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What is the scientific definition of Aquatic (physical) Therapy?
There are several organisations which concern themselves wiht Aquatic Therapy and propose broadly similar definitions for Aquatic Therapy:
“Aquatic (Physical) Therapy is a programme, using mechanical and thermal characteristics of water during partial or complete immersion, in combination with the effects of movement. It evokes short-term and long-term adaptational mechanisms of a person with a deranged biological system, using specific stimuli to create biological and thus therapeutic effects.” (source: Dutch Centre of Allied Health Care (NPi))
“A therapy programme utilising the properties of water, designed by a suitably qualified physiotherapist specifically for an individual to improve function, carried out by appropriately trained personnel, ideally in a purpose built, and suitably heated hydrotherapy pool.” (source: 2008 Aquatic Therapy Association of Chartered Physiotherapists (ATACP))
“Aquatic physiotherapy is physiotherapy which uses more than one of the unique properties of water for therapeutic rehabilitation.”. (source: 2009 South-African Aquatic Physiotherapy Group (AQPG))
“Aquatic Physiotherapy” refers to the special practice of physiotherapy, with therapeutic intent toward the rehabilitation or attainment of specific physical and functional goals of individuals using the medium of water. It differs from the more generic term “hydrotherapy” which connotes any water-based therapy conducted by an array of professional specialties, including immersion in warm water, immersion in mineralized water ( balneotherapy and spa therapy), immersion in mechanically turbulent warm water (spa therapy), application of pressurized water to the external body (whirlpool), application of warm water into the colon (colonic irrigation), the application of water of various temperatures and pressures via showers and towels (Kneipp therapy), and movement-based therapy in water (hydrokinesiotherapy). “Aquatic therapy” similarly refers to water-based activity of therapeutic intent, is common among American literature, and includes the practice of e.g. physical therapists, exercise therapists, nurses and exercise instructors. “Aquatic exercise” has the intention of fitness training in both healthy and symptomatic individuals, and “water exercise” is its synonym.” (source: Jenny Geytenbeek, author of the Aquatic Physiotherapy Evidence-Based Practice Guide (2008), published by the National Aquatic Physiotherapy Group of the Australian Physiotherapy Association)
Accepted positive effects of Aquatic (physical) Therapy
Aquatic Physical Therapy can be applied at all three dimensions of the International Classification of Functioning, Disability and Health (World Health Organisation, 2001). A fourth dimension is Quality of Life, also an important goal in Aquatic Physical Therapy.
Aquatic Physical Therapy might also be supportive in treating some of the modern life-style conditions as well. A special issue of Physiotherapy Theory and Practice titled ‘Physiotherapy practice in the 21st century: a new evidence-informed paradigm and implications’, identified topics like nutrition and weight control, sustainability of physical activity and exercise, management of sleep disturbance and undue life stress. Evidence is still scarce, but issues like obesitas (Nagle 2007), adherence (Kang 2007), management of sleeping patterns (Vitorino 2006) and stress reduction (Bood 2009) have been addressed in aquatic literature, see also the chapter of the physiology of immersion and the autonomic nervous system.
Aquatic physical therapy exercise
Aquatic Physical Therapy has a large focus on exercise in water which can include the following used in isolation or in combination:
- Balance training
- Strengthening and stabilising
- Cardiovascular conditioning
- Adapted swimming
- Flexibility or exercises for range of movement
Aquatic exercise is prescribed specifically for the participant following an assessment to identify main problems and includes the integration of evidence based practice along with shared goal setting. Specificity with exercise prescription remains a high priority along with further considering dose response to aquatic physical therapy. Focus must continue on outcome measures for measuring effectiveness and objective measures to improve accuracy of estimating load. Examples are a metronome or music for speed and resistance from turbulence, volume of floatation for buoyancy resisted exercise, repetitions and sets and measures of cardiovascular load. The use of outcome measures and objective measures will facilitate the transition from practice to research and vice versa. Nearly all aquatic approaches and exercises offer direct benefits to stabilising or strengthening. Resistance training in aquatic physiotherapy can have excellent outcomes. Clear protocols with progressive load, understanding the physics of the environment and measuring forces is important.
The aquatic environment is ideal for cardiovascular training not only for sporting populations or basic musculoskeletal rehabilitation but also in chronic conditions with support documented in patients with Rheumatoid Arthritis (Hall et al 2004), chronic low back pain (Barker et al 2003) and stroke (Driver et al 2004). The nature of any chronic condition is often reduced mobility and subsequently reduced VO2 max. With continuing research into this area, consideration should be given in all chronic patients to planning part of each session to address improving their VO2 max. The aquatic environment can be an exercise medium safe from falls or injury, it can also be highly challenging more at the edge of balance limits including practice in single limb stance. Larger movements of the centre of gravity, limbs and trunk are therapeutically useful but it is unclear if any influence on the fear of falling. Balance is specific to the environment and the task but aquatic programs have shown carryover into land based measures.
Adapted swimming covers all strokes that may be in some way modified. Adapted swimming offers not only a cardiovascular training, musculoskeletal challenge in terms of endurance and range of movement but most importantly it offers so much with regard to participation.
The physiology of immersion and the autonomic nervous system
The physiological changes upon immersion in thermoneutral water are well documented including the blood volume shift from the periphery to the central circulation due to hydrostatic pressure (Hall 1990, Becker 2009). The impact of increased stroke volume and cardiac output and reduced heart rate in addition to lung volume changes appears clinically well tolerated and beneficial but needs further investigation in chronic populations for general fitness or rehabilitation following a cardiac event or with pulmonary rehabilitation. The autonomic nervous system is made up of two opposing branches, the sympathetic (ergotropic / fight or flight) component and the parasympathetic (trophotropic / relaxation and recharging) component. Many chronic disease states have autonomic system changes or an imbalance between the two components. Increased sympathetic nervous system activity has been associated with cardiac dysfunction and autonomic imbalance is likely to also have a significant impact during and after prolonged periods of stress and influence mental health. The mechanisms of autonomic nervous system function are complex and the exact influences leading to reduced sympathetic nervous system activity when immersed are unknown. This area of research may help to further understand some physical and mental or emotional health interrelationships with immersion leading to a similar response to relaxation or meditation.