Effects of an Aquatic Therapy Program
EFFECT OF AN INITIAL AQUATIC THERAPY PROGRAM WITH
PROGRESSION TO LAND PROGRAM FOR ADULT FOLLOWING THREE
TOTAL HIP ARTHROPLASTY REVISIONS
________________________________________________________________
A Case Report
Presented to
The Faculty of the College of Health Professions and Social Work
Florida Gulf Coast University
Submitted in partial fulfillment of the requirements for the degree of
Doctor of Science in Physical therapy
________________________________________________________________
By
Kristin Mortenson
2015
Effects of an Aquatic Therapy Program
APPROVAL SHEET
This Case Report is submitted in partial fulfillment of the requirements for the
degree of
Doctor of Physical Therapy
__________________________________________
Kristin Mortenson
Approved: May 2015
___________________________________________
Kathleen Swanick, DPT, MS, OCS
Committee Chair/Advisor
____________________________________________
Stephen Black, DS.c, MeD, PT, ATC/L, NSCA-CPT
Committee Member
The final copy of this Case Report has been examined by the signatories, and we find that both the content and the form meet acceptable presentation standards of scholarly work in the above-mentioned discipline.
Effects of an Aquatic Therapy Program
Acknowledgements
I would like to thank several people for assisting in the development and final
completion of this scholarly paper. Firstly, to a wonderful and knowledgeable
committee, specifically Dr. Kathleen Swanick and Dr. Stephen Black, who
provided me with great insight and inspiration as I began to narrow the focus of
my Independent Study, and with finalizing this paper, I sincerely thank you. I also
would like to thank Gaynell Anderson and Andy Hovanec who were the case
patients primary PT’s they provided all the information for the case and
encouragement to pursue the idea for the paper. Finally, the greatest amount of
appreciation and thanks goes to Todd Mortenson, my husband, Logan
Mortenson, Colin Mortenson, and Justin Mortenson, my sons for always being
there for me, encouraging me to pursue my dreams and for putting up with me as
I underwent this great undertaking in the development of this paper. I cannot
thank you enough for providing me with the love and support I needed to achieve
my dreams.
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Table of Contents
Abstract 3
Background and Purpose 5
Review of Literature 10
Case Description 11
Test and Measures 12
Differential Diagnosis Screening 12
Observation 12
Cardiovascular Screening 13
Neurological Testing 13
Strength Testing 14
Active Range of Motion 14
Palpation 15
Pain intensity Level 15
Functional Screen 16
Special Tests – Trendelenberg Test 16
Evaluation 17
Interventions 18
Results 20
Discussion 22
Study Limitations 24
Conclusions 25
References 26
Effects of an Aquatic Therapy Program
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APPENDIX A – Home Exercise Program 31
APPENDIX B – Interventions 32
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Abstract
Background and Purpose: According to the Centers for Disease Control
and Prevention (CDC) Osteoarthritis (OA) is the most common form of arthritis, it
affects 33.6% of adults aged 65 and older an estimated 26.9 million adults in the
US in 2005, which is up from 21 million in 1990. Eighty-eight out of ten thousand
of these patients will suffer from hip OA leading to hospitalizations and potentially
hip replacement procedures. Patients suffering from OA who have opted to have
a total hip replacement may present with barriers to conventional land based
therapy due to inability to bear full weight on the affected extremity. Evidence
has shown that aquatic therapy is a good initial intervention for THA patients.
The unique qualities of water make it well matched for patients who are unable to
exercise on land, or find land-based activity too demanding. Aquatic therapy
provides an alternative strategy (Batterham, Heywood & Keating, 2011). Case
Description: The purpose of this case study is to describe the evaluation,
intervention, and outcome of a patient following a THA with 3 subsequent
revision surgeries who successfully participated in an aquatic therapy program.
The patient is a 54-year-old male referred to physical therapy following a THA
and 3 revision surgeries resulting in impaired gait positive Trendelenberg,
impaired balance, and overall decrease in functional mobility and subjective pain
stated 10/10 at worst and average of 6/10. The aquatic therapy sessions were
three times per week for the initial 4 weeks then the patient was progressed to
land based therapy for an additional 8 weeks. Results: The aquatic program
included progressive strengthening, gait training, and balance activities. After
Effects of an Aquatic Therapy Program
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three weeks, the patient reported a significant decrease in subjective pain levels
and demonstrated increased static standing balance with improved hip
stabilization. He also demonstrated improved strength, increased weight bearing
tolerance, and increased functional mobility. Demonstrated by manual muscle
testing, improved activities of daily living, and subjective increased functional
mobility. Conclusions: This case report advocates that aquatic therapy may be
valuable for patients with impaired weight bearing tolerance that would not be
able to progress with land therapy or are unable to tolerate land activities...
Effects of an Aquatic Therapy Program
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Background and Purpose
Total hip arthroplasty (THA) procedures are one of the most common and
successful orthopedic surgeries for patients suffering from osteoarthritis (Passias
& Bono 2006). Approximately 1-3% of the senior adult population will elect to
have a THA at some point making it one of the most prevalent elective
orthopedic surgeries (Passias & Bono 2006). Most frequently reported
complications following THA include dislocation, pulmonary embolism and deep
infection. These complications are highest immediately following surgery
however; they continue to rise over the first three months post surgery (Phillips et
al., 2003). The economic burden of arthroplasty revision has yet to be
systematically studied however it is considered to be substantial and if the
incidence of revision surgeries is not controlled it will likely continue to increase
(Ong et al., 2006).
Revision surgery can be defined as a procedure in which the exchange of
the acetabular components and/or liner, or the femoral or modular head, or any
combination thereof is involved (Wetters, et.al. 2012). Dislocation is said to be
the most frequent complication following revision of a total hip. A study was done
in 2012 to determine the risk factors involved in dislocation. Possible risk factors
were divided between patient factors and surgery specific factors. Patient factors
included age, sex, BMI, the femoral and acetabular classification, history of
instability prior to revision, number of hip surgeries, and abductor integrity.
Procedure-specific factors included cup diameter of the acetabular, femoral head
diameter, head to cup ratio, length of the femoral neck, use of constrained or
Effects of an Aquatic Therapy Program
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elevated rim liner as well as the type of procedure performed (Wetters et.al.,
2012). Results showed that femoral head size appeared to cause the highest risk
for dislocation along with trochanter nonunion/abductor deficiency, and previous
revision surgeries. Further analysis demonstrated that for patients receiving the
anterior surgical approach BMI was the only risk factor for dislocation (Wetters,
et.al., 2012).
The revision of THA poses a challenge for even the greatest qualified
surgeon. Common indications for THA revision surgeries include loosening of the
implant resulting in pain, infection in the joint, or fracture (Drake, Ace & Maale,
2002). Frequent dislocations often contradict the overall benefit of THA. A
recent study from Hip International showed dislocation rates with the posterior
approach to be 4.1%, while the transgluteal approach was 3.4% (Rogers, Blom,
Barnett, Karantana, & Bannister, 2009). There are many revision strategy
procedures currently being performed.
However, regardless of the method
successful surgery for recurrent dislocation
cannot be guaranteed. Outcomes will
depend on the initial approach used and
the direction in which the dislocation
occurred (Rogers et al., 2009).
There are two standard surgical approaches that are currently used for
THA procedures they include posterolateral approach (P-L) and the anterolateral
approach (A-L) (Madsen et.al. 2004). The P-L approach is the most common
Figure 1 - Posterior Lateral
Approach
Effects of an Aquatic Therapy Program
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approach. This approach affects the posterior
joint capsule the gluteus maximus, which is
separated in line with the fibers, and the
external rotator group (figure 1). The
external rotators (ER) are principally
responsible for stability laterally and
posteriorly. The ER’s are bisected near the
insertion. This method subsequently spares
the gluteus medius and vastus lateralis
muscles (Madsen et.al., 2004). Another
benefit is that a trochanteric osteotomy is
not performed. The main disadvantage in this approach is the high incidence of
joint instability resulting in dislocation or subluxation of the hip (Kisner & Colby,
2007), (Madsen et.al., 2004). Due to the proximity of the sciatic nerve to the
surgical field using the posterolateral approach there is an increased potential of
damage to the sciatic nerve (Lohana, Woodnutt, & Boyce, 2010). he A-L
approach typically affects gluteus minimus, gluteus medius, tensor fasciae latae
and vastus lateralis muscle function. Much of the torque necessary for hip
abduction and pelvic obliquity control during normal gait comes from the gluteus
medius and minimus (Madsen et.al., 2004). The A-L approach has been revealed
to yield more positive Trendelenburg signs (figure 2) (Madsen et. al., 2004). The
anterior lateral approach has gained in popularity in some populations due to the
decreased incidence of dislocations (Palan, Beard, Murray, Andrews & Nolan,
Figure 2 - Positive
Trendelenberg sign
Effects of an Aquatic Therapy Program
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2008). The advantages to the A-L approach include a reduction in leg
discrepancy length, decreased sciatic nerve damage, and dislocation due to
preservation of the posterior hip musculature (Pour, Parvizi, & Rothman, 2005).
In more recent years minimally invasive hip replacement procedure have been
introduced with some controversy in respect to the benefits. However, studies
have shown that these procedures can improve the immediate outcomes in
regard to decreased blood loss, shorter hospitalization and a faster recovery for
the patient (Pour et.al., 2005).
Physical therapy following THA is a significant component in improving
overall functional outcomes of patients. In the acute care phase physical therapy
may decrease the cost of care and accelerate the time to discharge, thereby
decreasing the length of stay in the hospital (Freburger, 2000). Numerous
studies have been conducted to determine discharge destination. One study
done in 2001 looked at 541 patients following THA, total knee replacement or hip
fracture. The research reviewed clinical outcomes and reimbursement for care
either at an inpatient facility (IPR) or skilled nursing facility (SNF). The
researchers determined that patients admitted to an IPR had shorter lengths of
stay and substantially better functional outcomes than those who were
discharged to SNF. However, the downside to the IPR was that it was
significantly more expensive that the SNF (Herbold, Bonistall & Walsh, 2001,
2011). Regardless of the location of discharge for rehabilitation or the surgical
approach used it is clear that patients require skilled rehabilitation following THA
to regain functional abilities.
Effects of an Aquatic Therapy Program
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The principal goals of physical therapy after THA are to reestablish
function, reduce pain, and increase muscle control in order to return the patient
to his/her prior level of function (O’Sullivan & Schmitz, 2007). Standard initial
physical interventions include therapeutic exercise, gait and transfer training and
ADL instruction and precaution education. A targeted strengthening program in
the postoperative rehabilitation period has shown to be effective in improving
muscle atrophy and weakness in the affected lower extremity (Galea et.al.,
2008). In order to improve gait and decrease pelvic drop during the swing phase
of gait the rehabilitation should include hip abduction specific strengthening
(Madsen et.al., 2004).
Aquatic therapy is a good initial rehabilitation intervention for THA
patients. Water offers unique properties that make it well matched for
rehabilitation of a variety of disorders. These properties include: buoyancy,
resistance, hydrostatic pressure, specific heat, and thermal conductivity
(Cameron, M.H., 2009). The buoyancy effects in particular allows for decreased
weight bearing, off loading joint compressive forces and relieving stress on
connective tissues which provides benefits to patients in the early stages of
rehabilitation and provides gradual transition from non weight bearing to full
weight bearing. When patients are unable to exercise on land, or find land based
activities too demanding, aquatic therapy programs provide an alternative
strategy (Batterham, Heywood & Keating, 2011). Recent evidence shows there is
an increase in skin blood flow to the affected tissues due to the moisture content
Effects of an Aquatic Therapy Program
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of the heat of the water as it interacts with the tissue leading to faster healing
(Petrofsky et.al., 2010).
Review of Literature
A review of the literature demonstrates that aquatic therapy has shown to
be an effective treatment for patients with a variety of conditions such as
osteoarthritis, balance deficits, musculoskeletal conditions, and post-surgical joint
replacement rehabilitation. Many researchers have sought to show that there is a
significant benefit to aquatic based therapy over land-based therapies.
However, most research has been unable to show a difference between the two
interventions.
Studies reviewed comparing aquatic therapy to land based therapy using
outcome measures such as pain, flexibility, and strength did not exhibit
statistically significant difference between the therapies. However, aquatic
therapy was found to have fewer adverse effects on patients (Lund et al., 2008).
One study used a two group randomized control. They chose 38 subjects from a
local community and assigned them to either a 12-week aquatic program, a land
based therapy group, or a non-exercise control condition. The results showed
that the aquatic exercise had statistically significant improvement in knee
flexibility, strength, and aerobic fitness. However, it did not show improvements in
function or pain (Wang, Belza, Thompson, Whitney & Bennett, 2006).
Another study showed that both land and aquatic therapies showed
improvements in quality of life, knee range of motion, and reducing pain.
However, aquatic therapy was not superior to land therapy when it came to
Effects of an Aquatic Therapy Program
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reducing pain (Wang et al. 2011). A third study however, showed that even
though there were no clinical benefits detected when compared with the control
group, there were significantly fewer adverse effects when compared with the
land therapy group (Lund et al., 2008). Aquatic therapy appears to provide short-
term benefits for patients with knee of hip OA suggesting it as a viable initial
treatment option particularly with patients with severe disease (Hammer, Naylor,
Crosbie & Russell, 2009). Aquatic programs are expensive and potentially labor
intensive. However, the benefits to the patients, and potential for business
diversification can make an aquatic program a successful one.
Case Description
The case patient was a 54-year-old male referred to outpatient physical
therapy five months after undergoing a third revision of his total hip arthroplasty
secondary to anterior dislocation. Following surgery patient was non-weight
bearing for 2 month. Patient reports recent MRI of spine showing signs of lumbar
stenosis. Prior to surgery patient was independent with ambulation, able to work
full time as a financial planner, and golf without any functional limitations pain
free. Patient presented with a chief complaint of inability to ambulate
independently without crutches. Since returning to weight bearing he reports
bilateral buttock and hamstring pain 6/10, which is aggravated with sit to stand
transfers and walking. Alleviating factors include the use of pain medication, and
cold pack as per patients report. He also complains of left plantar foot
numbness, which occurs intermittently with sitting and is alleviated with walking.
Patient has returned to work progressively working part time as tolerated.
Effects of an Aquatic Therapy Program
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Specific occupational requirements as a financial planner include long durations
of sitting and standing. He is independent with self-care utilizing adaptive
equipment for showering. He requires a modified sitting position for dressing and
needs assistance for don/doff socks and shoes. Past medical history includes
spinal stenosis and recent pulmonary embolism. Patient is currently taking
Gabapentin for peripheral neuropathy, tramadol for pain and Xarelto for
pulmonary embolism.
Tests and Measures
Differential Diagnosis Screening
The initial examination included a differential diagnosis consistent with
clinical practice guidelines. A system review was completed including screening
of the cardiopulmonary, neurological and integumentary systems. The screening
was found to be unremarkable for any systemic pathology. The patient was
considered appropriate for physical therapy.
Observation
Following the subjective interview portion of the initial examination
the physical exam was started with a postural assessment including sitting,
standing posture and gait analysis. Patient showed both sitting and standing
postures to be unremarkable. Gait analysis showed the patient ambulated with
an antalgic gait utilizing bilateral crutches demonstrating an alternating gait
pattern. During the initial contact phase of gait the patient displayed right-sided
foot drop. Initial contact also called heel strike occurs when the first limb
contacts the ground. Normal initial contact is with a heel strike however in an
Effects of an Aquatic Therapy Program
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abnormal gait the entire foot may initially make the first contact. Dorsiflexors
muscles weakness, peroneal neuropathy, or a nerve root lesion at L4 can all lead
to foot drop (Magee, 2008). The patients BMI was found to be 31.19 (Obese
Class 1). According to the Center for Disease Control and Prevention anyone
who is overweight is at higher risk for other conditions such as high LDL
cholesterol, high blood pressure and diabetes (Center for Disease Control,
05/04/2011). Also, this puts the patient at risk for dislocation (Wetters, et.al.,
2012).
Cardiovascular Screening
Baseline vital signs were taken at the initial exam. Blood Pressure was
assessed in the sitting position back supported and arm supported at the level of
the heart. It was 128/82 this recording falls within the normal range for adults.
The normal range for adults is systolic 110-130 diastolic 80-90 (Magee, 2008).
Neurological Testing
Bilateral muscle deep tendon reflexes were tested at the patella, tibialis
tendon, and Achilles tendon. The patella and Achilles were rated 2+ (normal)
and the tibialis was diminished, rated 1+. Reflexes are graded on a scale from 0
no response to 4+ being hyperactive. Normal deep tendon reflexes are 2+
(O’Sullivan & Schmitz, 2007). Sensation was assessed using light touch over the
lower extremity dermatomal distribution and found to be intact, however, the
patient complained of intermittent left plantar foot numbness.
Effects of an Aquatic Therapy Program
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Strength Testing
Manual muscle testing was performed to assess gross strength deficits in
the lower extremities. Manual muscle testing is subjective therefore it is accepted
that for conventional reliability the examiner should adhere to the same
procedure for each test (Hislop & Montgomery, 2007). The 0-5 rating scale was
used. Initial and follow up findings are provided in Table 1.
Table 1 - Manual Muscle Testing
Table 1 -Strength Initial Exam Discharge
Right Lower Extremity
Right Lower Extremity
Hip Abduction 2+/5 4/5
Hip Flexion 3-/5 4/5
Hip External Rotation 3-/5 4/5
Knee Flexion 3/5 4+/5
Knee Extension 3/5 4+/5
Dorsiflexion 3-/5 5/5
Platarflexion 4/5 5/5
Gr. Toe Extension 3-/5 5/5
Active Range of Motion
Flexibility of the hamstring muscles was tested by performing the straight
leg raise (SLR). A positive SLR done unilaterally is a sign of possible nerve
entrapment. The SLR can also be performed bilaterally one leg at a time to
assess flexibility and extensibility of the hamstrings as compared bilaterally.
When performing the test the patient’s leg is passively lifted off the table with
knee maintaining full extension and hips remain on the table. Test results for the
Effects of an Aquatic Therapy Program
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case patient we 90 degrees bilaterally, therefore showing no soft tissue limitation.
Dorsiflexion was measured using goniometry and found to be 0 bilaterally.
Palpation
Fascia restrictions were found at the thoracolumbar junction. Tenderness
was discovered at spinal segments of L5-S1, and at the lateral insertion of the
right hamstring. The patient also noted aching over the posterior lower
extremities with a stabbing pain along the lateral border of bilateral thigh and
legs. Patients also noted some numbness over the left anterior thigh. (Figure 3)
Figure 3 – Palpation chart
Pain intensity level
Pain intensity was quantified using a 10-mm visual analogue scale (VAS).
The patient reported a level of 10 at worst, and on average 6 occurring at mid
range squat during sit to stand transfer Figure 4.
Effects of an Aquatic Therapy Program
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Figure 4 – Pain Rating Scale
Functional screening
The patient works as a financial planner but has been unable to return to
work full time since the surgery. Patient is unable to ambulate independently
without bilateral crutches. Patient has difficulty transferring from sit to stand
independently, requiring the use of his upper extremities to initiate movement.
Patient has adapted his activities of daily living and self care by utilizing adaptive
equipment for showering, dressing and don/doff socks and shoes. Patient’s prior
level of function included working full time, golfing with no functional limitations
and pain free. No functional outcome measures were taken at initial examination.
A recent study showed that 50% of physical therapists do not use functional
outcome measure despite much development and testing of its effectiveness
(Jette, Halbert, Iverson, Miceli & Shah, 2009).
Special Tests - Trendelenberg Test
The Trendelenberg sign (Figure 2) is a respected test used to assess the
external rotators of the hip. (Asayama, I., Naito, M., Fujisawa, M., & Kambe, T.,
2002). A positive Trendelenburg sign accompanies gait abnormalities. The test
can be used to determine the condition of the mechanics of hip function. In many
patients with hip dysfunction the pelvis on the non-stance side moves downward
beneath the level of the stance side in comparison to the severity of the abductor
Effects of an Aquatic Therapy Program
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dysfunction (Asayama, et. al., 2002). The test when used to predict a tear of the
gluteus medius is neither sensitive nor specific, however the likelihood ratio is fair
(Cook & Hegedus, 2013). The case patient displayed a positive right
Trendelenberg sign when tested at the initial examination the patient was unable
to perform the single leg stance. The patient’s left side demonstrated hip
instability; patient was able to stand for 2 seconds on the left side.
Evaluation
Findings from the initial examination, the patient in this case report
presented with a primary chief complaint of the inability to ambulate
independently without the use of bilateral crutches. Aquatic therapy decreases
axial loading of the spine and peripheral joints through the effects of buoyancy.
By using the unique properties of water rehabilitation program coupling the
aquatic setting with land-based exercises will provide the patient the desired
outcome of independent ambulation and reduced pain.
Prior to the initiation of any aquatic program it is imperative to question the
patient about potential contraindications to aquatic therapy (Table 2). Preferred
practice pattern: Musculoskeletal H: Impaired joint mobility, motor function,
muscle performance, and ROM associated with joint arthroplasty. The
rehabilitative prognosis considered good potential to reach the established goals.
Effects of an Aquatic Therapy Program
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Table 2 – Contraindications for Aquatic Therapy
Contraindications for Aquatic Therapy
• Fever
• Incontinence of bowel
• Uncovered open wounds, incisions, or skin lesions
• Blistering
• Boils that have the potential to rupture soon
• Any communicable disease
• Skin infections
• Uncontrolled seizures
• Untreated Cardiac conditions
• Intolerance to water pressure, impaired vital capacity
• Acute lung infection
• Catheter or other lines that cannot be clamped off, or covered
• Tracheotomies
• No internal protection during the menstrual cycle
• Excessively high or excessively low blood pressure
• An extreme fear of water
• Patients that show an inappropriate or disruptive behavior that is uncontrolled
Interventions
A plan of care was established for three times per week for 4 weeks. At
the re-evaluation additional visits were recommended. Aquatic sessions were
introduced initially followed by land-based therapy. Early goals included reduction
of swelling reduce pain, offload the joints and facilitate comfortable correct
biomechanical ROM training. According to a study with 71 subjects randomly
chosen for a six-week aquatic therapy program the results showed decreased
pain and joint stiffness, greater physical function and increased hip strength
(Hinman & Heywood, 2007). The water temperature in the pool was maintained
at approximately 90 degrees. Research shows that aquatic exercise can be
performed in a wide range of temperatures however; warmer temperatures
appear to be more favorable for nonswimming activities (Becker & Cole, 2003).
Effects of an Aquatic Therapy Program
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According to the American Arthritis foundation water temperatures between 83
and 92 degrees are ideal and are a safe range for patients with arthritis and up to
100 degrees for patients with cardiovascular concerns (Arthritis Foundation). The
pool depth was up to the patient’s xiphoid thus providing joint off loading of
approximately 67%. The sessions were guided by a physical therapist with
experience in aquatic therapy.
Aquatic therapy interventions were initiated at the second visit. The
aquatic portion of the rehabilitation focused on decreasing pain and introducing
exercises that improved hip girdle strength, muscle control, core stabilization and
gait training. Each session consisted of a 5-minute warm-up period that included
walking forward and backward. Aquatic walking provides resistance as the
patient walks through the water. Studies have shown that walking in the water
burns more calories than water jogging (Melillo, 1991). Patient was instructed to
roll from heel to toe going forward and toe to heel moving backward to engage
the pelvic and core stabilizing musculature. Backward walking as compared to
forward walking can result in significantly higher muscle activation (Masumoto &
Mercer, 2008). Side stepping and heel raises were also included in the aquatic
program. Patient was given a home exercise program consisting of land based
supine exercises including bridging, supine marching and lumbar rotation
exercises. (Appendix A) As the patient progressed balance activities were also
incorporated. A study done in 2000 compared 24 women with lower extremity
arthritis either Rheumatoid or osteoarthritis. Subjects were randomly assigned to
an aquatic therapy group or a control group. Pretest and posttests were done to
Effects of an Aquatic Therapy Program
20
assess postural sway before and after a six-week program. Results showed that
the aquatic therapy group significantly reduced lateral sway and total sway
scores. Scores were higher under the no-vision condition than under the vision
condition in each group for both sessions (Suomi & Koceja 2000). Improving
balance has also been linked to improved psychological benefits (Colcombe &
Kramer, 2003). Balance activities included progression of narrow stance coupled
with upper extremity motions to challenge the core stabilizers.
At 3 weeks the patients reported subjective pain levels had significantly
decreased with patient also reporting that he felt much stronger since starting PT.
Land-based therapy began with therapeutic exercise including upright bike, total
gym mini squats, and heel raises, and hamstring curls and 4-inch step-ups
forward. Verbal cueing was given to engage gluteal and quadriceps muscles.
Exercises were progressed to include standing marches, sidestepping at cables;
hip abduction resistance training, marching on blue foam, and outside ambulation
among other exercises and progressed accordingly as patient strength
progressed (Appendix B).
Results
Patient adherence was 100% with the patient completing 25 visits none
missed. Upon discharge patient reported only occasional soreness in posterior
thigh mainly in the morning. Patient’s strength in lower extremities has improved
significantly right hip abduction strength improved by 67%, hip flexion 44%,
extension 44%, knee flexion 40%, extension 40%. Dorsiflexion improved by 55%
and great toe extension improved by 55% (Table 3). Patient reports ambulating
Effects of an Aquatic Therapy Program
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independently without a cane 100% of the time this is progressed from the
patient needing to use bilateral crutches to ambulate. Sit to stand transfers have
improved to maximum level of function independently without upper extremity
use. Activities of daily living and occupational activities have improved to 90% of
prior level of function. Patient demonstrated increased walking tolerance and the
ability to walk and stand for longer periods of time before fatigue. Trendelenberg
sign is negative bilaterally patients able to perform single leg stance right side for
8 seconds, left side for 14 seconds. Patient was discharged to the land and
aquatic HEP with excellent adherence.
Initial Exam
Discharge
Table 3 - Strength Comparison of Right Lower Extremity Initial exam to Discharge
Effects of an Aquatic Therapy Program
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Discussion
Initiation of the rehabilitation program with aquatic therapy allowed the
patient to fully benefit from the therapeutic effects of buoyancy, hydrostatic
pressure and viscosity. Buoyancy decreases weight bearing and joint
compression forces along with decreasing the risk or fear of falling. The property
of hydrostatic pressure supports the resolution of edema, helps to
counterbalance blood pooling in the lower extremities, and aids in the
strengthening of the muscles of inspiration and assists with exhalation. Viscosity
provides resistance to movement and increases with speed. This property gives
the patient more response time to counteract for balance or equilibrium deficits
(Schoedinger, 2002).
The findings in this case report indicate that a 12-week program
combining aquatic and land based therapy is beneficial in improving pain levels,
strength, mobility, and functional outcomes. Objective measurements such as
increased strength ratings, increased single leg stance time and negative
Trendelenberg sign show evidence of significant improvement.
Upon discharge the patient reported decreased subjective pain response
to mobility at 1/10, as compared to levels reported at the initial evaluation when
the patient reported average pain to be 6/10 and 10/10 at its worst. A study by
Hinman, Heywood, and Day found that compared with the control group which
received no therapy, a 6-week program of aquatic physical therapy resulted in
significantly less pain. Although, it is undistinguishable whether the benefits were
Effects of an Aquatic Therapy Program
23
causal to effects of the intervention or a placebo response (Hinman, Heywood &
Day, 2007).
In the 3-month time period the patient showed increased strength
measures in both lower extremities. The patient went from a 2+/5 manual muscle
testing in his right hip abduction to a 4/5 rating which is considered “good” the
improvement is 67% from the initial evaluation. It has been theorized that the
primary function of the gluteus minimus and medius is to act as the prime femoral
head and pelvis stabilizer (Levangie & Norkin, 2011). The patient’s gait was also
improved. At the initial evaluation they patient was unable to ambulate
independently without bilateral crutches this was due to extreme hip abductor
muscle weakness causing the pelvis to drop to the unsupported side. Prolonged
gait abnormalities can lead to knee, ankle and foot problems as well (Levangie &
Norkin, 2011).
The case patient attending all of his scheduled visits demonstrated
adherence in the program. A study by Resnick and Spellbring showed that there
are 6 main factors that affect adherence in adults to improve rehabilitation. The 6
factors are 1) beliefs about exercise; 2) benefits of exercise; 3) past experiences
with exercise; 4) goals; 5) personality; and 6) unpleasant sensations associated
with exercise (2000). To promote our patient’s adherence we discussed the
benefits of exercise. He was a believer in exercise and his goal was to improve
his lower body strength to be able to return to his previous level of function. Our
case patient also loved to play golf, so we came up with an exercise program that
incorporated lower extremity strengthening and activities that would enhance his
Effects of an Aquatic Therapy Program
24
golf game. We used our client’s goals to tailor an exercise program that was
specific for him. The case patient also has a great social support network with his
family, which helped to enhance his rehabilitation.
Study Limitations
Although this case study obtained relevant objective findings there were
some limitations to be considered when interpreting the results and making
assumptions. The study was lacking the use of outcome measures. A study was
done in 2009 to determine the extent of using standardized outcome measures in
outpatient clinics and the opinions regarding the benefits and difficulties of their
use by therapists (Jette et.al., 2009). The researchers found that more than 50%
of the respondents in the study reported that they do not use the standard
outcome measures. The most common response was that they were not familiar
with the measures or that they did not feel they had sufficient time to complete
the testing (Jette et. al., 2009).
Self-reporting outcome measures such as the Lower Extremity Functional
Scale (LEFS) can be a convenient way to track improvement. The patient is
asked a series of questions regarding their activities of daily living and the degree
of difficulty. Patients rate the difficulty on a scale of 0-4 with 4 being no difficulty
and 0 being extremely difficult. Scores are figured the higher the score the better
the function of the patient. Internal reliability of the LEFS test is excellent, and
validity is comparable to the SF-36. The limitations in using self-reporting
questionnaires to measure the outcomes include self-reporting may be
inaccurate if the patient does not fully understand the questions. As well as
Effects of an Aquatic Therapy Program
25
adherence and subjective information may be over-estimated or under-
estimated. The case patient likely would have showed significant improvements
in regard to his activities of daily living however.
In this particular case patient scenario the use of the Dynamic Gait Index
(DGI) may have enhanced the overall outcome by demonstrating significant
improvement before and after rehabilitation. The DGI is used to assess an
individual’s ability to modify balance when presented with external demands. It is
specifically designed to assess postural control during gait. The test includes 8
gait activities. The results determine risk of falling. Interrater/Intrarater reliability
is excellent as well as concurrent validity (Jonsson et. al., 2011). It is likely the
case patient would not have been able to perform most of the test prior to
therapy but would have made significant improvements following the 12-week
therapy program. It is unclear why the patients did not begin lateral step-ups
upon his initial treatment of land-based therapy. However, following that initial
land treatment a focus on hip abduction strength was implemented and
progressed throughout. It may have been beneficial for the patient to combine
aquatic and land based activities.
Conclusion
In conclusion, the results in this case report indicate that physical therapy
interventions consisting of an aquatic and land-based therapy exercise program
positively impacts decreased pain, strength, and functional measures.
Effects of an Aquatic Therapy Program
26
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Appendix A – Home exercise program
Supine marching
Supine Bridging
Supine Lumbar Rotation
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Appendix B - Interventions
Intervention week 1 – Aquatic
• Forward Walk
• Backward Walk
• Weight shift gluteal isometrics
• Side step
• March (hip flexion to approx. 60 degrees
• Heel raises with gluteal squeeze
• Corner cycle
• Conclude with cold pack and e-stim to R hip and low back Intervention week 2 – Aquatic
• Forward walk focus on heel strike
• Backward walk
• Weight shift gluteal isometrics
• Side stepping
• March to approximately 60 degrees of hip flexion
• Heel raises with gluteal squeeze
• Balance challenge shoulder horizontal abd/add verbal cues for gluteal squeeze
• Balance challenge shoulder horizontal abd/add with staggered stance
• Mini squats
• Deep-water exercises o Leg scissoring abd/add o Leg scissoring flex ext. o Corner cycle
• Conclude with cold pack and e-stim. To R hip and low back Intervention week 3 – Initiation of land based program
• Upright Bike 5 minutes
• Standing Calf Stretch
• Total Gym mini squats with yellow Spoband around knees
• Total Gym heel raises
• Total Gym march with verbal cueing to stabilize using gluteal and quadriceps
• Hamstring curls concentric /eccentric
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• Forward and lateral step-ups to 4-inch step verbal cueing to engage gluteal musculature
Interventions – Progression of Land program re-evaluation 4 weeks
• Upright bike 6 minutes
• Standing Calf Stretch
• Total Gym mini squats with yellow Spoband around knees 3x15
• Total Gym heel raises 3x10 level 2
• Total Gym march with verbal cueing to stabilize using gluteal and quadriceps 2x20
• Hamstring curls concentric /eccentric 3x10.
• Stand march with cane
• Ambulation gait training 2x around gym with standard cane left hand Interventions - Progressed of Land program re-evaluation at 8 weeks
• Upright bike 6 minutes
• Hamstring curls concentric /eccentric 3x10
• Stand march with cane
• Side step at cable 6 each direction
• Forward/ backward walk cables 5x
• Backward/forward walk cables 5x
• Hip abduction 2x10
• Sit to Stand 10x
• March on blue foam 2x10 verbal cues to stabilize gluteal muscles Interventions – At Discharge 12 weeks
• Hamstring curls concentric /eccentric 3x10
• Side step at cable 6 each direction
• Forward/ backward walk cables 5x
• Backward/forward walk cables 5x
• Hip abduction 2x10
• Sit to Stand 10x
• March on blue foam 2x10 verbal cues to stabilize gluteal muscles
• Cable march 5kg 10 steps x2
• Side step over cups on green foam 3 minutes
• Side shuffle with green spoband around knees
• Cable down swing focusing on engaging abdominal muscles 2 x15