V, Varga C, Schauss W, Gennaro C, Reiss A. The effect 22. of land and aquatic exercise on balance score in older adults. J Geriatr Phys Ther. 2003;26(1):3-6.

Lord SR, Matters B, George RS. The effects of water exercise on physical 23. functioning on older people. Aust J Ageing. 2006;25(1):36-41.

Devereux K, Roberston D, Briffa NK. Effects of a water-based program on 24. women 65 years and over: a randomized controlled trial. Aust J Physiother. 2005;51(2):102-8.

Salzman, AP. Evidence-based aquatic therapy for proprioceptive-training. 25. The Aquatic Resources Network. Atri’s Aquatic Symposium; Set 1998: H95-9.

Fabrício SCC, Rodrigues RAP, Costa Junior ML. Causas e conseqüências 26. de quedas de idosos atendidos em hospital público. Rev Saúde Pública. 2004;38(1):93-99.

Komi PV. Training of muscle strength and power: interaction of 27. neuromotoric, hypertrophic, and mechanical factors. Int J Sports Med. 1986;7:10-5.

Hakkinen K, Kallinen M, Izquierdo M, Jokelainen K, Lassila H, Malkia 28. E, et al. Changes in agonist-antagonist EMG, muscle CSA, and force during strength training in middle-aged and older people. J Appl Physiol. 1998;84:1341-9.

Bogle Thorbahn LD, Newton RA. Use of the Berg Balance Test to predict 29. falls in elderly persons. Phys Ther. 1996;76(6):576-85.



References

EWAC Medical

http://www.ewac.com

Hydrotherapy in adult neurology

By Johan Lambeck PT

Introduction Neurology is the medical field that focuses on treatment of the nervous system. In this text we will focus mainly on the central nervous system (brain, cerebellum and spinal cord). Neurological disorders that can be seen frequently in this part of the nervous system are cerebrovascular accident (CVA) or stroke, traumatic brain injury, Parkinson’s disease and Multiple Sclerosis. Aetiology in these diseases is quite different, still common symptoms and treatment principles can be described. We will also comment a little on an important disease of the peripheral nervous system - polyneuropathy or Guillain-Barré. In this document the main problems and treatment goals related to the above diagnoses will be discussed in general. We will also briefly explain how the principles of immersion and hydrotherapy can help us achieve these treatment goals and present some of the most well-known hydrotherapy methods used today. Finally you will find a case history of a client who has suffered from a stroke, together with a reference list.

Abnormal neurolocomotor function

Problems can occur in many central nervous subsystems such as the sensory systems, neurolocomotor systems, neuropsychological systems and cognitive systems. The results are a variety of problems on all levels of impairment, activity and participation. Here we will focus on the neurolocomotor system.

The abnormality of the neurolocomotor function is due to a different activation pattern of the muscles, which results in a combination of the following problems: � A decreased muscle activation and weakness, which results in a difficulty to

• elicit and sustain muscle activity

• generate and time force

• generate and control synergistic muscle activity

• support, propel and balance the body mass over the feet

• show a proper dexterity/skill � Hyperreflexia or spasticity (clonus, tendon jerks, extensor/flexor spasticity).

Hyperreflexia will also influence the above-mentioned difficulties but at the moment it is believed that decreased muscle activation is more disabling than hyperreflexia (Carr &

Sheperd, 1998).

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Spasticity & stiffness

Spasticity is an important phenomenon in clinical rehabilitation but in neurological physiotherapy this sign is often misinterpreted. Spasticity should always coincide with the other signs - clonus and increased tendon jerks. However, in clinical practice the word spasticity is also used when weakness is apparent and clonus etc. is not present. In these cases, groups of muscles tend to become stiff in order to guarantee body stability. All the established methods of neurological physiotherapy have for a long time been focusing on reducing this spasticity by using specific “inhibition” techniques in order to normalise muscular tonus. In many cases patients were not really spastic, but stiff. Hydrotherapy: spasticity vs. stiffness Spasticity as such can not really be influenced by hydrotherapy, stiffness can! In general, stiffness can be reduced through:

• activity: repeated lengthening/shortening

• passive stretch of muscles before activity, both of these interventions change the visco-elasticity of connective tissue.

Research showing that hydrotherapy (or immersion in warm water) doesn’t influence spasticity has been done by Bovy, (1991) on 10 spastic patients. After 20 minutes of immersion in warm water, he found that the extensibility (stretch) of the spastic hamstrings lessened and the excitability (spasticity) didn’t. He concluded that immersion affects the visco-elasticity of the connective tissue in the muscle.

Hydrotherapy provides both options: all kinds of balancing activities and stretching in the warm environment of water decrease stiffness. This decrease of stiffness is a starting point to increase the quality of motion, increase range of motion and to balance. Balance

Balance is a process to control equilibrium for a given purpose, or ability to control the centre of gravity relative to the base of support. Goals are:

• to support head and body against gravity

• to maintain the centre of gravity aligned and balanced over the base of support

• to stabilise parts of the body while other parts of the body move

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Figure 1 shows a task-oriented model of equilibrium. Balance has multiple aspects and depends e.g. on the environment.

The most important goal in rehabilitation of clients with central nervous disorders is to regain independence, or to prevent dependence. For all skills of daily living (standing, walking, reaching, self-care, sitting etc.), postural control is a central topic. In other words; one has to be able to balance/keep stable to be able to perform ADL tasks safely. Balance constraints must therefore be resolved. Constraints due to the impairments can be:

• reduced joint mobility and reduced muscle length

• abnormal motor control: changed activation and strength

• an altered physical environment (wheelchair, hospital)

• an altered visual, tactile, proprioceptive and vestibular perception

• fear, depression and lack of apprehension

• adaptive motor behaviour

BALANCE

Musculo-

skeletal

system

Motor

coordination

Predictive

central set

Perception

of

orientationSensory

organisation

Environ-

mental

adaptation

A task oriented model by Horack, 1991

Equilibrium

Figure 1

Balance constraints

• Environment

• Fear

• Too many

therapists

• Joint mobility

• Strength and

coordination

• Apprehension

• Visual Input

PICTURE

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Adaptive motor behaviour

The body has several mechanisms to protect its stability and when going into a new environment (like a hydrotherapy pool), these mechanisms are used. This is however not a problem. As long as the client is able to use disassociated head movement to steer balancing activities, as basis to learn is present. The motor behaviour that can be observed, may consist of:

• Widening the base of support

• Using the hands for support

• Stiffening of the body

• Avoiding the threat to balance

• Shifting weight to less affected parts

Adaptive motor behaviour in the pool In the recent past this adaptive behaviour has been a reason for some therapists, observing the stiffening, to deny hydrotherapy. However, going through a proper programme of teaching how to balance (see Halliwick) changes this adaptive motor behaviour quickly into motivation and movement. The most important reason is that fear of falling ceases to exist and therefore activity can be evoked. The changes in motor skills that can be seen when training balance in water can also be carried over to dry land, according to many experts in the field. This is also confirmed by clinical research on this topic (see Poteat, 1999). The change in motor skills will have qualitative and quantitative features that have been listed below. The principles of acquiring motor skills are a result of a motor learning process, but will be restricted because of pathology. Principles of acquiring motor skills

- Variable movements become more consistent - Coordination becomes more precise - Skills can be made at a faster speed without deterioration - Fewer synergist will be recruited and co-contraction will be less - The client needs less (or even no) visual control when performing the skill - The client needs less attention for the skill and is able to be distracted - The client can perform more tasks at the same time - Postural adaptations become less visible

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Acquiring motor skills in water The well-known Dutch psycho-neuro-pharmacologist Lex Cools (Cools, 1999) states that hydrotherapy “warms the neurological system up”. The reasons for this are that:

• Hydrotherapy forces a patient to return from a higher-order neurological system, allowing to balance around the transverse axis (= extension against gravity), to lower-order neurological systems that allow to balance around the longitudinal axis. The brain contains certain centres that are involved in the coordination of these balances. The “oldest one’ is the longitudinal balance system. This kind of balance can be exercised in the pool very well, so hydrotherapy prepares (warms up) for the normal extension against gravity

• Hydrotherapy reinstates earlier stages of ontogeny with successive activation of higher centres, using extero- and proprioceptive cues. This means that hydrotherapy should have a prominent place in early neurological rehabilitation.

Two studies have been published about the effects of hydrotherapy on balance in the elderly (with minor problems) (Lord, 1993; Simmons, 1996). Both found that balance on land improved after participating in a hydrotherapy programme. The clients were able to stand with less sway and to reach further without loosing balance. They had learned to move and to correct movement errors in a safe environment. They also got a chance to vary their practice, which is very important in motor learning. Morris (1996) measured the balance of three stroke patients on dry land after going through a programme of hydrotherapy. He found a small increase in balance ability and reaching, but the number of clients was too low to draw any firm conclusions

Physiological effects of immersion

Immersion in water elicits a range of reactions in the human body. Effects of immersion occur because of the hydrostatic pressure on the body and because of temperature effects of water. The physiological effects of immersion evoke:

• a mobilisation of interstitial and lymph fluids to the central cavities

• an increased blood supply to the muscles

• a reduced sympathetic output

• a increase in elasticity of connective tissue

• a decrease of muscular contraction forces

• mechano-sensory effects on nociception/pain transmission: less pain

• a decrease of joint compression forces

• isokinetic resistance, provided by turbulent drag

• an altered proprio-/exteroceptive input

• effects on the vestibular system

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Temperature Temperature effects are responsible for changes in stiffness (visco-elasticity) of connective tissue and thus provide the basis for the increase of joint range of motion, muscle length and relaxation. Especially stiffness related to the elastic part of the muscle, which is 90% of the total stiffness, can be influenced by warmth (warm water). This is shown in the next three graphs (Fig 2, 3 & 4).

Stiffness

0

10

20

30

40

50

60

70

80

90

100

elastic viscous friction

%

Wright, 1961Figure 2

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Tendon extensibility and temperature

0

2

4

6

8

10

12

0 55 Load (grams)

Length

incre

ase (

*%)

45 C

25 C

Lehmann et alFigure 4

Alteration of stiffness with

temperature

0 0.2 0.4 0.6 0.8 1.0 1.2

Displacement (radians)

Ela

stic s

tiffness a

t flexio

n 19,5 C

35,6 C

Johns, 1961Figure 3

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Pressure and buoyancy effects Pressure and buoyancy effects are responsible for the fact that:

• Circulation is increased in all muscles. This is enhanced by warm water (Baldinn, 1971). • Muscle and Skin Sympathetic Activity decrease with depth of immersion. This can be

seen as a change in EMG (electromyogram) output (figure 5) (Mano, 1985 & 1994). The effect of buoyancy will also add to this effect. The decreased EMG output in water compared to dry land has been seen in various studies (Erbe & Rusch, 1982; Mano, 1985;

Camus, 1987; Clarys, 1990; Poteat, 1996; Fuller, 1999; Pöyhönen, 1999). In other words, less strength is required in order to perform a certain task in water compared to on dry land.

This means that in water clients can make movements with less effort than what is required on dry land. Hydrotherapy provides an early initiation of muscular activity and decreases the amount of co-activation (spasticity) when clients try to initiate a movement, because less force needed for a movement means less need to use ( co-activate ) the spastic muscles. The increased circulation will warm up the muscles and connective tissue, provide nutrition & oxygen and deplete metabolic waste products. This is an important basis for tissue training.

EMG activity and immersion

-5

0

5

10

15

20

25

30

35

dry navel breast neck buoyed

Immersion level

Am

ount of N

MU

soleus

tib ialis ant

Mitarai, 1972Figure 5

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One of the most important functional goals of hydrotherapy is walking. The effects of buoyancy help to facilitate both swing phase and stance. In general, clients are able to walk independently in the pool earlier than on dry land, especially in cases of severe weakness. When comparing walking on dry land to walking in water, the following can be observed:

• Less antigravity muscle activity is needed when in water (see the EMG studies). Weight bearing will however depend on the velocity of walking (see figure 6).

• Stance will also become slower and one has more time to correct foot position in the water (see figure 7).

• An active swing and hip extension of the stance leg will be facilitated.

• Stance time is increased in water.

• Either an ipsilateral or a crosslateral gait pattern may be provoked.

• Forward trunk inclination increases and the abdominals are activated.

Harrison, 1987

Relative weightlessness when

walking in water

0

10

20

30

40

50

60

70

80

90

C7 Xyphoid ASIS

Anatomical level

% w

eig

htb

earing

stand

slow

fast

Figure 6 Harrison, 1987

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. Research has revealed that walking with simulated weight reduction, i.e. suspended walking on a dry land treadmill or walking in water, will result in the following effects:

• Increased stance time of the hemiplegic leg.

• Trunk symmetry and increase of stride length.

• Increased walking velocity (up to 3 times compared to dry land).

• Less activity in hypertonic postural muscles.

• More activity in weak antagonists

• Facilitation of the swing phase.

• After 6 weeks: 40 % greater speed on dry land than with conventional therapy. (Hassid, 1997; Hesse, 1997; Pillar, 1997)

These changes have also been indirectly confirmed by the researches of Zamporo (1998) and Pagliaro (1999). They found that even though the stretch reflex activity (spasticity) had not changed after hydrotherapy, the clients showed a decreased gait energy consumption, which reflects a more physiological gait pattern

Land and water walkingat 65 % body height = 1.2 m. depth

0

2

4

6

8

10

12

Time

Forc

e

Land GRF

W ater GRF

Becker & Cole, 1997

GRF=

Ground

Reaction

Force

Figure 7

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Neurological disorders & hydrotherapy

General training principles for neurological patients are:

• to prevent soft tissue contractures and mobilise stiff joints, preferably by active means

• to elicit muscle activity by e.g. compensating for gravity ( use of buoyancy)

• to train motor control using concrete goals as standing, walking, reaching etc.

• to increase muscle strength: repeat with relevant movements

• to change the environment to modify maladaptive movement strategies

• to train endurance (Adapted from Carr & Sheperd, 1998)

Differences in heart rate

50

70

90

110

130

150

170

190

2,55 2,77 3,02 3,31

Speed (km/h)

Heart

rate

(bpm

)

water

treadmill

Whitley & Schoene, 1987Figure 8

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By using hydrotherapy we will get the following advantages:

• Increased movement ability thanks to increased joint ROM and relaxation

• An easy way of strengthening weak muscles

• Movements can be made with less force and irradiation

• Cardiovascular endurance can be enhanced with a low mechanical impact (figure 8)

• Equilibrium, stability and adequate balance reactions can be facilitated (water is safe and provides “time to think”)

• Early ambulation can be achieved to prevent loss of “software”

• Proprio- and exteroceptive input can be increased

• Subjective complaints can be decreased, e.g. shoulder pain

• Abnormal tone and stiffness can be normalised

• Mood, motivation and self-esteem can be increased

• Body image can be improved (no use of sticks etc.)

• Socialisation can be increased

Stroke

A stroke, or Cerebro-Vascular Accident (CVA) generally results in a locomotor problem called hemiplegia. The abovementioned training principles and advantages of hydrotherapy all are valid for stroke patients. Other problems will however also be present, depending on the localisation in the right or left hemisphere of the brain. A person with a right sided hemiplegia (stroke in the left hemisphere) can suffer from an aphasia, which is a problem in the reception and / or the processing of language. Communication with the patient might have to be changed to alternative ways as the use of symbols, showing movements, guiding the activity to be done etc. Left sided hemiplegic patients may have problems with orientation in space, perceiving the affected side of the body, or sequencing complex skills as dressing and undressing. This will need additional help in the changing rooms, but will also influence motor learning in the pool. In these cases, guidance from an experienced neuropsychologist might be necessary to structure the hydrotherapy session adequately.

Multiple Sclerosis (MS) Most of the abovementioned training principles and advantages are valid for MS patients. MS is a progressive disease that can affect various parts of the central nervous system. Most prominent is the spasticity that may cause the patient to use a wheelchair. The patient has time to adapt to the symptoms, other than with a stroke. Hydrotherapy will mainly focus on prevention of function and skills: endurance, strength, balance and ambulation The main topic of discussion in multiple sclerosis is water temperature. Most patients favour cool water, but negative influences of warmth on progression has not been shown yet. So, it’s up to personal preference what temperature can be tolerated best. In one study (Gehlson, 1984) with multiple sclerosis patients, a marked increase in strength could be proved after a 10 week hydrotherapy programme.

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Parkinson disease

Parkinson’s disease progressively affects certain centres in the brain, causing a rigidity of muscles and a “slow” kind of behaviour. Because of the gradual change, therapy can be used to prevent deterioration to a certain degree. Hydrotherapy is focussed on the same goals as with multiple sclerosis. In the pool, Parkinson patients perform well, the fluidmechanical influences facilitate motion and seem to stimulate alertness. As yet there is no evidence that Parkinson patients can carry over the skills, learnt in the pool, to dry land, but Parkinson patients benefit from the general advantages: muscle and joint stiffness decrease during a session. This lasts for some time afterwards. Traumatic brain injury The traumatic brain injury causes, just as in stroke, a wide range of problems in all central nervous subsystems. The motor control shows in general a combination of spasticity, weakness and ataxia. The principles, described in the sections on general neurology and stroke can be followed. Special attention should be paid to breathing control, partly due to an intubation/tracheotomy that often is needed in the IC unit. The ataxic component can be addressed appropriately through hydrotherapy and shows a good carry over to dry land. In early rehabilitation, hydrotherapy can be used to increase alertness by using debalancing techniques (Halliwick) or stimulating the input by using Watsu with lots of movement and turbulence. A hydrotherapy advantage in this patient group is the ease of handling in the water in comparison to handling on dry land. Guillain-Barré Patients with the syndrome of Guillain-Barré can benefit enormously from hydrotherapy. An inflammation of nerval roots leads to severe paralysis all over the body. As soon as the acute symptoms have been resolved, the client has to gain strength. This is a long-lasting process, depending on the rate of nerve sheath regeneration, which may take many months. Hydrotherapy provides an environment in which clients with hardly any strength can make movements and thus it is the therapy of choice in the early phases of rehabilitation. Later on, hydrotherapy still is of value: balance, gait training and swimming are activities to gain a wide range of tissue effects and functional skills. The therapist should take into account the fact that patients can be fatigued easily, which might affect the disease negatively. Since hydrotherapy is tiring, treatment time should be short (15 minutes) to start with, and be increased carefully.

Note Many neurological patients will show a deterioration of their symptoms (increase of stiffness and a worse gait pattern than before hydrotherapy) when they leave the pool. This is quite normal. The patients generally are tired after a pool session and have to adapt to gravity again as well. This difficult combination often increases the problems. After about one hour patients feel well again. This is the time when dry physiotherapy should start to repeat the learning experiences in the actual daily environment on land.

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Different hydrotherapy methods

In this chapter the most important hydrotherapy methods are being presented. We will also discuss their relevance for the neurological population. One technique may be chosen or a combination of them, depending on diagnoses, hydrotherapy facility and personal preferences. Halliwick

Halliwick is the most suitable and used method in neurological rehabilitation. The Halliwick programme is a motor learning system where postural control (=balance) is of utmost importance. Task- and goal-oriented activities can easily be incorporated, allowing a very functional kind of hydrotherapy. James McMillan started to develop the Halliwick concept in 1950 as a swimming method for people with special needs. He based the concept on his knowledge of fluid mechanics, together with observations of the human body’s reactions in water. This combination of fluid mechanics and the neurobiological response of the body led to a sensori-motor learning sequence called the Ten-Point-Programme. The Ten-Point-Programme leads a person from water adaptation to a basic swimming stroke. A central topic in the programme is to get control of rotations around the various body axes. These rotations occur because of the so-called "metacentric” effects, i.e. the relationship between gravitational and buoyant forces. This relationship is altered by changes in shape and/or density, which occur in the disabled body. A thorough assessment of both changes in density and shape is therefore needed in order to predict the rotational problems that a swimmer with special needs might have. The Ten-Point-Programme includes three stages of motor learning; adjustment to the environment, balance restoration and movement, which show the process-oriented philosophy of the concept. The concept is therefore very popular in neurological and paediatric rehabilitation and is often said to be “Bobath in water”. The order of the different steps in the Ten-Point-Programme is shown below.

1) Mental Adjustment and Disengagement Adjustment to the environment

2) Sagittal Rotation Control 3) Transversal Rotation Control 4) Longitudinal Rotation Control 5) Combined Rotation Control 6) Upthrust or Mental Inversion 7) Balance in Stillness 8) Turbulent Gliding

Balance restoration

9) Simple Progression 10) Basic Halliwick Movement

Movement

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The Bad Ragaz Ring Method (BRRM)

The Bad Ragaz Ring Method has been developed in its basic form in Germany around 1950. It started as a way to strengthen muscles in simple one-dimensional patterns, e.g. just asking for an abduction in the shoulder. Patients were put in flotation devices and were being exercised in a supine position. The therapist would give resistance to the movement and the patient would move through the water. The patterns can also be used passively. The three-dimensional patterns provide an excellent possibility to stretch soft tissue in capsules, ligaments, muscles and nerves. When applying the BRRM passively, definite resemblances with Watsu can be seen. Because of the use of floatation aids in BRRM, a therapist is able to work more local compared to the possibilities offered by Watsu. In 1957 the method was introduced to the Health Spa Centre of Bad Ragaz in Switzerland. In the early sixties a physiotherapist named Bridget Davis started to include three-dimensional patterns to the movements, based on the ideas of PNF (Proprioceptive Neuromuscular Facilitation). The positions were increased; prone and side lying was included. Since BRRM can be quite exhausting for the therapist, alterations based on the mechanical principles used in Halliwick were made at the end of the seventies. The physiotherapist in charge of this renewal was Beatrice Egger, who 1990 wrote a book about the New BRRM. In the New BRRM, prone and side lying was left out (although still in use in some countries) and patterns with so-called counter resistance were added. These patterns are a combination of isometric and isotonic contractions, which makes it easier for the therapist to give a proper resistance with her own body mechanics. In recent developments prone patterns using mask and snorkel have been introduced together with more passive initiation techniques, allowing all kinds of tractions and translations of the spine and peripheral joints. Important features and considerations concerning BRRM:

• The three-dimensional patterns are adapted to the floating patient.

• The therapist forms the fixed point in the chain.

• The therapist should choose an adequate depth of water

• The resistance given is optimally adapted to the patient’s capability. It can be both isometric and isotonic.

• Handholds should be correct.

• Approximation and traction are used as stimulation techniques for stability and movement.

• Short, precise commands are important.

• Stretches can be applied.

• Passive initiation is used.

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Goals of treatment:

• To strengthen muscles and re-educate.

• Increased range of motion, incl. traction and elongation.

• Tone reduction and relaxation.

• Improved alignment and stability of the trunk. (Parts of) the Bad Ragaz Ring Method are of limited use in neurological rehabilitation. The client has to generate a relatively large amount of muscle force; therefore spastic patterns can be evoked easily. When properly applied, the above mentioned goals can be applied to the neurological population. The patterns can also be used passively. The three-dimensional patterns provide an excellent possibility to stretch soft tissue in capsules, ligaments, muscles and nerves. When applying the BRRM passively, definite resemblances with Watsu can be seen. Because of the use of floatation aids in BRRM, a therapist is able to work more local compared to the possibilities offered by Watsu. Watsu Hydro-relaxation techniques are based on the facts that warm water together with gentle movements and good support has tremendous effects on both somatic and psychological relaxation. There is a wide spectrum of different hydro-relaxation techniques but the one best described so far is Watsu. Watsu was developed by Harold Dull in the Health Spa Centre of Harbin Hot Spring in California USA. As a Zen-Shiatsu master, he began to apply some of the stretches (used to influence the body’s meridians) in water. He found that the combination of these stretches together with Shiatsu massage and gentle movements could bring about deep relaxation effects. He describes Watsu as a nurturing intervention, where being together is more important than providing a specific technique. Watsu was simply created as a wellness technique. When the method became known to physiotherapists, they immediately saw the therapeutic potential of Watsu. Apart from the relaxation effects, fine possibilities to stretch and elongate were seen. Watsu started as a method where the therapist (giver) fully supported the patient (receiver) but a clear development towards flotation aids can be observed. This enables therapists to be more precise and localised in their techniques. Also the normalising of energy flows in meridians is of minor importance today.

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On the one hand, people both in and outside the health profession apply Watsu for relaxation reasons. Here Watsu may be combined with dry land Shiatsu, meditation and other (alternative, Eastern) techniques for well being. On the other hand, there is a lot of resemblance with methods from physiotherapy:

• Neurotension or manipulation of the peripheral nervous system

• PNF (its passive initiation techniques)

• Basal Stimulation and Snoezelen

• Spiraldynamics and other “dry land rotational systems” Features and considerations concerning Watsu:

• The patient is passive

• The therapist should provide adequate support

• Joint instability should be handled carefully

• Vestibular arousal should be avoided

• The therapist should be aware of the emotional effects Goals of treatment:

• Relaxation and pain relief

• Elongation, traction and translation

• Muscle stretching

• Stimulation or sedation of the reticular formation Relaxation in neurological rehabilitation is generally used as an introduction to more active hydrotherapy methods. The client can be prepared to various balancing activities through the large mobilising and stretching movements. Conventional hydrotherapy

Conventional hydrotherapy includes various techniques and exercises that do not have a specific philosophy amongst them. The exercises are classified in:

• Buoyancy assisted exercises

• Buoyancy resisted exercises

• Exercises with neutral buoyancy

• Exercises that make use of a change of lever

• Exercises that make use of a change of speed

• Exercises that make use of a change of frontal plane In many cases these exercises are focussed on one joint and/or one muscle group. This is why the exercises with these variables can be easily used in group therapy and self-organised exercise schemes. Specific equipment as chairs, plinths, bars and smaller aids belonging to the conventional land based exercise are often used. Conventional hydrotherapy will also give neurological patients the opportunity to continue hydrotherapy independently after rehabilitation. The therapist should carefully programme exercises to customise these for the individual client.

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Aquatic fitness

During the last decade, aquatic fitness has become popular. The origin can be found in the publication of Glen McWaters, United States. He tried to walk in water with the use of a flotation belt, when having a leg injury from dry land running. His experiences led to the Deep-Water Walking method or Aquajogging. This method was initially used for injured athletes but was later also applied to other patient groups in orthopaedics, rheumatology and cardiology. Principles from the conventional hydrotherapy are used to increase difficulty when walking through water. The programme is generally focussed on increasing aerobic capacity. During the last few years, many other aquatic fitness programmes have been developed as variation of Aquajogging. Here are some of them:

• Shallow Water Walking

• Aqua-aerobic

• Aquasteps

• Aquanastics

• Hydrorobics

• Hydropower

• Aquadynamics Most of these methods can be done in shallow water and can also be applied to the neurological population. The “workouts” should however be tailored to fit the clients’ locomotor abilities. .

Case History

History and present state A 63-year-old truck-driver suffered from an apoplexia (CVA or stroke) 2 months ago. This resulted in a right-sided hemiplegia with minor phatic problems. After a short period in the acute hospital, the man was referred to the rehabilitation centre for clinical rehabilitation. The method of rehabilitation, used by all disciplines is Bobath/NDT. At this moment, the patient is able to ambulate slowly with manual facilitation by a therapist. He needs an AFO (ankle-foot-orthosis) to hold the right foot in dorsal flexion. Both physiotherapy and occupational therapy focus on posture training since there is a marked tendency to shortening the affected side of the trunk. In daily activities he still needs a wheelchair. Transfers are independent, so is personal care. The right hand is spastic. The arm shows some signs of recovery, although the shoulder hurts, despite wearing a sling. Before the patient got a stroke, he swam on a recreational basis.

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Treatment plan in water The physiotherapist suggested hydrotherapy to support the sensori-motor rehabilitation. The objectives are:

• to facilitate independent head to shoulder movements, i.e. to facilitate righting reactions

• to relax the right shoulder and arm in order to decrease tone and pain

• to work on trunk symmetry and to train the affected abdominals (these are hypotonic)

• to disassociate hip-pelvis-thorax-head activity

• to reinforce sensory input and vary experience in order to enhance motor learning

• to increase aerobic capacity / stamina

• to work on independent ambulation

• to teach the patient to swim again

• to present an enjoyable situation that distracts from dry land rehab and motivates to move.

Considerations

• Immersion in water prevents the mechanisms that can occur to compensate for the “normal physiological” extension against gravity

• Immersion in warm water, and added slow movements promote relaxation that can be used as a preparation for stretching (neurodynamic) techniques.

• The relative unstable position in the pool ( fixed points fail ) force the body to actively balance, especially around the symmetry-axis of the body

• Lack of fixed points also facilitate the use of the head during balancing activities

• The tactile input of water is a different source of feedback, compared to dry land, and is important in motor learning

• The patient will go into a sedentary lifestyle. There is a clear need for a kind of physical activity that he favours, which is swimming.

Choices A pool is needed that can give space to ambulate and swim. The water depth should be about waist-deep, because it enables:

• The patient to swim, including a safe way to stand up (make a vertical rotation)

• The patient to ambulate in such a way that both the advantages of buoyancy (weight reduction) and gravity (working in a relatively closed kinetic walking chain) can be combined.

• The physiotherapist to use various techniques Water temperature should enable the methods of choice as well. The patients should be in thermal comfort during the hydrotherapy time (of 15 to 60 minutes). A temperature of some 32 0C makes both relaxation and low impact endurance training possible and generally is chosen as the most optimal temperature for hydrotherapy.

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Methods to choose 1) Relaxation (e.g. in concordance to Watsu) of the right arm and shoulder. The therapist

gently moves the patient through the warm water. Flotation aids can be used to enable the therapist to localise stretching and mobilisation. The BRRM also offers passive stretching and mobilisation possibilities, when flotation aids are being used. In BRRM, stretching can proceed to rhythmic initiation to active movements.

2) The Halliwick Method can be used for all other objectives. 3) Adapted swimming, e.g. according to Halliwick. 4) The Bad Ragaz Ring Method can be used for increasing strength of the hypotonic

abdominals; care should be taken to prevent co-activation of spastic muscles. The BRRM also offers passive stretching and mobilisation possibilities, when flotation aids are being used. In BRRM, stretching can proceed to rhythmic initiation to active movements.

Programme Start with Relaxation and Halliwick, continue with Halliwick and Bad Ragaz Ring techniques and finally proceed to swimming. The frequency should preferably be at least twice a week to establish proper progress. Duration of a session could be 30 to 45 minutes. The patient should continue the swimming in a swimming club for people with special needs.

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References

Balldin, UI., et al. Changes in the elimination of 133-Xenon from the anterior tibialis muscle in man induced by immersion in water and by shifts in body position. Aerospace Medicine, 1971, 42, 489-493. Becker, B.E., & A.J. Cole. Comprehensive aquatic therapy. Butterworth-Heinemann, 1997, ISBN 0-7506-9649-4.

Bovy, P., et al. Influence des bains chauds sur les propriϑtϑs musculaires des sujets sains et spastiques. Medica Physica, 1990, 13, 121-124.

Camus, G., et al. Rϑpercussions physiologiques de la flottaison, comparϑes Β celles de l‘immersion. Medica Physica, 1984, 10, 41-43. Carr, J., & R. Sheperd. Neurological Rehabilitation, Optimizing motor performance. Butterworth Heinemann, 1998, ISBN 0-7506-0971-0 Clarys, J.P. Muscle tone (?), - relaxation (?) and – activity in an aquatic environment. In: J. Lambeck (Ed), Proceedings Congres Halliwick in 1986. Stichting NDT-Nijmegen, 1990, ISBN 90-800538-1-3. Cools, AR. Hydrotherapie: bewogen bewegen. Congresboek: Hydrotherapie van ‚practice based naar evidence based‘. 1999, Nederlands Paramedisch Instituut, ISBN 90-73054-71-0

Erbe, HP, & D. Rusch. Die Wirkung von Sole-, CO2-Sprudel-Sole- und Sη8wasserb≅dern

auf den Ruhetonus der Skelettmuskulatur. Zeitschrift fηr Physikalische Medizin, 1982, 11, 54-56. Fuller, RA., et al. The activity level of the vastus medialis oblique muscle during a single leg squat on the land and at varied water depths. J. og Aquatic Physical Therapy, 1999, 7, 13-18. Gehlson, G.M., et al. Effects of an aquatic fitness program on the muscular strength and endurance of patients with multiple sclerosis. Phys. Ther., 1984, 64, 653-657. Hassid, E., et al. Improved gait symmetry in hemiparetic stroke patients induced during body weight supported treadmill stepping. J. Neuro. Rehab., 1997, 11, 21-26. Hesse, S., et al. Treadmill training with partial body weight support: influence of body weight release on the gait of hemiparetic patients. J. Neuro. Rehab., 1997, 11, 15-20. Lord, S., et al. Effect of water exercise on balance and related factors in older people. Australian Physiotherapy, 1993, 39, 217-222.

EWAC Medical

http://www.ewac.com

Mano, T., et al. Sympathetic nervous adjustments in man during simulated weightlessness induced by water immersion. Sangyo Ika Diagaku Zasshi, 1985, 7 (suppl), 215-227. Mano, T. Autonomic responses toenvironmental stimuli in human body. Nagoya J. Med. Sci., 1994, 57 (suppl), 59-75. Mitarai, G., et al. Electromyographic study on human standing posture in experimental hypographic state. Annual report of the Research Institute of Environmental Medicine, Nagoya University, 1972, 19, 1-9. Mitarai, G., et al. Correlation between vestibular sensitization and leg muscle relaxation under weightlesness simulated by water immersion. Acta Astronautica, 1981, 8, 461-468. Morris, DM., at al. Aquatic community-based exercise programs for stroke survivors. J. of Aquatic Physical Therapy, 1996, 4, 15-20 Pagliaro, P., & P. Zamporo. Quantitative evaluation of the stretch reflex before and after hydro kinesi therapy in patients affected by spastic paresis. J. of Electromyography and Kinesiology, 1999, 9, 141-148. Pillar, T., et al. Walking reduction with partial relief of body weight in rehabilitation of patients with locomotor disbilities. J. of Rehab. Research and Development, 1997, 28, 47-52. Poteat AL., et al. Quantification of aquatic physical therapy water-based methods: part 1: surface electromyography. J. of Aquatic Physical Therapy, 1996, 4, 13-20 Poteat-Salzman A. Justifiable aquatic therapy: scientific support for intervention, neurological and neurosurgical population. Congresboek: Hydrotherapie“van pracice based naar evidence based“. Nederlands paramedisch Instituut, 1999, ISBN 90-73054-71-0

Pyhnen, T., et al. Human isometric force production and electromyogram activity of knee extensor muscles in water and on dry land. Eur. J. Appl. Physiol., 1999, 80, 52-56. Simmons, V., PD Hansen. Effectiveness of water exercises on postural mobility in the well elderly: an experimental study on balance enhancement. J. Gerontol., 1996, 51A, M233-M238. Zamparo, P., & Pagliaro, P. The energy cost of level walking before and after hydro-kinesi therapy in patients with spastic paresis. Scand. J. Med. Sci. Sports., 1998, 8, 222-228.

HYDROTHERAPY

Introduction

Hydrotherapy is a therapeutic modality that uses water in any of its states

(liquid, steam …) to treat disease and functional disability. Hydrotherapy

specifically is designed to improve neuromuscular, skeletal, and

proprioceptive function in patients with acute, subacute, and chronic

disabilities.

Hydrotherapy also is used for long-term maintenance. Hydrotherapy is a

useful adjunct to or a viable substitute for traditional PT treatment. Ideally,

the patient progresses to an independent exercise program designed to

maintain and improve health and fitness at an appropriate level.

No water exercises are safe without instruction from a qualified therapist.

Participants in hydrotherapy activities can be injured during any exercise,

simply because the exercise protocols are performed in water. When

underlying pathological conditions are not acknowledged, participants enter

programs unaware of their abilities and limitations.

General safety precautions

Patients should never be left unattended/unsupervised.

Staff should know how to monitor basic vital signs (e.g., blood pressure,

pulse, respirations) and should be able to recognize signs of patient distress.

Responsibilities of the aquatic personnel should be well delineated and

versed prior to initiating care of any patient. Responsibilities that need to

be delineated include who calls 191, who evacuates the patients, and who

directs emergency medical technician (EMT) responses (i.e., pre-EMT and

post-EMT responses).

In-service training for staff should be conducted on a regular basis.

Simulated emergency situations should be rehearsed. All typical emergency

scenarios should be documented in the employee procedures manual.

Each staff person should learn how to immobilize the cervical spine;

providing head support, chin support, and a head splint. Ideally, at least one

staff member who is certified by a nationally recognized training agency

should be present during operating hours.

A log of in-service training dates, the type of training, and attending

personnel should be kept on file for a minimum of 5 years for insurance

purposes.

An inspection log of the facility's maintenance, chemical use, and cleaning

schedule should be kept on file.

• Indications for hydrotherapy

� Subacute/chronic soft tissue injury

� Muscle contractures

� Scar formation

� Osteoarthritis

� Subacute/chronic rheumatoid arthritis

� Patients who are postfracture

� Open wounds

� Burns with intact thermal sensation

� Pressure ulcers

� Muscle spasm

� Tension

� Anxiety

� Muscle weakness from disuse

� Muscle weakness from central nervous system or

peripheral nervous system pathology

• Contraindications to hydrotherapy

� Cardiac dysfunction

� Infectious diseases/fever

� Vomiting

� Urinary infections

� Suprapubic catheter

� Scabies or lice

� Open wounds or contagious rash

� Membrane rupture with pregnancy

� Severe burns if altered or impaired thermal sensation

� Bowel or bladder incontinence

� Menstruation without internal protection

� Nontunnel IV catheters

� Respiratory dysfunction

� Severe peripheral vascular disease

� Bleeding disorders

� Impaired/decreased thermal sensation

� Atopic eczema

� Ichthyosis

� Acute rheumatoid arthritis

� Infections of the skin surface

o Patients with open wounds should not be allowed to submerge in

water until the wounds sufficiently are healed. Generally, 7-10

days following surgery is ample time for a wound to heal before

immersion. Anyone with a contagious infection should not

immerse because of the risk of passing the illness to others.

• Precautions for hydrotherapy

o Precautions need to be considered for the safety of staff as

well (eg, patient-therapist ratio, ability to transfer in and out

of the pool).

o Precautions include the following:

� Hypersensitivity to chemicals used in pool

� Multiple sclerosis (water warmer than 88° is not

appropriate)

� Ostomy

� Thermoregulatory problems (eg, effects of Ditropan)

� Epilepsy

� IV lines

� Excessive fear of water

� Never force a patient with a fear of water to

engage in hydrotherapy.

� If the patient is willing to try, encourage the use

of a vest flotation device to provide additional

buoyancy. Even then, start exercises slowly,

allowing time for the patient to gain confidence in

the water.

� Peripheral vascular disease

� Fever

� HIV (risk of catching opportunistic infection)

� Perforated ear drum

� Most hydrotherapy activities can be performed

with the head maintained comfortably above water.

� As a safety precaution, individuals susceptible to

ear infections should wear an ear protection device

while in the water.

� Dysphagia

� Compromised respiratory function

� Unstable high or low blood pressure

� Severely weakened or deconditioned state

o Each staff person should be proficient in monitoring vital signs

(eg, blood pressure, heart rate, pulse rate, respiratory rate).

Freely visible clocks or timers and blood pressure cuffs should

be available at multiple locations within the hydrotherapy area.

o Appropriate and clear posting of information and warnings is

required (eg, sign stating no diving, list of pool rules and

regulations).

o Check all wiring and outlets for leakage at least twice a year

o General care before and after each patient may include but is

not limited to the following:

� Empty the tank after use, or be sure proper water

recirculation is occurring (i.e., agitator intake and outflow

is clear).

� Scrub the inside of tank with a commercial disinfectant.

Rinse tub with clean water. Dry the tank.

� Polish external surface of tank with a commercial

stainless steel polish.

� All electrical outlets should have a ground fault circuit

interrupter and should be of the highest industry quality

standard available. At no time should a patient or staff

person who is touching or in water be allowed to switch a

circuit on or off.

� All electrical outlets should be positioned so that persons

being treated are not easily able to turn the agitator on

or off.

o Available agents that are recommended for the general

maintenance of hydrotherapy equipment include the following:

� Alcohol wipes

� Industrial grade of stainless steel cleaner

� Chlorazene, which is a whirlpool additive for sterilization

� Enzymatic cleaner for use on hard surfaces to break

down blood, protein, and other organic matter. Works to

get hair and skin out of internal pump systems and

turbines.

� D-Foam controls excessive hydrotherapy foaming.

Prescription guidelines

When writing a prescription for aquatic-based PT and hydrotherapy, include

the following details:

• Areas to be treated - Designate the anatomic area

• Precautions (eg, open wounds, ROM restrictions, cardiac precautions)

o Cardiac precautions are a set of explicit instructions written by

a physician detailing pertinent signs, symptoms, and objective

findings that would warrant the cessation of a therapy session.

o Cardiac precautions include the following:

� Elevation of systolic or diastolic blood pressure over

parameters established for the patient

� Decrease in systolic blood pressure of >20 mm Hg

� Elevation in heart rate >80% of age-predicted maximal

heart rate

� Drop in heart rate >10 bpm

� Angina, shortness of breath, lightheadedness, or fatigue

• Duration and frequency - Indicate how many times a week and how

many successive weeks to implement therapy

• Goals of hydrotherapy may focus on the following:

o Flexibility

o Strengthening

o Aerobic conditioning

o Advanced ambulation

o Stability

• Type of exercise (eg, type of aquatic therapy approach; isotonic,

rhythmic, and aerobic; should use large muscle groups, should not

involve a large isometric component, walking/jogging)

• Intensity - May be prescribed as a percentage of the maximum

attainable heart rate (HR) or oxygen consumption. The optimum level

is 70-85% of maximum HR or 60-80% of VO2max.

Guidelines for therapy

• Encourage trunk stability.

• Move from deeper water to more shallow water.

• Use a rhythmic pattern throughout ROM exercises.

• Increase speed and resistance as strength allows.

• Gradually extend the duration of exercise.

Forms of hydrotherapy

Whirlpool

• Indications for whirlpool therapy :

� Open contaminated wounds

� Contractures

� Burns

� Muscle spasms

� Degenerative arthritis

� Acute musculoskeletal injuries

� Skin ulceration and infection

� Patients who are morbidly obese and immobilized who

cannot be cleaned in another manner

Whirlpools, which usually are utilized for immersion of all or part of the

body, use agitated water to produce convective heat or cooling, massage, and

gentle debridement. Unit size, water temperature, agitation intensity, and

solvent properties may all be adjusted to meet treatment goals.

Water temperature is determined by the amount of the body submerged,

patient health, and goals of treatment. Because only a portion of the body is

submerged, no significant core body temperature changes occur. However, as

more body surface area is immersed and the temperature changes, there is

an increasing potential for alteration of core body temperature. A hand or

limited portion of a limb with intact sensation may tolerate temperatures up

to 45°C. With immersion to the waist, decrease water temperature to 40-

41°C. If most of the body is submerged, decrease water temperature to 38-

39°C.

Personnel who are treating patients should monitor for signs of discomfort

and, during treatment, should inspect skin for evidence of conditions that

could result in cross-contamination or be worsened by moisture. Pressure

should be avoided around knees and axillae if only an extremity is immersed

in water. Patients should be encouraged and assisted to dry their skin

thoroughly after treatment to avoid becoming chilled.

Whirlpool tanks are especially helpful in treating the athlete who is resuming

activity after immobilization or casting, whose primary problem is restricted

ROM.

Water for the tank can be agitated by turbines, which mix air and water.

The body part is submerged and can be actively moved during the treatment.

The usual length of treatment is 20 minutes.

• Different types of whirlpool tanks

o The limb tank is used for immersion of one upper limb, both

upper limbs, or the distal lower limb.

o The lowboy and highboy tanks are used for lower limb immersion

or immersion of the trunk up to the mid thoracic level. In the

lowboy tank, the patient is in the long sitting position and can

perform ROM exercises with both knees. In the highboy tank,

the patient is seated in chest-high water with flexed hips and

knees. Temperature is 100-102°F when immersing lower limbs

and 100-105°F when immersing upper limbs.

o The Hubbard tank is used for whole-body immersion, thus

allowing for motion of all 4 limbs. Temperatures should be less

than 102.2°F. Duration of treatment is 10-20 minutes,

depending on cardiopulmonary tolerance. Water agitation may

facilitate wound healing. With immersion of the entire body,

most of the regulatory mechanisms that maintain body

temperature are short-circuited; skin vasodilation from heating

picks up more heat from the water bath rather than

transferring core heat to the exterior. For this reason,

patient's oral temperature should be checked if the water

temperature is greater than 37.8°C (100°F). Water

temperatures over 40.6°C (105°F) are contraindicated for

whole-body immersion. For partial immersion of a limb or other

body part, water temperatures may be up to 46.1°C (115°F).

Treatment duration should be no more than 20 minutes, and the

patient should never be left alone.

Contrast bath

Contrast bath is used for the treatment of distal limbs. Contrast bath

commonly is used to treat patients with rheumatologic disease, neuropathic

pain, or other pain syndromes such as complex regional pain syndrome (reflex

sympathetic dystrophy). Also, this form of hydrotherapy is used in the

treatment of ligament and joint capsule sprains, as well as in cases of stasis

edema to improve circulation.

A contrast bath alternates exposure to heat (100-105°F/40-43°C) and cold

(59-68°F/15-20°C) to produce reflex hyperemia. Two tubs are used, one

containing warm water and one containing cold water. Begin with warm

submersion for 10 minutes and follow with 4 cycles of alternating 1- to 4-

minute cold soaks and 4- to 6-minute warm soaks. The cycle is repeated 4

times, with total treatment time usually being 30 minutes.

Use caution in patients with small vessel disease, diabetes, arteriosclerotic

endarteritis, or Berger disease. Also use caution in those with heat or cold

intolerance.

Shower cart

The shower cart was created to avoid the risk of autocontamination and/or

cross-contamination. The shower cart allows for gentle spray or shower

hydrotherapy with the use of overhead/handheld shower heads, with

independently adjustable water temperature and pressure. The temperature

of the water and air should be able to be closely controlled.

This form of hydrotherapy uses less water and space and requires less

maintenance than other hydrotherapy mechanisms.

- References :

1- Fedorczyk J: The role of physical

agents in modulating pain. J Hand Ther

1997 Apr-Jun; 10(2): 110-21. 2- Grana WA: Physical agents in

musculoskeletal problems: heat and cold

therapy modalities. Instr Course Lect

1993; 42: 439-42.

HYDROTHERAPY.

Review on the effectiveness of its application in physiotherapy and occupational therapy.

by Dr. Craig W. Martin, Senior Medical Advisor

Kukuh Noertjojo, Health Care Analyst

(May 2004)

Program Design Division

Hydrotherapy. Review on the effectiveness of its application in physiotherapy and occupational therapy.

TABLE OF CONTENTS Page

1. Introduction and Objectives .................................................................................... 1 II. Material and Methods.............................................................................................. 2 III. Results .................................................................................................................... 2 High level evidence on the effectiveness of hydrotherapy ................................ 2

Hydrotherapy and arthritis ........................................................................... 2 Hydrotherapy and chronic low back pain .................................................... 6 Hydrotherapy and ankylosing spondylitis .................................................... 7 Hydrotherapy and rehabilitation of patients With anterior cruciate ligament disruption ................................................ 8 Hydrotherapy and pressure ulcer healing.................................................... 10 Hydrotherapy and fibromyalgia ................................................................... 10

Interesting application of hydrotherapy among children diagnosed with Complex Regional Pain Syndrome (CRPS) (Evidence level 3-4) ............... 12 Complications due to hydrotherapy................................................................... 12 IV. Summary ................................................................................................................ 13 Appendix 1 .................................................................................................................... 14 References ................................................................................................................... 15

1

Hydrotherapy. Review on the effectiveness of its application in physiotherapy and occupational therapy. I. Introduction and Objectives.

Hydrotherapy or hydrotherapeutics is sometimes referred to as hydropathy(1). It is said to incorporate the use of the “healing powers” of water. Its use dates back to as early as 2400 BC(2). Many practitioners of ‘hydrotherapy’ feel water has significant curative properties and that, unlike other medicinal agents, is not harmful nor potentially toxic(1). Thallasotherapy literally means sea therapy. The official definition of thallasotherapy came from the French Sea and Health Federation in 1986. It states “in a privileged marine location, thallasotherapy is the combined use, under medical supervision, and with a curative and preventive goal, of the benefits of the marine environment which include the marine climate, seawater, mud, sand, seaweed and other substances derived from the sea”(1). Balneotherapy or spa therapy is defined as the use of baths (hot or cold springs or natural occurring waters) and other natural remedies (including mud) for healing(1,3,4). In contrast, current rehabilitation professionals generally define hydrotherapy as a pool therapy program specifically designed for an individual in an attempt to improve neuromuscular and skeletal function. This therapy is conducted and supervised by appropriately qualified personnel, ideally in a purpose-built hydrotherapy pool(5-8). The use of hydrotherapy as a rehabilitation tool was first described by Hippocrates (c. 450 - 375 BC) and is now commonly employed by physiotherapists(5,7,8,44) and occupational therapists(6).

It has been argued that rehabilitation-related hydrotherapy uses only the physical qualities of water (i.e. the buoyancy, resistance and sometimes its temperature), while the spring waters being used in balneotherapy are bacteriologically pure, have mineral content, and that these minerals have therapeutic potential(5,8,9,12) in themselves.

Currently, hydrotherapy is applied in many rehabilitative programs. Examples of its use include improving muscular and cardiopulmonary endurance in the elderly(50), pulmonary rehabilitation in patients with severe asthma(1,3,4), ventilated patients with Guillain-Barre Syndrome(10), sports injuries(11), osteoarthritis and rheumatoid arthritis(4,9,20,49), various dermatological conditions(12), Rett syndrome(13), chronic heart failure(14,15), reducing spasticity in severe traumatic brain injury patients(16), burns and wound healing(17-19,45), ankylosing spondylitis(20), fibromyalgia(21,31,48,66), low back pain(22), rehabilitation post anterior cruciate ligament surgery(23,43) , Colles' fracture(46), and total femur replacement(24), pressure ulcer(25,47), children with complex regional pain syndrome(26), rehabilitation of patients with supraspinatus muscle tears(27) , rehabilitation of patients with spinal muscular atrophy(28), rehabilitation of ankle sprains grade I and II(29), improving functional mobility in patients with incomplete C-6 spinal cord lesion(30), venous stasis/insufficiency(35-37) including hemorrhoids(38), common colds(39), urolithiasis(40), various psychiatric conditions(41) including hysteria(42). It is occasionally used during labour and birth(32,33).


2

The purpose of this review is to investigate the effectiveness of hydrotherapy in musculoskeletal rehabilitation as applied by physiotherapists and occupational therapists.

Levels of evidence are rated according to the hierarchy described in Appendix 1.

II. Material and Methods.

A literature review (up to March 26, 2004) was conducted on multiple databases

including OVID, Cochrane Library Database, DARE, NICE, AHRQ, as well as INAHTA and member countries for any review on naturopathic medicine. OVID is a commercial database which encompasses, among others, Biosis (from 1969 to week ten, 2004), Embase (from 1980 to week eight, 2004), MEDLINE (from 1966 to March week 2, 2004) and CINAHL (from 1982 to March week 2, 2004).

The search was limited to human, adults (age ≥ 19) and English language literature (or the availability of English language abstract). The search was done by employing keywords: (hydrotherapy or water pool therapy or pool therapy or aquatic physical therapy) AND (physiotherapy or physical therapy or occupational therapy). The search results were further restricted to high level evidence by employing keywords clinical trials or controlled clinical trials or randomized controlled trials or meta-analysis or review or systematic review or multicase review.

Based on these criteria, 194 articles were extracted. Preliminary analyses were done by reviewing the abstracts of these articles. All articles in English language that did not have abstracts were then retrieved for further evaluation. Research on labour, parturition and on normal subjects were excluded. III. Results. III.1. High level evidence on the effectiveness of hydrotherapy. III.1.1. Hydrotherapy and arthritis.

• In 1997, Verhagen et al(51) published a systematic review (level 1 evidence) on the efficacy of balneotherapy in patients with arthritis. The authors searched Medline and Cochrane library (up to 1995) by employing combination keywords of balneotherapy, hydrotherapy, spa therapy, water therapy, thallasotherapy, arthritis, randomized controlled trials, controlled clinical trials and clinical trials. The search was limited to articles published in English, French, German or Dutch languages. Reference checking and personal communication with experts were also conducted.

There were 37 articles that fulfilled the inclusion criteria. Of these 37, 23 were excluded. Of the 14 articles included in the review, 3 were randomized controlled trials (RCT) within which hydrotherapy was one of the treatment options. These 3 RCTs included patients with osteoarthritis. The results suggested that there was improvement in various different outcome


3

measurements at the end of treatment. However, the difference between hydrotherapy and other treatment modalities were not statistically significant. Further, the authors concluded that these studies were of medium to low quality.

• In 1999, Van Baar et al(51) conducted a systematic review (level 1 evidence) on the effectiveness of exercise therapy in patients with osteoarthritis of the hip and knee. The authors searched Medline, Embase, CINAHL and Cochrane Trial Register databases (up to September 1997) on any kind of exercise therapy among patients with hip or knee osteoarthritis. There was no restriction with regard to publication language. Seventeen trials were identified. Of these, 10 trials were relevant to the objectives of the review.

Only one trial employed hydrotherapy as one of the main treatments under investigation. This study compared the effectiveness of an aerobic walking program, aerobic hydrotherapy and a non aerobic program directed to range of motion. The results showed that there was no difference between the three exercise groups with regard to flexibility, number of clinically active joints, duration of morning stiffness or grip strength.

• Green et al(52) conducted a randomized, single blind, controlled trial (level 1 evidence) among patients with osteoarthritis of the hip attending two hospitals in Leeds, England. Eligible patients were stratified according to sex and age (above or below 70 years). Randomization toward the two treatment groups (home exercise alone and home exercise plus hydrotherapy) was done within the strata and the outcome was presented accordingly (thus, the outcome would be controlled by age and sex already).

Sixty-three patients were eligible to participate and 47 (74.6%) were randomized. Twenty-four patients were randomized into hydrotherapy and 23 patients were randomized to home exercise. The authors described the type and duration of the interventions prescribed. After randomization and prior to the intervention, baseline assessments were done at 0 (at randomization), 3 and 6 weeks. Patients were taught exercises according to the results of the randomization. Those who were randomized into hydrotherapy were asked to attend their treatment twice weekly in a deep pool for a period of 6 weeks, on top of the home exercise that all patients were required to undertake.

Assessments were done at weeks 9, 12 and 18. The outcome measures included active range of motion, muscle strength, analgesic requirement, subjective pain score (10 cm visual analog scale), descriptive pain scale and an overall change score.

The outcomes showed that there was an improvement with regard to both subjective and objective measurements in both groups. There was no significant difference with regard to these measurements between the two treatment groups, independent of age, sex and the radiological level of severity of the osteoarthritis. The authors concluded that, for most patients with osteoarthritis of the hip, a carefully graded and supervised regimen of home exercise was beneficial and there was little benefit in adding hydrotherapy to this regimen.


4

Despite the possibility of running into multiple comparison problems due to the number of outcomes being measured and compared (no designated primary outcome measurement), the study by Green et al(52) was well done and documented.

• A single blind, 3-group, randomized controlled trial conducted by Foley et al(53) investigated the impact of hydrotherapy on the strength and physical function in patients with osteoarthritis (OA). Hip or knee OA patients were identified from various departments at a general hospital and from community advertisement in South Australia.

Four hundred and twenty-nine potential participants were recruited; 324 of these were excluded mainly due to not meeting the inclusion criteria. One hundred and five participants were randomized into 3 groups; 35 into a hydrotherapy exercise group, 35 into a gym based exercise group and 35 were controls (no exercise at all). The exercise interventions included either 3 water based or 3 gym based exercise sessions a week for six weeks.

The outcome measures included Western Ontario and McMaster Universities OA index (WOMAC), the Adelaide Activities Profile (AAP), The Short Form -12, quadriceps strength and a six-minute walk test. The outcome measurements were done at week 0 and 6.

At baseline, there was no significant difference with regard to the characteristics of the study population in each group. At week 6, in the gym based group, both left and right quadriceps strength was significantly increased as compared to the controls and the right quadriceps was significantly stronger than the hydrotherapy group. The hydrotherapy group demonstrated significantly increased left quadriceps strength but only when compared to controls. The hydrotherapy group was significantly different from controls with regard to distance walked and the physical component of the “SF-12” questionnaire. The gym group was significantly different from the control group for walk speed and self-efficacy satisfaction. With the exception of right quadriceps strength mentioned above, there was no significant difference between gym based and hydrotherapy group in various outcome measurements. There was no difference in drug use between the 3 groups. The authors concluded that functional gains were achieved regardless of the type of exercise programs. It should be noted that there was no significant difference in any outcome between hydrotherapy and the gym based exercise group.

Despite the possibility of running into multiple comparison problems due to the number of outcomes being measured and compared (no designated primary outcome measurement), this study would be assessed as being well done and would rate an evidence level of 2.

• A single blind randomized controlled trial on the effectiveness of structured hydrotherapy program in the management of patients with rheumatoid arthritis (RA) was presented by Hart et al(54) (abstract only) in 1994.

Forty-six patients with rheumatoid arthritis were randomized into either a group receiving hydrotherapy or one in which hydrotherapy was withheld. Both groups (presumably 23 patients on each group) were similar in terms of their


5

demographic characteristics and medication usage. Within 3 weeks following randomization, patients in the hydrotherapy group received 15 sessions of supervised pool exercise.

The primary outcome measure in this study was joint range of motion. The secondary outcome measures included subjective pain, joint tenderness, joint swelling, early morning stiffness, grip strength, muscle power, patient function, erythrocyte sedimentation rate, patient's self-assessment and the independent assessor's own assessment of patient's progress. The outcome measurements were done at entry, and at day 7, 14, 21 and 42 after the intervention was initiated.

At 21 and 42 days treatment, there was a clear trend towards improvement in both the hydrotherapy and non-hydrotherapy groups for the primary and all secondary outcome measures. However, there was no significant difference between the 2 groups with regard to any of the outcome measures. The authors concluded that they had been unable to demonstrate the effectiveness of hydrotherapy as one of several interventions in a comprehensive treatment program.

Our reviewers were not able to provide a full assessment on the quality of this trial due to the unavailability of the fully published report. However, the authors presented a comprehensive description of the study in the short published abstract and, on that basis, it was felt to be a well-designed trial.

• Suomi and Koceja(55) conducted a randomized controlled trial to investigate the effects of the Arthritis Foundation Aquatic Program (AFAP) on postural stability in women with arthritis (abstract only). Twenty-seven females were randomized into an AFAP exercise treatment group (17 females) and control (10 females). The AFAP group participated in a 3 times per week, 6-week aquatic program which was designed to increase strength, range of motion and mobility. The outcome measures in this study were static and dynamic postural stability using a Kistler force platform and custom designed software.

The authors reported that for static postural stability, the AFAP group demonstrated significant decreases in total and lateral sway areas, while the control group did not. For the dynamic condition, the AFAP group demonstrated quicker recovery times. The authors concluded that the AFAP intervention program increased static and dynamic postural stability in females with arthritis.

It was difficult to assess the quality of this trial due to insufficient information provided by the authors in the published abstract. However, the information suggests that the authors' conclusions were not supported by the type of statistical analysis being used in analyzing the outcomes of this study. Hence, this would be classified as a past study and, at best, is of low level evidence.

• In 1996, one hundred and thirty-nine patients were randomized into hydrotherapy, seated immersion, land exercise or progressive relaxation in this study among chronic rheumatoid arthritis patients conducted by Hall et al(56) (abstract only). Patients attended 30-minute sessions twice weekly for 4 weeks.


6

Physical and psychological measurements were done before and after the intervention, and at 3 months follow-up.

The authors reported that all patients improved physically and emotionally as assessed by Arthritis Impact Measurement Scales 2 questionnaire. Among females (presumably a sub group analysis), hydrotherapy was shown to improve joint tenderness and knee range of motion. At 3 months follow-up, the hydrotherapy group maintained an improvement in emotional and psychological state. The authors concluded that although all patients experienced some benefit, hydrotherapy produced the greatest improvement.

Because of a lack of detailed information on the methodology of the study, it is not possible to evaluate the quality of this trial.

In summary, high level evidence obtained from primary research in hydrotherapy among arthritis patients does not provide conclusive evidence of its effectiveness over other type of exercises prescribed among arthritis patients.

III.1.2. Hydrotherapy and chronic low back pain. • Maher(22) conducted a review on effective physical treatment modalities

for chronic low back pain. This review could not be classified as a systematic one; however, a duplicate search done in the past by the Evidence Based Practice Group on the area of hydrotherapy and chronic low back pain suggested that the author’s search was exhaustive in identifying systematic reviews or randomized controlled trial on this topic.

There were two randomized controlled trials appraised in this review. The first, a study by McIlveen and Robertson(57) found that subjects randomized to a 1 month program of hydrotherapy did not have better outcomes at 1 month follow-up as compared to those randomized to a waiting list. The hydrotherapy program provided no benefit in pain, disability or lumbar range of motion.

The second study by Sjogren et al(58) compared a hydrotherapy group to a land-based treatment program group. Subjects were assessed at baseline, after a no-treatment run-in period, and then after 1 month of treatment. Sjogren et al(58) reported that there was no significant difference, for pain, disability and walking speed, between the two types of treatment. Sjogren et al(58) concluded that both treatments were equally effective. However, Maher(22) argued that to have no between group differences might reflect the fact that both treatments were ineffective. He further argued that the size of the difference within group differences suggested that this was the case (the changes in pain and disability were trivially small and of the same magnitude observed in the no-treatment run-in period). With regard to this argument provided by Maher on the Sjogren et al paper, the conclusions provided by Maher appear sound. In the absence of control (no treatment or standard accepted treatment) group and the small


7

size of within group differences, it is highly likely that both treatment methods were not effective.

Maher concluded that based on these two trials, there was no evidence that hydrotherapy was effective in treating chronic low back pain.

• Liddle et al(59) conducted a systematic review on the effectiveness of various types of exercise being offered for treating chronic low back pain. Due to the inclusion and exclusion criteria employed in this systematic review, Liddle et al were only able to identify one randomized controlled trial on hydrotherapy and chronic low back pain (McIlveen and Robertson's study(57)). This has been discussed above.

In summary, high level evidence suggests that hydrotherapy is not effective in treating chronic low back pain. III.1.3. Hydrotherapy and ankylosing spondylitis.

• Dagfinrud and Hagen(60) conducted a Cochrane systematic review on physiotherapy based interventions for patients with ankylosing spondylitis. The authors searched the Cochrane Trials Register, Medline, Embase, CINAHL and PedRo up to February 2000 by employing the following keywords: (randomized controlled trials or controlled clinical trial) and (spondylitis or ankylosing or spondyloarthropathies or Mb. Bekhterev) and (physiotherapy or physical therapy or exercise or training or hydrotherapy or manual therapy or electrotherapy or education) and (treatment). There were various inclusion and exclusion criteria implemented in this study, including English and Scandinavian languages limitation. Twenty-one studies were identified and 16 of them were excluded. These five studies were included in the review. However, two of these studies were deemed to be follow-up studies and there were, therefore, only 3 studies included in the systematic review, two(61,62) of which had a component of hydrotherapy as part of the physiotherapy programs.

In the study conducted by Helliwell et al(61), 44 patients diagnosed with ankylosing spondylitis were 'randomized' (by throwing dice) into 3 different interventions, including 3 weeks as an in-hospital patient involved in physiotherapist supervised intensive group exercises that included hydrotherapy, outpatient hydrotherapy and home exercise (for 6 weeks) and home exercise only (for 6 weeks). The authors presented their sample size calculation. However, the sample size calculation was not conducted in order to detect differences between groups (which was what the study needed to answer the objective). The outcomes measured in this study included cervical rotation, chest expansion, lumbar movement (Schober's test), 10 cm visual analog scale for pain and joint stiffness. Outcome variables were collected twice prior to intervention, immediately after intervention, and at 2, 4 and 6 months after intervention. There was a significant difference seen between groups for pain and cervical rotation immediately after the intervention.


8

However, there was no difference at 6 months follow-up. Further, despite randomization and risk stratification, there were baseline differences between intervention groups. The authors did not take into account the differences in baseline measurements in presenting the outcome analysis.

Hidding et al(62) conducted a randomized controlled trial on the effect of adding supervised group physical therapy to unsupervised individualized therapy among ankylosing spondylitis patients. One hundred forty-four patients were randomized (unclear method) into home exercise or home exercise and weekly group physical therapy (which included 1-hour hydrotherapy in each session). The outcome measures included spinal mobility, maximum work capacity, Sickness Impact Profile, Health Assessment Questionnaire for Spondyloarthropathies and Functional Index (the primary outcome was not defined). Outcomes were measured at baseline and at 3, 6 and 9 months intervention. The authors reported that weekly physical therapy group had significantly better outcomes (spinal mobility, maximum work capacity and global assessment) compared to the home exercise group. It should be noted that a quality assessment of this paper would rate this research as poor.

• Van Tubergen et al(63) conducted a randomized controlled trial on ankylosing spondylitis and spa-exercise therapy. The components of spa-exercise therapy included physical exercises, walking, postural correction therapy by lying supine on bed, hydrotherapy, sports, bathing and thermal visits. In total, 120 patients were randomized into 3 groups of 40 patients each. Group 1 received 3 weeks of spa therapy at a spa resort in Austria, group 2 received 3 weeks spa therapy in the Netherlands and group 3 stayed home and continued standard treatment. Hydrotherapy was a component in each of the spa therapy groups.

Even though the authors claimed that the spa-exercise groups were better than controls at 16 and 28 weeks follow-up, the effect of hydrotherapy component alone in this primary study could not be measured separately. The study design precluded this measurement. It also should be noted that this study was of better quality than the two previous studies among ankylosing spondylitis patients; however, no direct comment on ‘hydrotherapy’ can be obtained from this research.

In summary, there was no significant positive evidence on the effectiveness of hydrotherapy treatment (alone or as a component of physical therapy program) among ankylosing spondylitis patients.

III.1.4. Hydrotherapy and rehabilitation of patients with anterior cruciate ligament disruption.

Thomson et al(23) conducted a Cochrane systematic review on the effectiveness of physiotherapist-led programs and interventions for rehabilitation of anterior cruciate ligament (ACL), medial collateral ligament


9

(MCL) and meniscal injuries (M) of the knee in adults. The authors conducted searches on Cochrane Musculoskeletal Injuries Group specialized database (up to June 2001), Medline (1966 to August 1999), Embase (1987 to February 1997), CINAHL (1982 to April 1999), Current Contents (up to March 1999), reference lists of relevant articles and consulted their colleagues. The following words were employed: anterior cruciate ligament or tibial menisci or posterior cruciate ligament or patellar ligament or medial collateral ligament or soft tissue injuries or sprains or strains or athletic injuries or knee injuries or knee ligament. All subheadings within each keyword were explored. Various inclusion and exclusion criteria were also implemented in this systematic review. The authors found 31 trials, involving 1545 mainly young and male patients. Only two(64,65) of these 31 trials involved the application of hydrotherapy vs. land-based rehabilitation program among patients.

A review of these two trials notes that McClintock et al(64) randomized (method not clear) 20 post ACL reconstructive surgery patients into two rehabilitation programs: 10 days 'standard' home program followed by 7 hydrotherapy sessions and 10 days 'standard' home program followed by 7 land based therapy sessions. The hydrotherapy based and land-based programs were not similar or equivalent. Both rehabilitation programs took 28 days. Outcome, i.e. knee ROM, was measured blinded at pre-operation, 10 days post operation and pre and post therapy sessions (7 measurements in all up to 28 days follow-up). There was no further outcome data available as it was only available as a conference proceedings abstract. However, the authors did report that patients in the hydrotherapy program demonstrated significantly greater gain in mean flexion and range of motion at four weeks. The authors also reported that hydrotherapy based patients showed a significantly faster rate of return to pre-operative values of knee extension.

In the second paper, Tovin et al(65) randomized (by coin toss and alternation in pairs) 20 patients post arthroscopic ACL reconstructive surgery into two equivalent rehabilitation program groups. One was land-based and one water-based. Ten patients were randomized into each group. In the first week, both groups attended the same standard home exercise program including partial weight bearing. From week 2 to 8 post-operatively, patients were then assigned to a series of equivalent rehabilitation programs that were performed in the same sequence, one group in land and the other group in water-based therapy. Outcome measures included joint laxity, thigh girth, passive range of motion (at 2 weekly intervals) and muscle strength (at week 8 only). These outcome measures were done by one, blinded, assessor). Subjective assessment of knee function (as measured by Lysholm scale) was done at week 8. At week 8, the mean Lysholm score was significantly higher among the hydrotherapy group of patients compared to the land-based rehabilitation patients. At week 8, there was no significant difference between the two groups with regard to muscle strength, passive range of motion, girth measurement above mid patella level. Less joint effusion was also noted among the hydrotherapy group (not significant). The authors concluded that, although hydrotherapy based exercise might not be as effective as exercise on


10

land for regaining maximum muscle performance, hydrotherapy might minimize the amount of joint effusion and lead to greater self report of functional improvement in patients with intra-articular ACL reconstruction.

In summary, there was evidence that post op hydrotherapy may be more effective than a land-based rehabilitation program for those patients undergoing ACL reconstructive surgery. III.1.5. Hydrotherapy and pressure ulcer healing. Burke et al(25) conducted a randomized trial (randomization method

unclear) on the effects of hydrotherapy on pressure ulcer healing among hospital inpatients with grade III-IV pressure ulcers. A total of 42 wounds (from 18 patients) were randomized into one group (24 wounds), in which each wound was treated for 20 minutes of whirlpool therapy every day for at least 2 weeks and 18 wounds were assigned into non-whirlpool treatment group. Each wound, regardless of the randomization group, was also treated with 'standard' care for pressure ulcer treatment. The wounds were viewed and classified on admission to the study, and then once per week by a study physician who was blinded to the group assignment. At the end of the study period (duration of the study was not reported), the authors reported that the whirlpool group improved at a significantly faster rate than non whirlpool group.

It should be noted that this study did not provide clear outcome criteria and there was no information on the baseline characteristics of the study population reported. The statistical methods employed in the data analysis were felt to be inappropriate and the outcome measures were not adjusted to potential confounders within the trial.

In summary, there was no high level evidence on the effectiveness of the addition of whirlpool sessions in treating grade III-IV pressure ulcers.

III.1.6. Hydrotherapy and fibromyalgia. In 2000, Mannerkorpi et al(66) conducted a randomized controlled trial

among 58 patients diagnosed with fibromyalgia in an attempt to investigate the effects of a program of 6 months of pool exercise therapy combined with 6 education sessions. Sixty-nine women diagnosed with fibromyalgia (according to the American College of Rheumatology criteria) were recruited from primary health care and rheumatology clinics in Sweden. Inclusion and exclusion criteria were explained. Thirty-seven patients were randomized into a treatment group and 32 patients were controlled. ‘Randomization’ was done using sequential


11

allocation according to age and symptom duration. Nine patients in the treatment group and 2 in the control group dropped out after ‘randomization’ (and subsequent data was not analyzed according to the intention to treat principle). The patients were instructed to continue their baseline medical treatment. It was noted that the control group had a significantly higher baseline consumption of non-steroidal anti-inflammatory drugs when compared to the treatment group.

Patients in the treatment group received an exercise program in a temperate pool, supervised by a physiotherapist, once a week for 6 months. The education program consisted of six 1-hour sessions led by one physiotherapist and was based on active participation of the patients. The aim of the program was to introduce strategies to cope with fibromyalgia symptoms and to encourage physical activity.

Primary outcome measures in this study included the Fibromyalgia Impact Questionnaire (FIQ) and the 6 minutes walk test. Secondary outcome measures included the Short Form 36 (SF-36), The Swedish version of the Multidimensional Pain Inventory (MPI), The Arthritis Self Efficacy Scale (ASES), The Arthritis Impact Measurement Scale, The Quality of Life Questionnaire and various tests of functional limitations which were undertaken by one physiotherapist blinded to patient group allocation. The authors did not provide a sample size calculation. At baseline, patients in the treatment group showed significantly higher scores on general health and mental health in the SF-36, and higher levels of social support on the MPI. Also found were higher scores for self-efficacy for pain and symptoms on the ASES, and a lower degree of depression on the FIQ than the control group. The authors noted that adjustments for these differences were done in a subsequent analysis and did not change the results of between group analyses. Even though adjustments were made, the application of Mantel’s technique of pooling applied to Fisher’s permutation test, as mentioned in the statistical methods, is felt to not be the appropriate method to analyze such differences. Further, given the number of statistical tests being performed and reported, the authors did not attempt to adjust the level of p-value (set at 0.05) to take into account the multiple comparisons being done.

At 6 months, significant differences between groups were found for the FIQ total score, the 6 minutes walk test, physical function, grip strength, pain severity, social functioning, psychological distress and quality of life. The treatment group had significantly better performance in these variables compared to controls. The authors concluded that the results of the 6-month exercise program in a temperate pool combined with education improved many parameters of patients with fibromyalgia.


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In summary, the only ‘high level’ study on the effectiveness of hydrotherapy in treating fibromyalgia did not provide sufficient evidence to suggest it was efficacious. The study conducted by Mannerkorpi et al(66) should be seen at best, as a case control study (instead of a randomized controlled trial); thus, it would be classified as low level evidence. Further, the authors did not employ proper statistical methods in analyzing and presenting the data.

III.2. Interesting application of hydrotherapy among children diagnosed with

Complex Regional Pain Syndrome (CRPS) (Evidence level 3-4). Sherry et al(26) followed 103 children (49 were followed for more than 2

years) who were diagnosed with CRPS and had been treated in an extensive exercise program which included 4 hours of aerobic, 1 to 2 hours of hydrotherapy and desensitization, everyday, without any other medications or modalities being used. The extensive exercise program was performed, on average, for 14 days.

Outcome measures included pain, presence of physical dysfunction, recurrent episodes of CRPS and other disproportional musculoskeletal pain measures. Ninety-five children (92%) initially became symptom-free. Of those followed for more than 2 years, 43 (88%) were symptom free (15 of these patients had one reoccurrence), 5 (10%) were fully functional but had some continued pain and 1 (2%) had functional limitations. The median time of reoccurrence was 2 months; 79% of the reoccurrences occurring during the first 6 months of treatment.

III.3. Complications due to hydrotherapy. Several studies reported complications, including legionella infections,

burns, folliculitis and hypersensitivity pneumonitis, which were related to hydrotherapy.

Marrie et al(67) reported the isolation of legionella pneumophila from a physiotherapy pool in Halifax. Among physiotherapists who used the pool during the contamination, 16 (75%) had an antibody titer < 1:64 and 1 (5%) had a titer of 1:256. Further, the authors reported the isolation of Legionella pneumophila from whirlpool spa by the Vermont department of health in a 1998 study. The authors also reported two outbreaks of Pontiac fever associated with whirlpool use.

Hanzlick et al(68) reported burns of the torso and extremities as the result of whirlpool treatment with overheated water in an elderly man. The elderly man was in a nursing home and in long term care due to post stroke immobility and paresis, and the hydrotherapy was part of the treatment he received. The elderly man subsequently died due to the burns and wound sepsis.

Hwang et al(69) reported a case of a paraplegic patient who was receiving hydrotherapy for treatment of his malleolar ulcer. This 39 year old paraplegic


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patient lacked sensation below the T-12 dermatome. In one of the hydrotherapy sessions, he sustained immersion scald burns that ultimately necessitated below knee amputations of both legs.

Schlech et al(70) reported an outbreak of hospital-acquired Pseudomonas aeruginosa folliculitis among hospital staff and patients using a swimming pool in a newly constructed physiotherapy unit. Pseudomonas folliculitis developed in 21% of outpatients and 33% of inpatients who had used the facility. Pseudomonas infection of a surgical wound also developed in one of four inpatients with wounds, who received treatment in that pool.

Aksamit et al(71) reported 9 cases of hypersensitivity pneumonitis in association with hot tub exposure. Subsequent testing showed that the Mycobacterium avium complex (MAC) organisms isolated from these patients matched those isolated from the hot tub water. The authors compared these 9 cases with 32 similar cases reported in the literature.

It should be noted that this review did not conduct an exhaustive search on the complications associated with hydrotherapy. The above are for illustration purposes only and one meant to give the reader a sense that such treatment is not always innocuous.

IV. Summary. 1. The application of water to treat disease has been used throughout history.

It is known that Hippocrates (460 – 375 BC) used hot and cold water in the treatment of multiple disease states. At present, hydrotherapy is applied to treat a myriad of diseases, including musculoskeletal problems. The majority of the evidence on the effectiveness of hydrotherapy to treat the described disease states and ‘conditions’ comes from small case series/reports and subsequent low level evidence (Level 4).

2. The higher level evidence that was reviewed does not suggest hydrotherapy is effective in treating osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, chronic low back pain, fibromyalgia or pressure ulcers. There were two papers that did suggest that post ACL reconstructive surgery patients may have better outcomes than those undertaking land based exercises alone.

3. The application of hydrotherapy is not always without risk. There are reports in the literature regarding legionella infections, burn, folliculitis and hypersensitivity pneumonitis which were directly related to the hydrotherapy.


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Appendix 1 Workers’ Compensation Board of B.C. – Evidence-Based Practice Group. Quality of evidence (adapted from a,b,c,d). Quality of Published Evidence 1 Evidence from at least 1 properly randomized controlled trial (RCT) or systematic

reviews of RCTs. 2 Evidence from well-designed controlled trials without randomization or systematic

reviews of observational studies. 3 Evidence from well-designed cohort or case-control analytic studies, preferably from

more than 1 centre or research group. 4 Evidence from comparisons between times or places with or without the intervention.

Dramatic results in uncontrolled experiments could also be included here. 5 Opinions of respected authorities, based on clinical experience, descriptive studies or

reports of expert committees. Reference a Canadian Task Force on the Periodic Health Examination: The periodic health examination. CMAJ.

1979;121:1193-1254. b Houston TP, Elster AB, Davis RM et al. The US Preventive Services Task Force Guide to Clinical Preventive

Services, Second Edition. MA Council on Scientific Affairs. American Journal of Preventive Medicine. May 1998;14(4):374-376.

c Scottish Intercollegiate Guidelines Network (2001). SIGN 50: a guideline developers’ handbook. SIGN. Edinburgh.

d Canadian Task Force on Preventive Health Care. New grades for recommendations from the Canadian Task Force on Preventive Health Care. CMAJ. Aug 5, 2003;169(3):207-208.


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References. 1. Beamon S and Falkenbach A. Hydrotherapy for asthma (protocol). In: The

Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley and Sons, Ltd. 2. Karel R. Aquatic physical therapy: Civilian and military perspectives. PT

Magazine. January 2003; 42:42-48. 3. Strauss-Blasche G, Ekmekcioglu C, Vacariu G et al. Contribution of individual spa

therapies in the treatment of chronic pain. Clinical Journal of Pain. 2002;18:302-309.

4. March LM, Stenmark J. Managing arthritis. Non-pharmacological approaches to managing arthritis. Medical Journal of Australia.19 Nov 2001;175(SUPPL.):S102-S107.

5. ..Australian Physiotherapy Association: Clinical standards for hydrotherapy. Australian Journal of Physiotherapy. 1990;36(3):207-210.

6. Brown CA. Occupational therapists' beliefs regarding treatment options for people with chronic pain. British Journal of Occupational Therapy. Sept. 2002;65(9):398-404.

7. Goldby LJ and Scott DL. The way forward for hydrotherapy. British Journal of Rheumatology. 1993;32(9):771-773.

8. Bender T, Balint PV and Balint GP. A brief history of spa therapy. Annals of the Rheumatic Diseases. 2002; 61(10):949-950.

9. Jones G, Francis HW, Grimmer KA et al. Ancillary services in rheumatology. Medical Journal of Australia. 1997;166(8):434-439.

10. Taylor S. The ventilated patient undergoing hydrotherapy: a case study. Australian Critical Care. Aug 2003; 16(3):111-115.

11. Prins J and Cutner D. Aquatic sports injury rehabilitation. Aquatic therapy in the rehabilitation of athletic injuries. Clinics in Sports Medicine. April 1999;18(2):447-461.

12. Matz H, Orion E, Wolf R. Balneotherapy in dermatology. Dermatologic Therapy. 2003;16:132-140.

13. Leonard H, Fyfe S, Leonard S and Msall M. Functional status, medical impairments and rehabilitation resources in 84 females with Rett syndrome: A snapshot across the world from the parental perspective. Disability and Rehabilitation. 2001;23(3-4):107-117.

14. Michalsen A, Ludtke R, Buhring M et al. Thermal hydrotherapy improves quality of life and hemodynamic function in patients with chronic heart failure. American Heart Journal. Oct 2003;146(4):E11.

15. Cider A, Schaufelberger M, Sunnerhagen KS et al. Hydrotherapy - a new approach to improve function in the older patient with chronic heart failure. European Journal of Heart Failure. Aug 2003;5(4):527-535.

16. Keren O, Reznik J, Groswasser Z. Combined motor disturbances following severe traumatic brain injury: an integrative long term treatment approach. Brain Injury. Jul 2001;15(7):633-638.


16

17. Acikel C, Ulkur E and Guler MM. Prolonged intermittent hydrotherapy and early tangential excision in the treatment of an extensive strong alkali burn. Burns. May 2001; 27(3): 293-296.

18. Meeker BJ. Whirlpool therapy on postoperative pain and surgical wound healing: an exploration. Patient Education and Counseling. 1998;33:39-48.

19. Hess CL, Howard MA, Attinger CE. A review of mechanical adjuncts in wound healing: hydrotherapy, ultrasound, negative pressure therapy, hyperbaric oxygen and electrostimulation. Annals of Plastic Surgery. 2003;51:210-218.

20. van Tubergen A and Hidding A. Spa and exercise treatment in ankylosing spondylitis: fact or fancy? Best Practice and Research. Clinical Rheumatology. 2002;16(4):653-666.

21. Mannerkorpi K, Ahlmén M, Ekdahl C. Six- and 24-month follow-up of pool exercise therapy and education for patients with fibromyalgia. Scandinavian Journal of Rheumatology. 2002;31:306-310.

22. Maher CG. Effective physical treatment for chronic low back pain. Orthopedics Clinics of North America. January 2004;35(1):57-64.

23. Thomson LC, Handoll HHG, Cunningham A and Shaw PC. Physiotherapist-led programmes and interventions for rehabilitation of anterior cruciate ligament, medial collateral ligament and meniscal injuries of the knee in adults (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley and Sons, Ltd.

24. Katrak P, O'Connor B, Woodgate I. Rehabilitation after total femur replacement: a report of 2 cases. Archives of Physical Medicine and Rehabilitation. July 2003; 84: 1080-1084.

25. Burke DT, Ho CHK, Saucier M, Stewart G. Effects of hydrotherapy on pressure ulcer healing. American Journal of Physical Medicine and Rehabilitation. Sept-Oct 1998;77(5):394-398.

26. Sherry D, Wallace C, Kelley C et al. Short- and long-term outcomes of children with complex regional pain syndrome type 1 treated with exercise therapy. Clinical Journal of Pain. Sept 1999; 15(3): 218-223.

27. Palmer SL. Aquatic physical therapy case report: rehabilitation of a patient with a supraspinatus tear by aquatic therapeutic home exercises. Journal of Aquatic Physical Therapy. Nov 1998;6(2):24-27.

28. Cunha MC, Oliviera AS, Labronici RH et al. Spinal muscular atrophy type II (intermediary) and III (Kugelberg-Welander). Evolution of 50 patients with physiotherapy and hydrotherapy in a swimming pool. Arquivos de Neuro-Psiquiatria. Sept 1996;54(3):402-406.

29. Geigle P, Dadonna K, Finken K et al. The effects of a supplemental aquatic physical therapy program on balance and girth for NCAA division III athletes with a grade I or II lateral ankle sprain. Journal of Aquatic Physical Therapy. Fall 2001; 9(1): 13-20.

30. Stowell T, Fuller R, Fulk G. An aquatic and land-based physical therapy intervention to improve functional mobility for an individual after an incomplete C6 spinal cord lesion. Journal of Aquatic Physical Therapy. Fall 2001; 9(1): 27-32.


17

31. Kendall SA, Ekselius L, Gerdle B et al. Feldenkrais intervention in fibromyalgia patients: a pilot study. Journal of Musculoskeletal Pain. 2001; 9(4): 25-35.

32. Zick SM, Raisler J, Warber SL. Pregnancy. Clinics in Family Practice. 2002;4(4):1005-1028.

33. Tanizaki Y, Komagoe H, Sudo M et al. Swimming training in a hot spring pool as therapy for steroid dependent asthma. Japanese Journal of Allergology. 1984;33(7):389-395.

34. Thorp JA, Murphy-Dellos L. Epidural and other labour analgesic methods. Drugs of Today. 1998;34(6):525-536.

35. Schlenzka K. Treatment by natural remedies in phlebology. Phlebologie. 2003;32(3):60-64.

36. Mancini S, Piccinetti A, Nappi G et al. Clinical, functional and quality of life changes after balneokinesis with sulphurous water in patients with varicose veins. Vasa. Febr 2003;32(1):26-30.

37. Lacroix P, Aboyans V, Cornu E. Water cures in venous insufficiency. Revue du Praticien. Jun 2000;50(11):1212-1215.

38. MacKay DJ. Hemorrhoids and varicose veins: a review of treatment options. Alternative Medicine Review. 2001;6(2):126-140.

39. Ernst E. Is protection against common colds possible?. Fortschritte Der Medizin. 1990;108(31).

40. De Luca S, Nappi G, Menconi Orsini A. 'Project Naiad': lithiasic pathology of urinary tracts and water therapy with oligomineral waters. Medicina Clinica e Termale. 2001;13(47):197-206.

41. Braslow JT. Punishment or therapy: patients, doctors, and somatic remedies in the early twentieth century. Psychiatric Clinics of North America. 1994;17(3):493-513.

42. Dubois O. From hydrotherapy to other body mediation therapies in the management of hysteria. Neuro-Psy News. 2003;2(1):20-23.

43. Kuhne C, Zirkel A. Accelerated rehabilitation following patellar tendon autograft anterior cruciate ligament reconstruction using the aqua-jogging protocol: a primary study. Sports, Exercise and Injury. 1996;2(1):15-23.

44. Toomey R, Grief-Schwatrz R. Extent of whirlpool use in Canadian physiotherapy department: a survey. Physiotherapy Canada. 1986;38(5):277-278.

45. Gogia PP, Hurt BS and Zirn TT. Wound management with whirlpool and infrared cold laser treatment. A clinical report. Physical Therapy. Aug 1988;68(8):1239-1242.

46. Toomey R, Grief-Schwartz R, Piper MC. Clinical evaluation of the effects of whirlpool on patients with Colles' fractures. Physiotherapy Canada. 1986;38(5):280-284.

47. McCulloch JM Jr, Kemper CC. Vacuum-compression therapy for the treatment of an ischemic ulcer. Physical Therapy. Mar 1993;73(3):165-169.

48. Gunther V, Mur E, Kinigadner U, Miller C. Fibromyalgia - the effect of relaxation and hydrogalvanic bath therapy on the subjective pain experience. Clinical Rheumatology. Dec 1994;13(4):573-578.

49. Clarke AK. Effectiveness of rehabilitation in arthritis. Clinical Rehabilitation. 1999; 13(Suppl 1):51-62.


18

50. Satterfield MJ, Yasumara K, Goodman G. Impact of an engineered physical therapy program for the elderly. International Journal of Rehabilitation Research. 1984;7(2):151-162.

51. van Baar ME, Assendelft WJJ, Dekker J et al. Effectiveness of exercise therapy in patients with osteoarthritis of the hip or knee. Arthritis and Rheumatism. July 1999; 42(7): 1361-1369.

52. Green J, McKenna F, Redfern EJ, Chamberlain MA. Home exercises are as effective as outpatient hydrotherapy for osteoarthritis of the hip. British Journal of Rheumatology. 1993;32:812-815.

53. Foley A, Halbert J, Hewitt T and Crotty M. Does hydrotherapy improve strength and physical function in patients with osteoarthritis - a randomized controlled trial comparing a gym based and a hydrotherapy based strengthening programme. Annals of Rheumatic Disease. 2003;62:1162-1167.

54. Hart LE, Goldsmith CH, Churchill EM, Tugwell P. A randomized controlled trial to assess hydrotherapy in the management of patients with rheumatoid arthritis. ACR Poster Session. Miscellaneous Rheumatologic Disorders. Arthritis and Rheumatism. 1994;37(9 Suppl):S416.

55. Suomi R, Koceja DM. Effects of the Arthritisi Foundation Aquatic Program (AFAP) on postural stability in women with arthritis. Annual meeting abstract. A-17 Poster chronic disease and disability. Medicine and Science in Sports and Exercise. May 1996;28(5 Suppl):8.

56. Hall J, Skevington SM, Maddison PJ, Chapman K. A randomized and controlled trial of hydrotherapy in rheumatoid arthritis. Arthritis Care and Research. Jun 1996;9(3):206-215.

57. McIlveen B, Robertson VJ. A randomized controlled study of the outcome of hydrotherapy for subjects with low back or back and leg pain. Physiotherapy. Jan 1998;84(1):17-26.

58. Sjogren T, Long N, Storay I, Smith J. Group hydrotherapy versus group land-based treatment for chronic low back pain. Physiotherapy Research International. 1997;2(4):212-222.

59. Liddle SD, Baxter GD, Gracey JH. Exercise and chronic low back pain: what works? Pain. 2004;107:176-190.

60. Dagfinrud H, Hagen K. Physiotherapy interventions for ankylosing spondylitis (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley and Sons, Ltd.

61. Helliwell PS, Abbott CA, Chamberlain MA. A randomized trial of three different physiotherapy regimes in ankylosing spondylitis. Physiotherapy. 1996;82(2):85-89.

62. Hidding A, van der Linden S, Boers M et al. Is group physical therapy superior to individualized therapy in ankylosing spondilytis? A randomized controlled trial. Arthritis Care and Research. Sept 1993;6(3):117-125.

63. van Tubergen A, Landewe R, van der Heijde D et al. Combined spa-exercise therapy is effective in patients with ankylosing spondylitis: a randomized controlled trial. Arthritis and Rheumatism. Oct 2001;45(5):430-438.

64. McClintock JH, Kirkley A, Fowler PJ. Prospective randomized controlled trial of standard physiotherapy versus aquatic therapy for early rehabilitation of the ACL


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reconstructed knee. Journal of Bone and Joint Surgery. British volume. 1995;77 Suppl III:313-314.

65. Tovin BJ, Wolf SL, Greenfield BH et al. Comparison of the effects of exercise in water and on land on the rehabilitation of patients with intra-articular anterior cruciate ligament reconstructions. Physical Therapy. 1994;74:710-719.

66. Mannerkorpi K, Ahlmén M, Ekdahl C. Pool exercise combined with an education program for patients with fibromyalgia syndrome. A prospective, randomized study. Journal of Rheumatology. Oct 2000;27(10):2473-2481.

67. Marrie TJ, Gass R, Sumarah R, Yates L. Legionella pneumophila in a physiotherapy pool. European Journal of Clinical Microbiology. 1987; 6(2):212-213.

68. Hanzlick R. Case of the month. Complications of therapy, nursing homes and the elderly. Archives of Internal Medicine. April 13 1998;158:695-696.

69. Hwang JCF, Himel HN, Edlich RF. Bilateral amputations following hydrotherapy tank burns in a paraplegic patient. Burns. 1995;21(1):70-71.

70. Schlech EF, Simonsen N, Sumarah R, Martin RS. Nosocomial outbreak of pseudomonas aeruginosa folliculitis associated with physiotherapy pool. Canadian Medical Association Journal. April 15 1986;134(8):909-913.

71. Aksamit TR. Hot tub lung: infection, inflammation, or both?. Seminars in Respiratory Infections. Mar 2003;18(1):33-39.

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Effects of hydrotherapy in balance and prevention of falls among elderly women