REVIEW OF LITERATURE

PRESENTED BY
PANKTI A. PATEL
MPT 1 st YEAR
DEPARTMENT OF ORTHOPAEDIC PHYSIOTHERAPY
AQUATIC THERAPY IN LOWER LIMB
ORTHOPAEDIC CONDITION
CONTENTS
Definition
Indications
Contraindications
Properties of Water
Precautions
Pools for aquatic exercises
Aquatic Equipments
Techniques
Aquatic Exercises
References
DEFINITION
 Aquatic exercise refers to use of water that
facilitates the application of established therapeutic
interventions.
INDICATIONS
 To facilitate ROM exercise
 To initiate resistance training
 To facilitate weight bearing activities
 To facilitate cardiovascular exercise
 To initiate functional activity
 3- dimensional access to the patient
 Manual techniques
 Patient relaxation
 Risk of injury
CONTRAINDICATIONS
 Cardiac failure and unstable angina
 Respiratory dysfunction
 Severe peripheral vascular disease
 Bleeding or hemorrhage
 Severe kidney disease
 Open wound
 Uncontrolled bowel or bladder
 Menstruations
 Water and airborne infections or disease
 Uncontrolled seizures during the last year
PRECAUTIONS
 Fear of water
 Neurological disorder
 Respiratory disorder
 Cardiac dysfunction
 Open wound
PROPERTIES OF WATER
1) Physical properties of water
2) Hydromechanics
3) Thermodynamics
4) Center of Buoyancy
1) Physical properties of water :-

 Buoyancy:-
 Archimedes Principle
 Clinical significance :
 Hydrostatic Pressure:
 Pascal’s law
 Clinical significance:

 Viscosity:
 Properties: Resistance from viscosity α velocity of
movement
 Clinical significance:
 Surface Tension:
 Properties:
 Clinical Significance:
2) Hydromechanics:-
Hydromechanics comprises the physical properties and
characteristics of fluid in motion.
 Components of flow motion:-

o Laminar flow

o Turbulent flow

o Drag
oLaminar flow:
oTurbulent flow:

oDrag:
The
 cumulative effects of turbulence and fluid
viscosity acting on an object in motion.
Clinical Significance:

3) Thermodynamics:-

 Specific Heat:
 Properties
 Clinical Significance:

4) Center of Buoyancy:-
 Center of buoyancy, rather than COG, affect the
body in an aquatic environment.
Properties:
Clinical significance:
POOLS FOR AQUATIC EXERCISE:
o Traditional therapeutic pools:-
 Length- 100 feet, Width- 25 feet.
 Depth 3-4 feet to 9-10 feet.
 Larger type of pool – group ex
 These pools have built in chlorination and filtration
system.
o Individual patient pools:-
 Smaller, self contained units.
 These pools have built in filtration system.
AQUATIC EQIPMENTS
Two types of equipment…
1. Buoyant devices:
 Collars

 Rings

 Buoyant belts

 Buoyant dumbbells

 Ankle cuffs

 Kickboards

 Buoyant vest
2. Drag Resistive Devices:
 Gloves

 Hand Paddles

 Hydro-tone Bells

 Hydro-tone boots

 Pool noodles

 Fins
o Aqua steps

o Treadmill

o Parallel bars
TECHNIQUES
1) Ai Chi

2) Aqua Running

3) The Bad Ragaz Ring Method

4) Burdenko Method

5) Halliwick And Water Specific Method

6) Watsu
1) Ai Chi:-
 Ai chi was developed by Japanese aquatic fitness

practitioner and swimming coach Jun Konno in the

mid 1990s.
 Position

 Movements

 Weight transferred

 Uses
2) Aqua Running:-
 Deep water exercise are used in treatment and conditioning

programs. It consist of running in deep water at end of the pool

aided by flotation device(tether cord)and head will be out of
water.
 No contact with the bottom thus eliminating the weight from

joints and make this an ideal method for conditioning in

injured athlete's.
3) The Bad Ragaz Ring Method:-

It was developed by physiotherapists in Bad

Ragaz, switzerland.
It is a collection of therapeutic techniques.

Uses
4) Burdenko Method:-
 It was developed by Dr. Igor Burdenko.

 Both land and waater

 In this the movements are progressed from simple to

complex.
 Shallow water ex

 Land ex
5) Halliwick And Water Specific Method:-
In 1949 James Mc Millan , introduced new method in teaching

swim. Purpose: To maintain balance and posture in water.

The Ten-Point-Program:

1) Mental adjustment :

2) Disengagement

3) Sagittal rotation control

4) Transversal rotation control

5) Longitudinal rotation control

6) Combined rotation control
7) Upthrust inversion
8) Balance in stillness
9) Turbulent gliding
10) Simple progression and basic swimming movement
6) Watsu:-
It was introduced by Harold dull in 1980 at Harbin hot springs California.

It is a form of aquatic body work in which therapist gently cradles, moves,

stretches and massages the pattern in chest deep warm water.(35º-36ºC)

Technique :

1. Opening
2.Basic moves – water breath dance.
Accordion .
Rotational accordion.
Near leg rotation.
Far Leg Rotation
 It is performed 1 to 1 with the patient totally relaxed and

predominantly in supine position with the therapist in a

wide based stance, supporting with one arm under the
neck and other arm under the hips or knees.
 The patient is also moved into sitting and fetal positions.

 The therapist focus on tuning with the breathing patterns

of patient and movements.

Aquatic rehabilitation for hip conditions:-
oGoal:-
increase the range of motion
Strengthen the lower extremity muscles

Phase I
Phase II
Phase III
Phase IV
HIP STRETCHING EXERCISES:-
HIP STRENGTHENING EXERCISES:-
 Aquatic rehabilitation protocol for conditions of
knee:-
o Goals:-
 To restore the range of motion
 To strengthen the muscles

Phase I
Phase II
Phase III
Phase IV
KNEE STRECHING EXERCISES:-
KNEE STRENGTHENING EXERCISES:-
 TITLE Aquatic exercies for treatment of knee osteoarthritis in elderly people: A randomized
controlled trial

AUTHOR AND Sirous Azizi, Afsaneh Dadarkhan, Zahra Rezasoltani et al.

PUBLICATION Interventional Medicine and Applied Science vol.11 no.2 (2019)
AIM To assess the efficacy of aquatic exercise on pain, gait, and balance among elderly
patients with knee osteoarthritis.

METHOD We performed a randomized controlled trial at a university hospital. Overall, 32 men

with knee osteoarthritis, aged ≥ 60 years, were included. Pain, balance, and gait were
evaluated before and 2 months after interventions. The group control used
acetaminophen and followed lifestyle recommendations. The intervention group
performed the aquatic exercise three sessions per week for 8 weeks.

RESULT At the end of the study, mean pain scores were significantly different between the
groups (p = 0.010). Within-group analyses showed that group intervention experienced
significant pain relief (p = 0.019), whereas group control did not show the significant
change (p = 0.493). There was significant improvement in favor of aquatic exercise with
regard to static (p = 0.001) and dynamic (p = 0.001) balance, step length (p = 0.038),
stride length (p < 0.001), and cadence (p < 0.001). However, we did not find a significant
difference in step time and width between the two groups.

CONCLUSION Aquatic exercise would be beneficial in decreasing subjective pain of osteoarthritis.

There are some recognizable improvements in patients’ gait and balance as well.
 TITLE The short-term effects of hydrotherapy on pain and self-perceived functional status in
individuals living with osteoarthritis of the knee joint

AUTHOR AND Kganetso Sekome,Stacey Maddocks et al.

PUBLICATION South African Journal of physiotherapy vol.75 no.1 (2019)
OBJECTIVE The aim of this study was to determine the effects of a 4-week hydrotherapy programme
on measures of pain and self-perceived functional status in individuals living with knee
OA.

METHOD A total of 18 participants with chronic knee OA participated in this study. Participants
completed 4 weeks of hydrotherapeutic intervention provided by an independent
physiotherapist. Outcome measures for the study included pain assessed using the
visual analogue scale (VAS) and self-perceived functional status using the Western
Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Outcome measures
were assessed at baseline and after the 4 weeks of intervention.

RESULT The 4-week hydrotherapy programme resulted in a significant decrease in pain and a
significant improvement in self-perceived functional status in all participants. There was
a statistically significant mean decrease in VAS scores of 3.72 (± 2.45), p ≤ 0.05, with a
95% confidence interval ranging from 2.506 to 4.938. There was also a statistically
significant mean decrease in WOMAC scores of 29.5 (± 15.51), p ≤ 0.05. with a 95%
confidence interval ranging from 21.788 to 37.212.

CONCLUSION This study demonstrated that a 4-week hydrotherapeutic exercise programme results in
significantly reduced pain and improved self-perceived functional status in individuals
living with knee OA.
 A randomized clinical trial

AUTHOR AND Thorlaf elbies, Wolfgeng hersbang et al.

PUBLICATION South African Journal of physiotherapy vol.93 no.2 pg no. 192-199 (2014)
OBJECTIVE To evaluate if the timing of aquatic therapy influences clinical outcomes after Total Knee
Arthroplasty (TKA) or Total Hip Arthroplasty (THA).

METHOD Two university hospitals, 1 municipal hospital, and 1 rural hospital.

Participants. Patients (N=465) undergoing primary THA (n=280) or TKA (n=185): 156
men, 309 women. Patients were randomly assigned to receive aquatic therapy (pool
exercises aimed at training of proprioception, coordination, and strengthening) after 6
versus 14 days after THA or TKA. Primary outcome was self-reported physical function
as measured by the Western Ontario and McMaster Universities Osteoarthritis
Index (WOMAC) at 3-, 6-, 12-, and 24-months postoperatively. Results were compared
with published thresholds for minimal clinically important improvements. Secondary
outcomes included the Medical Outcomes Study 36-Item Short-Form Health Survey,
Lequesne-Hip/Knee-Score, WOMAC-pain and stiffness scores, and patient satisfaction.

RESULT Baseline characteristics of the 2 groups were similar. Analyzing the total study
population did not result in statistically significant differences at all follow-ups.
However, when performing sub analysis for THA and TKA, opposite effects of early
aquatic therapy were seen between TKA and THA. After TKA all WOMAC subscales
were superior in the early aquatic therapy group, with effect sizes of WOMAC physical
function ranging from .22 to .39. After THA, however, all outcomes were superior in the
late aquatic therapy group, with WOMAC effect sizes ranging from .01 to .19. However,
the differences between treatment groups of these sub analyses were not statistically
significant.

CONCLUSION The result of this study do not support the use of early aquatic therapy after THA. The
timing of physiotherapeutic interventions has to be clearly defined when conducting
studies to evaluate the effect of physiotherapeutic interventions after TKA and THA.
Aquatic exercise therapy protocol of the
ankle and foot for following conditions:
o Goals:-
 Restore the range of motion
 Strengthening of ankle and intrinsic muscles
 Improve balance and co ordination

Phase I
Phase II
Phase III
Phase IV
ANKLE STRETCHING EXERCISES:-
ANKLE STRENGTHENING EXERCISES:-
 TITLE The role of 6-week hydrotherapy and land-based therapy plus ankle taping in a
preseason rehabilitation program for athletes with chronic ankle instability

AUTHOR AND Poonyanat Nualon, Pagamas Piriyaprasarth and Pongsak Yuktanandana 

PUBLICATION Asian Journal of biomedicine vol. 7 no.4 (2018)

AIM AND OBJECTIVE to compare the effect of a 6-week functional rehabilitation program in athletes with chronic
ankle instability between a hydrotherapy plus ankle taping group and a land-based plus ankle
taping group on ankle functional ability, ankle joint position sense and the number of re-
injuries.

METHOD Forty-seven university level athletes with chronic ankle instability and residual symptoms
were randomized into a hydrotherapy group (24 participants) and a land-based group (23
participants). All participants were taped using a heel lock technique at the injured ankle
during the training session. The rehabilitation program included stretching, aerobic exercise,
balance exercise, strengthening exercise, and skill training using an aquatic or land-based
environment according to the group for 6 weeks. A single-limb hopping test and ankle joint
position sense were measured at baseline, 6 weeks, and 3 months. Recurrent ankle injuries
were also recorded.

RESULT In the hydrotherapy group, the time taken in the single-limb hopping test significantly
decreased immediately after exercise and at the follow up compared with baseline (p =
0.001). In the land-based group, time taken in the single-limb hopping test significantly
decreased at 3 months follow up compared with baseline (p = 0.05). No significant
differences were detected between groups in ankle joint position sense and the number of
recurrent ankle sprains. All participants returned to their athletic activity and competition.

CONCLUSION The combined rehabilitation program of ankle taping, land-based exercise and/or
hydrotherapy could be recommended for clinical uses in athletes with chronic ankle
instability.
REFERENCES
 Carolyn kisner, Lynn allen colby: Therapeutic exercise, 6 th
edition.
  Richard G. Ruoti, David M. Morris, Andrew J. Cole :
Aquatic rehabilitation.
 Azizi S, Dadarkhah A, Rezasoltani Z, Raeissadat SA,
Mofrad RK, Najafi S. Randomized controlled trial of
aquatic exercise for treatment of knee osteoarthritis in
elderly people. Interventional Medicine and Applied
Science. 2019 Oct 7:1-7.
 Sekome K, Maddocks S. The short-term effects of
hydrotherapy on pain and self-perceived functional status
in individuals living with osteoarthritis of the knee joint.
The South African Journal of Physiotherapy. 2019;75(1).
 Goehring M, Bergmooser AB, Decker KJ, Mason NR.
The Effectiveness of Aquatic Therapy Following Total
Hip or Total Knee Arthroplasty: A Systematic Review.
 Holmes A, Delahunt E, Kaminski TW, Hertel J, Amendola
N. The role of 6-week hydrotherapy and land-based
therapy plus ankle taping in a preseason rehabilitation
program for athletes with chronic ankle instability.
THANK YOU