Patients with Low Back Pain Can Make 'Waves' Through

AQUATIC THERAPY

By Christine McLaughlin

Most individuals experience low back pain at some point in their lives, which makes it the most prevalent cause of disability. And many of the people who experience it are in too much pain to exercise on land, but the aquatic environment offers them a place to stretch and strengthen their backs with minimal discomfort.

While a variety of on-land therapeutic interventions can help alleviate back pain, aquatic therapy is the only treatment that can increase range of motion without weight bearing and can encourage patient confidence; thus helping speed patient recovery.

According to one aquatic therapist, the success rate of increasing function in patients with back pain who go through his program is "above average." Jeffrey Meyers, MS, aquatic rehab program director for Score Physical Therapy the Specialty Center for Orthopedic Rehabilitation and Evaluation in Waterbury, CT, said he believes posture is the single most important factor when conducting an aquatic program for patients with low back pain.

"We're such creatures of habit that it can take a long time to change behavioral conditions like poor posture, which contributes to back pain," said Meyers. "Especially when dealing with patients with back pain, there should always be a carry over of what postural techniques are learned and corrected in the pool to what is incorporated on land therapy."

BOTH ACUTE and chronic pain can be successfully treated through aquatic therapy, but the temperature of the water can be one of the most important factors in facilitating progress. Robert Babb, PT, said that at his facility there are two pools: one with 83 degree water and the other with 94 degree water. Patients with acute back pain are typically treated in the 83 degree water, in addition to treatment modalities like cold packs and electrical stimulation. Patients with chronic pain usually perform cardiovascular conditioning in the 83 degree water first, but shortly after they are transferred to the warmer pool for manual therapy.

"It's much easier as far as patient comfort is concerned for those with chronic pain to go from a cold pool to a warm pool where they have the manual work done," explained Babb, who is vice president and director of rehabilitation at the Centers for Aquatic Rehabilitation in Philadelphia and Cherry Hill, NJ. Warm water reduces muscle tension and helps prevent restricted joint movement, as well as helps patients relax and feel more comfortable.

"Superficial heat in the water can decrease muscle tightness or spasm, which works well for patients with chronic pain who can't stand up right because they're in so much pain," Babb said. The warm water also provides support for injured limbs, which allows for comfortable positioning without increased pain.

However, before splashing in the pool, patient evaluations always take place on land because that is where the patient will end up in therapy, said Babb. He mentioned using a dual inclinometer system, which is recommended by the American Medical Association to test range of motion in the trunk. Also performed in an evaluation are an abdominal strength test, back extension assessment and full extremity strength test of the myotomes to determine specific weaknesses of the muscle groups and lumbar spine. "We also determine body weight and fat, and check all elastic components of the trunk and lower extremities by doing a muscle length test and a postural evaluation."

ONCE THE evaluations are complete, about 95 percent of Babb's patients with low back pain are initially treated in the water. Among that 95 percent, 100 percent progress to a land program.

The aquatic program typically starts with a warm up such as deep water running which is popular among his patients, noted Babb.

The first step in his aquatic rehab back program involves strengthening the proximal trunk, which is vital to developing proper posture and facilitating function. To do this, he has his patients lie in a pelvic neutral position, and then pushes them side to side to help strengthen the proximal trunk. If they are determined to be somewhat stable in pelvic neutral, Babb provides resistance below the knee through pushing their trunk side to side and up and down, making sure the patient is maintaining the pelvic neutral position.

Once patients are able to maintain the pelvic neutral position, Babb incorporates arm and leg movements to see if they can continue to stabilize.

While using similar stabilization exercises, Meyers noted that he also has his patients stand with both feet on the bottom of the pool and rock back and forth, shifting their weight from one foot to the other. In addition, he has his patients put all their weight on one leg, squeeze the buttock muscles and tighten the hip for a few seconds and then shifts to the other leg. These exercises also help to promote pelvic stabilization through tightening the musculature of the pelvis, and upper and lower back using isometric contractions. Meyers then progresses his patient to more dynamic movements once posture and range of motion are achieved.

BABB SAID that once his patients demonstrate their range of motion, he has them perform additional extension exercises that mimic land exercises such as lunges, squats, step ups, trunk rotations and side bends. Shallow water walking is done in the pool to prepare them for using the treadmill in land therapy.

Some treatments don't always apply directly to a land exercise, but they help ease pain and relax the patient. Meyers told ADVANCE that he implements vertical floating traction (also known as decompression floating), whereby weights are placed on the patients' feet and they drape their body over a floatation device dangling their legs in the water and, as a result, the back lengthens and decompresses.

Although this technique is considered controversial among many aquatic therapists, Meyers said that the therapists at his facility feel that it really helps patients relax, and the patients seem to enjoy it.

Babb noted that he doesn't use weights in the water because he believes that the viscosity of the water is enough resistance for most of his patients. "By using the water alone, we can adjust the resistance with speed of movement and surface area."

After patients progress from aquatic therapy, most of Babb's patients with low back pain go through a "pool deck" program that involves several dynamic stabilization exercises to prepare them for land therapy. The exercises include proprioceptive neuromotor facilitation patterns such as trunk chops and lifts keeping pelvic neutral using physioballs and sticks.

FOR EXAMPLE, he explained, therapists might have their patients in quadruped position and practice activities like grabbing a stick and pulling it toward themselves while keeping pelvic neutral positioning. Meanwhile, the therapists are trying to knock them out of the pelvic neutral position. "By challenging their proximal stability, we try to gradually load them in a specific movement pattern that they may have to go back to after therapy. And we do the deck program to educate them to know what to expect when they get to the gym later so they develop a sense of proximal stability on land."

Meyer's patients typically progress to a land therapy program after spending about four months of three weekly one-hour sessions in aquatic therapy. During that time, the therapists at Score Physical Therapy will incorporate one day of land therapy and two days of aquatic therapy into the program. Subsequently when patients demonstrate even more progress, they are switched to two days of land therapy, one day of pool therapy--eventually moving to three days a week of traditional land PT.

Whatever treatment protocol is employed, above all else, when dealing with patients with chronic back pain therapists should try to instill to them a proactive approach toward their own rehabilitation, said Babb. "It's most important for chronic back pain patients to be 'adaptive copers'--meaning get them to understand that their function is alterable through [aquatic] therapy and to deal with it and take responsibility to their own treatment.

"Even though their pain level may not change significantly through aquatic therapy, their level of function can improve through our skilled treatments and through their active participation."

Reference

Bates, A., & Hanson, N. (1996). Aquatic Exercise Therapy. Philadelphia: W.B. Saunders Company.