NEW WAVES IN AQUA THERAPY

Water Ideal for Treating Low Back Pain

By Christine McLaughlin

Low back pain is not only the leading cause of disability, it's difficult to treat--especially on land. Water, however, can lessen treatment discomfort as patients stretch and strengthen their way to recovery.

In fact, aquatic therapy is the only treatment that can increase range of motion without weight-bearing, and it encourages patient confidence, thus fostering rehab.

Witnessing the results of an aquatic environment, aquatic therapist Jeffrey Meyers, MS, reports an "above average" success rate of increasing function in patients with back pain through aqua therapy. Key to this success is a focus on posture, stresses Meyers, aquatic rehab program director at Score Physical Therapy, the Specialty Center for Orthopedic Rehabilitation and Evaluation in Waterbury, Conn.

"We're such creatures of habit that it can take a long time to change behavioral conditions like poor posture, which contribute to back pain," says 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."

Water Temperature

When it comes to the pool, water temperature can practically make or break progress, whether it's chronic or acute pain. Because of this, Robert Babb, PT, says his facility features two pools, one 83 degrees, one 94 degrees. Babb, vice president and director of rehabilitation at the Centers for Aquatic Rehabilitation in Philadelphia and Cherry Hill, N.J., typically treats patients with acute back pain in the 83-degree pool, and later uses modalities, such as cold packs and e-stim. He also helps patients with chronic pain perform cardiovascular conditioning in the 83-degree water before sending them to the 94-degree pool for manual therapy.

Warm water reduces muscle tension, helps prevent restricted joint movement and fosters relaxation and comfort. It also supports injured limbs, allowing for comfortable positioning without greater pain.

Likewise, superficial heat in the water can decrease muscle tightness or spasm--good for patients with chronic pain who can't stand upright, Babb adds.

On-Land Evaluations

Before entering the pool, however, clinicians must evaluate patients on land, says Babb, who suggests using a dual inclinometer system to test trunk ROM, as recommended by the American Medical Association. Evaluations should also include 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.

By doing a muscle length test and a postural evaluation, Babb also determines body weight and fat, and checks all elastic components of the trunk and lower extremities.

After these evaluations, Babb initially treats about 95 percent of his patients with low back pain in the water, all of whom progress to land. The aquatic program typically starts with a warm-up, such as deep water running, which is popular among patients, he notes. He then strengthens the patient's proximal trunk--vital to developing proper posture and facilitating function.

To do this, patients lie in a pelvic neutral position as Babb pushes them side to side. If they remain somewhat stable in pelvic neutral, Babb provides resistance below the knee by pushing their trunk side to side and up and down while ensuring that the patient maintains the pelvic neutral position. Once patients can maintain this, Babb incorporates arm and leg movements to see if they can continue to stabilize.

Using similar stabilization exercises, Meyers has patients stand on the bottom of the pool and rock back and forth, shifting their weight from one foot to the other. He also instructs them to put all their weight on one leg, squeeze the buttock muscles and tighten the hip for a few seconds before shifting to the other leg. These exercises promote pelvic stabilization because they tighten the musculature of the pelvis and upper and lower back with isometric contractions. Patients then move to more dynamic movements once they achieve posture and ROM.

When Babb's patients have ROM, he then instructs them to do additional extension exercises that mimic land exercises, such as lunges, squats, step-ups, trunk rotations and side bends. They also do shallow water walking to prepare for the treadmill they'll soon use in land therapy.

Some treatments, however, don't always apply to a land exercise, but they ease pain and relax the patient. One such treatment is vertical floating traction, also known as decompression floating.

This exercise consists of placing weights on the patients' feet as they drape their body over a flotation device. As their legs dangle in the water, their back lengthens and decompresses. Although controversial, this technique helps patients relax, says Meyers, and they seem to enjoy it.

Babb, however, opts not to use weights in the water, noting that water's viscosity provides enough resistance for most of his patients. "By using the water alone, we can adjust the resistance with speed of movement and surface area," he says.

Back on Land

Before progressing to land, Babb's patients go through a "pool deck" program involving dynamic stabilization exercises. These include proprioceptive neuromotor facilitation patterns such as trunk chops and lifts, keeping pelvic neutral with physioballs and sticks.

"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," says Babb. "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."

Meyers' patients are typically land-bound after about four months of three weekly one-hour sessions in the pool. During that time, therapists at Score Physical Therapy incorporate one day of land therapy and two days of aquatic therapy into the program. When patients show more progress, they are switched to two days of land therapy, one day of pool therapy--eventually moving to three days a week of land PT.

Incidentally, the time frame for treatment may raise concerns regarding reimbursement. However, this is rarely a problem at Score, because therapists stay abreast of reimbursement trends and standard aquatic therapy CPT codes.

While the pool can prove ideal when dealing with patients with chronic back pain, it is more essential to instill a pro-active approach toward their rehabilitation, stresses 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...[get them to] take responsibility for 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," Babb says.

Reference

Bates, A., & Hanson, N. (1996). Aquatic exercise therapy. Philadelphia: W.B. Saunders Co.

Christine McLaughlin is on staff at ADVANCE.