Aquatic Therapy in the Management of Chronic Low Back Pain

Chronic Low Back Pain

Chronic low back pain (CLBP) refers to pain that persisted for longer than 3 months, even after an initial injury or underlying cause of acute low back pain has been treated. It can further classify into two main types according to whether there is a specific pathology behind the LBP.

Non-specific LBP is defined as ‘Pain, tension, soreness and/or stiffness in the low back region between the lower margin of the 12^th ribs and the gluteal folds that is not attributed to any recognisable pathology.’ NSLBP affects approximately 90% of all patients with LBP which is a diagnosis based on the exclusion of particular pathology. These pathologies can be classified as follow:

• Disc herniation
• Spondylolisthesis
• Lumbar muscles or spinal ligament strain/ sprain
• Scoliosis
• Osteoporosis
• Scoliosis
• Ankylosing spondylitis
• Cauda equina syndrome
• Scheuermans disease

Lower back pain classification by duration:

Acute low back pain- 6 weeks or less

Sub-acute low back pain- 7-12 weeks

Chronic low back pain- More than 12 weeks

Epidemiology

Low back pain affects around one-third of the UK adult each year and is the leading cause of disability in the UK. Of these, around 20% will consult their GP about their back pain. Approximately 5.5 million people are estimated to have chronic LBP in Egland and around 20% individual affected by acute lo back pain develop into chronic low back pain.

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Anatomical relevant

The lumbar spine consists of 5, movable relative to each other, lumbar vertebrae (L1-L5). They are the largest segments of the vertebral column, because it supports greater weight of the body against gravity, as compared to the thoracic or cervical region. Each lumbar vertebra consists of a vertebral body, a vertebral arch and a processus spinosus, a processes transversi and facets joints.

Prognostic indicator

The importance of prognostic factors

1. By determining which variables are prognostic outcomes, clinicians gain insight on the biology and natural of the disease
2. Appropriate treatment strategies may be optimised based on the prognostic factor
3. Prognostic factors are often used in the design, conduct and analysis of clinical trials
4. Patient and their families are informed about the risk of recurrence or future development of the disease.

Prognostic indicators for poor outcomes in chronic low back pain

• Age
• Gender
• Working status (active/ not working)
• Referred leg pain (yes/ no)
• NSLBP pain medication (yes/no)
• Current episode duration (acute/ sub-acute/ chronic)
• Maladaptive psychosocial factors
• Current pain intensity
• Disability
• HRQoL

Aquatic Therapy

What is Aquatic Therapy?

Aquatic therapy can be defined as “A physiotherapy programme utilising the properties of water, designed by a suitably qualified physiotherapist” (The ATACP, n.d).  This treatment method involves various exercises in water which should be carried out by appropriately trained therapists in a heated, purpose-built hydrotherapy pool.

Group Aquatic Therapy Session

The use of aquatic therapy is popular amongst patients with musculoskeletal and neurological disorders (Castro-Sánchez et al., 2011). Patients report benefits of increased strength, flexibility, mobility, as well as decreased pain levels (Larmer, Kersten and Dangan Bsc, 2014). These benefits are resultant of the unique properties of water, and therefore cannot always be replicated through land-based exercise.

Unique Properties of Water

Water Density

The water density counterbalances the effect of gravity which allows the human body to float. This buoyancy effect allows for reduced impact on joints. This is valuable during rehabilitation as it allows patients who are experiencing pain to exercise with reduced loading through the joints. Additionally, this buoyancy effect controls the downwards movement of the body and therefore decreases the need for eccentric control.

Exercises such as walking, jogging or running which may be painful to patients, can therefore be performed in water with less impact on the joint and therefore less pain.

What this means for spinal patients?

- Reduces axial loading and joint stress on the spine

Natural Resistance of Water

Water has a natural resistance as a result of its density and viscosity. This allows for effective strengthening during rehabilitation treatment sessions. The intensity of the resistance can be manipulated as well to fit the individual needs of the patient. Altering depth of submergence, speed of exercises performed, and the surface area of the body can affect the resistance profile of the water. For example, when stationary there is less resistance from the water on the body. However, during high speed movements, the resistance from the water will increase. Therefore, high speed resistance training can be performed in water allowing for strength to be built with low impact on the joints. As a result, aquatic therapy can be used as an alternative to land-based strength exercises.

Water as a Compressor

When a patient is submerged in water, they are subjected to hydrostatic pressure. This pressure has resultant effects on the body. For example, increased blood flow and circulation. This allows for greater oxygen delivery to the muscles and relaxation. Hydrostatic pressure can also compress the chest wall which alters pulmonary function and respiratory dynamics. As a result, work of breathing is increased by around 60% compared to that on land. This can actually strengthen respiratory muscles and improve the aerobic fitness of individuals.

Temperature

Hydrotherapy pools are usually heated to between 32-28 degrees Celsius. When submerged, this warm pool temperature can increase blood flow and range of motion. It can also produce greater muscle elasticity which can be beneficial for patients experiencing tightness of the muscles, stiffness or spasticity.

Indications, Contraindications and Precautions to Aquatic Therapy

Indications

• Management of muscle tone problems
• Decreased range of movement
• Decreased muscle strength
• Reduced balance
• Joint instability
• Pain
• Gait re-education
• Decreased sensation
• Neurological patients
• Patients who are willing to self-manage through a water-based exercise programme which they can continue with in pools available in leisure centres
• Patients who would benefit from aquatic physiotherapy in the short term to then progress to land-based exercise when ready

This would include conditions such as:

• Fibromyalgia

• Hemiplegia
• Cerebral palsy
• Ankylosing spondylitis
• Juvenile idiopathic arthritis
• Parkinson’s Disease
• Obesity
• Chronic low back pain
• Multiple sclerosis
• Traumatic brain injuries
• Stroke
• Rheumatoid arthritis

Contraindications

Absolute Contraindications

• Patients with the following are not suitable to receive aquatic physiotherapy:
• Acute systemic illness/pyrexia
• Acute vomiting or diarrhoea
• Medical instability following an acute episode e.g. CVA, DVT
• Chlorine or bromine allergy
• Resting angina
• Shortness of breath at rest
• Uncontrolled cardiac failure
• Open infected wounds

Relative Contraindications

• Known aneurysm
• Poorly controlled epilepsy
• Open wounds
• Thyroid deficiency
• Neutropenia
• Weight in excess of evacuation equipment limit
• Oxygen dependency
• Unstable diabetes – blood sugar may drop

Precautions

• Incontinence of urine/faeces
• Epilepsy
• Hypotension
• Renal failure
• Poor skin integrity
• Risk of aspiration
• Prone to blackouts
• Sickle cell anaemia
• Tracheostomy
• Fear of water
• Pregnancy is water temperature exceeds 35°C
• Low calorie intake

Equipment used in Aquatic Therapy

Resistance Aids

• Flippers/fins
• Aquatic Dumbbells
• Wrist and Ankle Weights
• Submersible Steps

Floatation Aids

• Pool Noodles
• Aqua round body support
• Floatation Belts
• Arm Bands
• Kick boards
• Aqua Plinth
• Sensafloat

Underwater Treadmill

Cardiovascular Equipment

• Underwater Treadmill
• Underwater Stationary bike

Benefits of Aquatic physiotherapy

• Improved flexibility
• Improved balance
• Improved coordination
• Increased muscle strength and endurance
• Enhanced aerobic capacity
• Gait re-education and improving weight bearing capacity
• Relaxation
• Increased mobility
• Improved health-related quality of life
• Decreased pain levels

Assessment and Diagnosis

On initial assessment, it is important to examine the patient to diagnostically triage patients as recommended in the international back pain guidelines. Screening patients with new onset of back pain for red flag diagnosis such as neurologic compromise, inflammatory disease, infection, trauma/ fractures, and cancer which may require emergency attention

Next it is important to identify any less serious or non-specific causes of back pain. NICE guidelines recommends considering using risk stratification such as the STarT Back risk assessment at first point contact for new episodes of low back pain with or without sciatica for shared decision-making. If the low back pain is non-specific, it will usually be mechanical in nature and is exacerbated by movement and relived by rest and is affected by psychological and social factors.

Subjective History

Undertaking a subjective history allows to build a rapport with your patient, gain a further insight into their low back pain such as onset, duration, location, character, severity and aggravating and relieving factors in addition to identifying serious pathologies.

Physical Assessment

• Observation – posture, abnormal deformity, and curvature
• Palpation – along spinous process and transverse process, musculature, sacroiliac joint
• Gait – through stance and swing phase
• Range of Motion – Passive and Active of lumbar, thoracic spine, and hip
• Muscle strength – Lumbar spine and Hip
• Neurological testing – Reflexes, Motor and sensory testing, straight leg raise, femoral nerve test
• Testing SIJ and Hip – thigh thrust test, pelvic compression, FABER’s
• Motor control testing – Waiter’s Bow, Pelvic tilts
• Imagining is not routinely offered in non-specialist setting for people with low back pain – NICE

Patient-reported outcome measures

• Physical function – Oswestry Disability Index or Roland Morris Disability Questionnaire
• Pain intensity – Numerical Rating Scale or Visual Analogue Scale
• Health-related quality of life – Short Form Health Survey 12 or EuroQol-5D-3L
• Work – Work Ability or Work productivity questionnaire
• Psychological functioning – Hospital Anxiety and Disability Scale
• Pain interference – Pain Interference subscale of the Brief Pain Inventory

Psychosocial Effects of Chronic Low Back Pain

Introduction

Known predictors of chronicity and disability in patients with lower back pain include depression, distress, and somatisation (Pincus et al., 2013). Psychological factors that are associated with all chronic pain include depression and anxiety, fear avoidance, low self-efficacy, and post-traumatic stress disorder (Pincus et al., 2013; Arnold et al., 2006; Chaitow, 2016). Finally, social factors include abstaining from work, detaching and isolating from others and compensatory mechanisms (Pincus et al., 2013)

The Biopsychosocial Model of Chronic Pain

Numerous psychosocial factors are associated with chronic low back pain, therefore a biopsychosocial perspective is important to provide optimal care (Hartvigsen et al., 2018a). The biopsychosocial model of back pain is based on a holistic view which recognises the reciprocal influences of the biological, psychological, and social variables that influence low back pain. This is vital to understand due to the variable human experiences of back pain (Lall and Restrepo, 2017).

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Dueñas et al. (2016) explains that chronic pain causes significant consequences for not only patients but their professional and social environment and therefore both social and psychological domains are important to understand.

Psychosocial factors affect back pain and how the pain influences ones life

Psychological and social factors create a continuous detrimental cycle whereby they not only affect back pain itself but also impact on one’s life. For example, depressive symptoms may worsen back pain and increase the disability associated with back pain (Hartvigsen et al., 2018b).

Back pain patients are more likely to experience:

-         Major depressive disorders

-         Anxiety disorders

The coexistence of these conditions and associated back pain may lead to decreased quality of life and a greater chronicity. Despite this, mechanisms of the associations that underly chronic back pain are still not fully understood (IASP, 2021).

Avoidance Behaviour

Avoidance behaviour may lead to the maintenance of chronic pain for longer. By avoiding movements, it may lead to cycles of greater disability and increasing pain. Described in the Fear Avoidance and Beliefs Model (FAMB) (Crombez et al., 2012).

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Low Back Pain and Depression

A study by Robertson et al. (2017) with 1013 first year Canadian university students looked at the association between low back pain and depression and somatisation in adults. Participants completed the modified Zung Depression Index, the modified somatic perception questionnaire and a survey about low back pain and intensity. Results revealed that over 50% of subjects reported low back pain across grades, and both depression and somatisation was positively associated with low back pain, consistent with other studies and reinforcing the understanding of the detrimental association.

Psychosocial Effects of Aquatic Therapy on Chronic Low Back Pain

Introduction

There are numerous psychosocial benefits from engaging in aquatic physiotherapy and recent research explains that all aquatic exercise is vital in promoting and managing mental health. Firstly, partaking in physical exercise can have many positive effects on quality of life due to the facilitation and promotion of social interaction (Moore et al., 1999; Salmon, 2001; Silva et al., 2019). On the other hand, psychosocial stressors and a sedentary lifestyle has been shown to reduce cellular functioning. Thus, promoting physical exercise is vital when treating and preventing depression (Hearing et al., 2016) and other mental health disorders.

Psychosocial benefits

• Stress relief
• Relaxation of muscles
• Water is associated with fun and relaxation
• Promotes body awareness
• Increases self-efficacy and confidence

The warm water and physical properties of water (buoyancy and hydrostatic pressure) can provide stress relief allowing the muscles to relax, leading to tension relief and a reduction in muscle spasms (Sawant and Shinde, 2019), promoting a less anxious state. Women partaking in aquatic physiotherapy report feeling comfortable and relaxed in the warm water (Maude and Foureur, 2007).

Additionally, aquatic therapy can provide a sense of control and understanding of your own body due to the hydrostatic pressure promoting sensory receptors, allowing patients to take back control of their own movements, increasing self-efficacy and confidence (Frye, Ogonowska-Slodownik and Geigle, 2017).

Aquatic Physiotherapy and Depression

Silva et al. (2019) completed a study with 92 elderly people to determine the effects of aquatic exercise on mental health. The participants were allocated into two groups (depression group and non-depression group) in which they completed an aquatic exercise programme for 12 weeks. They discovered that, in depressed elderly individuals, aquatic physiotherapy reduces depression and anxiety, improves activities of daily living, and reduces oxidative stress.

Swim England Supports Aquatic Physiotherapy

Swim England’s 2019 Value of Swimming report and the 2021 Decade of Decline report were created to encourage and improve the awareness of swimming and aquatic therapy.

(https://www.csp.org.uk/campaigns-influencing/campaigns/aquatic-physiotherapy)

Conclusion

PSYCHOLOGICAL FUNCTIONING = HADS – Because there is a big biopsychosocial

Prescription of Aquatic Therapy for Chronic Low Back Pain

As previous studies have shown, aquatic physiotherapy can be proven useful for reducing symptoms of chronic lower back pain. However, the question remains as to how frequent this intervention needs to take place for it to be effective in the short and long term.

Frequency Per Week

There are a couple studies which look at the effect of different frequencies for this intervention. For example, Baena-Baeato et al., (2013) compared the effect of completing aquatic therapy either 2x or 3x a week for chronic lower back pain patients over an 8-week period. This study included 54 participants who had chronic lower back pain for more than 12 weeks. They were split into a control group (education/advice only), aquatic therapy 2x a week and then aquatic therapy 3x a week. Outcome measures of pain, disability, quality of life, body composition and health related fitness were used to determine the effects of the different frequencies. Results showed that both groups experienced significant improvements in back pain and disability compared to the control group. However, the 3x a week group showed significantly greater benefits with pain into flexion and disability levels compared to the 2x a week group. Both groups experienced significantly improved quality of life and health related parameters. There were no significant changes between the treatment groups and control in regard to body composition.

Another study by Cuesta-Vargas et al., (2015) investigated the optimal frequency of aquatic therapy for individuals with chronic musculoskeletal pain. This randomised control trial included 114 people with chronic musculoskeletal pain and had them participate in aquatic therapy either 2x or 3x a week for a year. Patients included experienced 1 of 3 musculoskeletal disorders: chronic lower back pain, chronic neck pain or osteoarthritis. Outcome measures included quality of life, disability index and WOMAC for OA patients. Measurements were taken at baseline, 8 weeks, 6 months and a year after the programme started. Results showed that there were no statistical differences between the two groups except the neck disability index at 8 weeks. There were improvements for all groups and all variables from baseline to a year.

Length of Session and Content of Session

Both studies included aquatic therapy sessions which were on average 60 minutes long. This is consistent with other studies which look generally at the effectiveness of aquatic therapy on chronic lower back pain. For example, in a systematic review by Christakou and Boulnta (2020), 13 studies were reviewed, and the majority used interventions of aquatic therapy ranging from 45-60 minutes. Aquatic therapy sessions included warmups, muscle strength exercises, aerobic exercises and cool downs working on flexibility. This systematic review concluded that aquatic therapy improved pain, disability and quality of life.

What the Evidence Suggests

As a result of these studies, it can be concluded that the optimal aquatic therapy prescription for chronic lower back patients should be 2x a week for 60-minute sessions. These sessions should include a mixture of aerobic and resistance exercises as well as a warmup and cool down. This knowledge has implications for rehabilitation, as it shows that 2x a week is often comparable to 3x a week of aquatic therapy for outcomes of chronic lower back pain. This can save resources and cost for patients and service providers without compromising the effects of the treatment.