Physical therapists are regularly brought in to direct shoulder rehabilitation, either before or after surgery or instead of it. As such, aquatic therapy presents itself as a viable option to get patients moving again to maximize their functional abilities. It is a great medium to use when people are in too much pain to move on land, or as an adjunct to their land-based program. I've also noticed that the addition of the aquatic medium expedites functional outcomes.
Of course, there are considerations to keep in mind prior to beginning water therapy on an individual with a shoulder injury. These include:
1. The need to assess the patient's comfort level with the aquatic medium. It is ideal if patients are willing to get their faces or hair wet in order to provide the most thorough aquatic physical therapy treatment. This allows for the ability to complete supine or prone activities that will assist in maximizing range of motion and strengthening capabilities for exercises.
Though this might seem a tiny concern, it can greatly affect whether or not aquatic therapy will be a perfect fit. If a patient is uncomfortable in a warm-water therapy pool, the physical therapist must be able to modify the program as needed.
As most physical and occupational therapists know, creativity is a must when working with the unique needs of patients. Consequently, water therapy exercises can always be adjusted to minimize physical or psychological discomfort for patients as much as possible.
2. The necessity for the aquatic therapist and patient to be physically stable at all times. Solid foot placement is a must during all aquatic therapy sessions. This is one of the main reasons to invest in a therapy pool with an adjustable floor depth.
Gravitational pull versus buoyancy should always be evaluated, and an adjustable therapy pool will give maximum flexibility.
Other options include small ankle weights to counteract buoyancy and allow for more stable foot position for the therapist and patient.
Ankle weights are ideal for patients who are very buoyant or if water is too deep for participants to maintain a flat foot position.
Appropriate Exercises
After these considerations are addressed, the perfect types of aquatic therapy exercises for the shoulder-injury patient need to be planned. Below are several techniques that have worked well in the past; however, note that all can be modified or changed according to the patient's unique requirements.
Standing exercises. During standing shoulder exercises, the patient can, under the direction of his physical therapist, methodically work on building muscle tone and repairing injured soft tissue. This is a good starting position for initial visits, as it allows patients to become accustomed to the physical properties of water (i.e., buoyancy, hydrostatic pressure), as well as how they affect positioning and movement.
A few favorite exercises include push/pull down, ER/IR, flexion/extension, horizontal abduction/adduction, diagonals (with or without head rotation), figure eights and/or circles. Each exercise can be adapted as the patient's shoulder becomes stronger.
Various types of resistive or buoyant equipment can be used during standing aquatic therapy. From gloves, noodles of various sizes, small buoyant barbells, resistive "aquacizers" and kickboards, to aquafins, snorkels, large barbells and buoyant hydrofit cuffs, it's critical for physical therapists to use any peripherals they can.
Adjustable resistance jets can also be helpful for progressing the strengthening portion of a program. (Some of this equipment can be used to facilitate stretching as well, not just resistance for strengthening).
The one limitation to standing activities is the inability to work greater than 90 degrees of flexion or abduction; this is where a patient's willingness to get his hair wet or face in the water is helpful.
Supine and prone exercises. Water therapy is especially unique because it allows individuals to float in a supine position. However, it's important to note that the patient need not float on his own. Instead, flotation can be achieved with a lumbar belt, cervical collar, noodles and/or Bad Ragaz rings. This ensures the patient will have both comfort and buoyancy during rehabilitation.
Once in the supine (face-up) position, exercises such as making "snow angels" in the water emphasize scapular muscle groups. One caveat: Physical therapists must ensure that patients aren't overcompensating; they must maintain neutral pelvis positioning at all times to avoid straining other muscles or weakening the results of the exercises.
Observation
Appropriate observation and cuing by the therapist is essential to assist patients in developing correct movement strategies, since it is common in this position for patients to compensate with spinal extension due to weakness in their scapula.
In the prone (face-down) position, a snorkel and mask are used to allow breathing during aquatic exercises. Many of the same movements covered in the supine exercises can be mimicked or adapted in the prone position with different results.
The prone position also allows for inhibition and/or relaxation of some of the cervical musculature that, when combined with the buoyant properties of the water, enables greater shoulder range of motion, especially in the sagittal (flexion of the upper extremity) and transverse planes (horizontal abduction of the upper extremity).
Again, the patient must be highly comfortable in a water-based environment. If he is unable or unwilling to take the prone position, it is best to focus on standing and supine water therapy exercises instead.
In the supine and prone positions, the patient can utilize the types of equipment outlined in the previous section, in either a buoyant or resistive manner, to achieve desired effects.
As with all rehabilitation options, aquatic therapy techniques can and do open the doors to ensuring that patients get moving safely and comfortably. Best of all, individuals who enjoy their therapy sessions are less likely to cancel and more likely to refer their physical therapists to others.
This is just a sampling of what can be accomplished in the aquatic medium for shoulder rehabilitation.
I recommend consulting additional sources for further information, including the Postural Restoration Institute, the Aquatic Therapy and Rehab Institute, and the Aquatic Therapy Section of the APTA.
Veronica Paquette can be contacted at vpaquette@gmavt.net