Impact of aquatic interventions

on treatment of spasticity

Submitted to
Prof.Dr. Ebtsam Khattab
Prepared by
Khaled Hussein Yusuf
 Introduction to spasticity
• Spasticity (meaning to draw or tug) is involuntary,
velocity-dependent, increased muscle tone that results in
resistance to movement.
• The condition may occur secondary to a disorder or
trauma, such as a spinal cord injury (SCI), a brain injury,
a tumor, a stroke, multiple sclerosis (MS), or a peripheral
nerve injury.
• A lag time may exist between injury and spasticity onset,
and severity may wax and wane over time. Spasticity
may be static or dynamic in nature. Although many
therapeutic and medical interventions can attenuate its
effects, spasticity can be severely debilitating.
Morbidity/disadvantages of spasticity
• Orthopedic deformity, such as hip dislocation,
contractures, or scoliosis
• Impairment of activities of daily living (e.g., dressing,
bathing, toileting)
• Impairment of mobility (e.g., inability to walk, roll, sit)
• Skin breakdown secondary to positioning difficulties and
shearing pressure
• Pain or abnormal sensory feedback
• Poor weight gain secondary to high caloric expenditure
• Sleep disturbance
• Depression secondary to lack of functional
independence
 Aquatic Therapy

• The Standards and Steering Committees of the Aquatic

Therapy and Rehabilitation Industry Certification define
aquatic therapy and rehabilitation as:

• "The use of water and specifically designed activity by

qualified personnel to aid in the restoration, extension,
maintenance and quality of function for persons with
acute, transient, or chronic disabilities, syndromes or
diseases “
 Definition of Hydrotherapy

• Hydrotherapy is the use of water by external

applications, either for its pressure effect or as a means
of applying physical energy to a tissue. The term often
refers to the use of water in wound management, such
as whirlpool baths, but can be used interchangeably with
the term, "aquatic therapy."
 Indications for Aquatic Therapy
• Sensory Disorders
• Limited Range of Motion
• Weakness
• Poor Motor Coordination
• Pain
• Spasticity
• Perceptual/Spatial Problems
• Balance Deficits
• Respiratory Problems
• Circulatory Problems
• Depression/Poor Self-Esteem
• Cardiac Diseases
• Joint Replacement
• Motor Learning
• Orthopedic Injuries / Trauma
• Obesity
• Prenatal
• Neurological (MS)
• Osteoporosis
• Rheumatology (Arthritis /
Fibromyalgia)
 Benefits of Aquatic therapy:
1-Buoyancy
• One benefit of aquatic therapy is the provided by the
water. While submerged in water, buoyancy assists in
supporting the weight of the patient. This decreases
the amount of weight bearing which reduces the force
of stress placed on the joints. This aspect of aquatic
therapy is especially useful for patients with arthritis,
healing fractured bones, or who are overweight. By
decreasing the amount of joint stress it is easier and
less painful to perform exercises.
 2-Viscosity

• Provides an excellent source of resistance that can

be easily incorporated into an aquatic therapy exercise
program. This resistance allows for muscle
strengthening without the need of weights. Using
resistance coupled with the water’s buoyancy allows a
person to strengthen muscle groups with decreased
joint stress that can not be experienced on land.
 3-Hydrostatic pressure
• Aquatic therapy also utilizes to decrease swelling and
improve joint position awareness. The hydrostatic
pressure produces forces perpendicular to the body’s
surface. This pressure provides joint positional
awareness to the patient. As a result, patient
proprioception is improved. This is important for patients
who have experienced joint sprains, as when ligaments
are torn, our proprioception becomes decreased. The
hydrostatic pressure also assists in decreasing joint and
soft tissue swelling that results after injury or with arthritic
disorders.
 4-Warmth of the water
• Lastly, the experience during aquatic
therapy assists in relaxing muscles and
vasodilates vessels, increasing blood flow
to injured areas. Patients with muscle
spasms, back pain, and fibromyalgia find
this aspect of aquatic therapy especially
therapeutic.
 Contraindications of aquatic therapy

• It is important to know however, that aquatic

therapy is not for everyone.
• People with cardiac disease should not participate
in aquatic therapy. Those who have fevers,
infections, or bowel/bladder incontinence are also
not candidates for aquatic therapy. Always discuss
this with your physician before beginning an
aquatic therapy program.
 Examples for aquatic training lines

Ai Chi
• Created by Jun Konno of Japan, ai chi is
a combination of deep breathing and
slow broad movements of the arms, legs,
and torso, using concepts of T'ai Chi,
Shiatsu, and Qigong. Ai Chi is performed
standing in shoulder-depth water with an
ideal pool temperature of 88F to 96F.
 Ai Chi Ne

• Ai Chi Ne (pronounced Eye Chee Knee) is

a partner stretching program. "Ne" is the
Japanese word for "two". Ai Chi Ne
involves breathing techniques to increase
relaxation and therefore enhance the
stretch abilities. Using the breathing
techniques decreases stress, joint tension,
muscular tension, and the stretch reflex
response.
 BackHab

• This is an integrated program that the individual

can do on his or her own. It was developed for
people with back problems but is now being
used by group programs for people with
disabilities. Rather than focusing on healing one
part of the body, all the body parts coordinate to
work on healing and fixing the affected area.
BackHab is an aquatic walking program using
various strides to accomplish a variety of
benefits. It is excellent for gait re-training
 Bad Ragaz

• This technique originated in Germany in 1957

and was introduced by a German therapist to the
therapeutic thermal pools of Bad Ragaz in
Switzerland. The technique has since become
more clearly defined as the Bad Ragaz Ring
Method. Bad Ragaz is a method of muscle re-
education utilizing specific patterns of
resistance, endurance, elongation, relaxation,
range of motion, and tonal reduction.
 Proprioceptive Neuromuscular Facilitation
(PNF)

• PNF is an approach to therapeutic

exercise which aims to improve motor skill
through positive motor transfer, using the
principles of facilitation/inhibition,
irradiation/reinforcement, and reciprocal
innervation. Exercises consist of spiral and
diagonal patterns and must incorporate
three components of motion: flexion or
extension, adduction or abduction, and
rotation.
 Treatment Goals
• (vary depending on the individual& level of
involvement)
– Increase ROM
– Improve mobility and strength
– Decrease Pain
– Increase Endurance & Cardio Fitness
– Improve Proprioception
– Improve Gait & Fall Prevention
– Decrease Energy Expenditure
– Decrease Spasm Frequency
– Improve Self Esteem
 Aquatic Factors to Consider for Safety for
Individuals with Spasticity
(Reduce all internal and external factors that can exasperate spasticity)
• Extreme changes in temperature
• Loud noises
• Irritants
• Tight fitting suit or aqua shoes
• Introduction to hydrostatic pressure
• Quick movements during transfers
• Placement and use of aquatic equipment
• Contact with pool floor and walls, benches, jets, stairs, ladders,
railings
• Velocity of movements
• Turbulence
• Fatigue
 Pre-Aquatic Therapy Assessment
(Re-evaluate client following set # of aquatic treatments)
• Proprioceptive skills- sensory, balance, coordination
• Motor skills- functional mobility assessment
• ROM & Posture– specific musculoskeletal assessment
• Spasmodic Activity- muscle involvement, focal or diffuse, frequency,
degree, chronic vs. acute
• Reflexes – deep tendon response, primitive, developmental
• Cognition- comprehension of activity/environment, decision-making,
etc.
• Communication skills- must have established communication plan
• Pharmacology – medications that could interact adversely with
water based activity
• Assistive Care and/or Services/Equipment
Manual Treatments for Spasticity that are
utilized in Aquatic Therapy Applications
• Soft Tissue • Vibration
Mobilization • Stretching
• Joint Mobilization • Breath Awareness
• Deep Tissue • Positional Cuing
Massage • Exercises, active-
• Fascia's Release assist, active, resisted
• Trigger Point Therapy • Strengthening –
• Joint Approximation isometric, isotonic,
• Joint Distraction isokinetic
• Cardiovascular • PNF proprioceptive
Training neuromuscular
• Compression facilitation patterns
Spasticity Specific Aquatic Therapy
Accommodations
• Slow rhythmical movement with rotational components.
• Slow sustained stretch, minimize frictional resistance and
turbulence.
• Stop stretch movement 5 degrees before spasm initiation,
gently repeat.
• Gradual release of agonist - antagonist using slow reversals
and rhythmic
• initiation PNF patterns.
• Passive figure 8 patterns to reduce muscle tone and inhibit
co-contractions.
• Utilize water assistive and supported activities for active
stabilization and functional
• use activities.
• Aquatic equipment selection to: maximize
relaxation, for stabilization, or to facilitate a
neuromuscular response.
• Easy reciprocal active/ assisted open chain
movements.
• Applications of tactile cuing and movement
assistance using: compression, stroking,
• tapping, jamming, vibration, turbulence into or from
body segment
 Exercise Session Format
• Start with 10 to 15 minutes and increase in 5-
minute intervals.
• Use deep breathing to increase vital capacity.
• Use GRADUAL progressive overload.
• Work on balance.
• Work on strength.
• Work on flexibility.
• Longer cool down.
 Program Modifications
• Use fewer reps of the same muscle group when beginning.
• Center the body between transitions.
• Reach across the midline and overhead across.
• Use hands behind head and body.
• Move backwards as well as forward.
• Exercise to improve posture.
• Use slow, controlled movement.
• Begin weight-bearing issues in deeper water and progress to
shallower.
• Enter water slowly so all systems have an opportunity to gradually
accommodate the environment.
• Keep medications at pool edge.