Aquatic Therapy in the Management of Chronic Low Back Pain
Chronic Low Back Pain[edit | edit source]
Aquatic Therapy[edit | edit source]
What is Aquatic Therapy?[edit | edit source]
Aquatic physiotherapy 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.
The use of aquatic physiotherapy 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[edit | edit source]
Water Density[edit | edit source]
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[edit | edit source]
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 physiotherapy can be used as an alternative to land-based strength exercises.
Water as a Compressor[edit | edit source]
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[edit | edit source]
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[edit | edit source]
Indications[edit | edit source]
- 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[edit | edit source]
Absolute Contraindications[edit | edit source]
- 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[edit | edit source]
- 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[edit | edit source]
- 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[edit | edit source]
Resistance Aids[edit | edit source]
- Flippers/fins
- Aquatic Dumbbells
- Wrist and Ankle Weights
- Submersible Steps
Floatation Aids[edit | edit source]
- Pool Noodles
- Aqua round body support
- Floatation Belts
- Arm Bands
- Kick boards
- Aqua Plinth
- Sensafloat
Cardiovascular Equipment[edit | edit source]
- Underwater Treadmill
- Underwater Stationary bike
Benefits of Aquatic physiotherapy[edit | edit source]
- 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
1. Subjective History – it is important to gain a subjective history from the patient regarding their back pain such as onset, duration, location, character, aggravating and relieving factors and severity- more about subjective history can be found here
2. Physical Assessment
a. Observation – posture, abnormal deformity, and curvature
b. Palpation – along spinous process and transverse process, musculature, sacroiliac joint
c. Gait – through stance and swing phase
d. Range of Motion – Passive and Active of lumbar, thoracic spine, and hip
e. Muscle strength – Lumbar spine and Hip
f. Neurological testing – Reflexes, Motor and sensory testing, straight leg raise, femoral nerve test
g. Testing SIJ and Hip – thigh thrust test, pelvic compression, FABER’s
h. Motor control testing – Waiter’s Bow, Pelvic tilts
i. Imagining is not routinely offered in non-specialist setting for people with low back pain – NICE
3. Patient-reported outcome measures
a. Physical function – Oswestry Disability Index or Roland Morris Disability Questionnaire
b. Pain intensity – Numerical Rating Scale or Visual Analogue Scale
c. Health-related quality of life – Short Form Health Survey 12 or EuroQol-5D-3L
d. Work – Work Ability or Work productivity questionnaire
e. Psychological functioning – Hospital Anxiety and Disability Scale
f. Pain interference – Pain Interference subscale of the Brief Pain Inventory
