Approximately 10 million Americans are living with osteoporosis and another 34 million are at risk for the disease based on statistics from the National Osteoporosis Association. The human bone is made up of three major components including collagen, calcium-phosphate mineral complexes and living bone cells.
By the time we reach age 25, we have the greatest amount of bone and there is more balance between bone loss and bone growth. Following age 25, the gap begins to grow between bone loss versus bone growth and osteoporosis can be defined as what happens when you lose too much bone, not make enough bone, or both.1
Regardless of the etiology of a disability, and more specifically a spinal cord injury (SCI), osteoporosis is a common result. As a result of osteoporosis and fragility fractures, there are a range of complications including sensory loss, pressure sores, loss of range of motion, autonomic dysreflexia, heterotopic ossification at the fracture site, and even amputation. Besides medical management of osteoporosis, the question becomes how to provide physical rehabilitation services without placing the patient at too much risk.2
Benefits of Aquatic Therapy
There are many benefits of the aquatic environment, including temperature control, which can help patients achieve their goals. Properties that are unique to water include hydrostatic pressure, buoyancy, viscosity and resistance.
· Buoyancy is the upward thrust that occurs on a submerged body. When the depth of the water can be adjusted, so can the amount of buoyancy as the patient progresses.
· Hydrostatic pressure improves peripheral edema, increases cardiovascular response, balance and proprioceptive training, and creates a safe, supportive and forgiving environment.
· Viscosity can be used to facilitate movement or provide resistance, depending on direction and timing of movement, and use of equipment.3
These properties provide support to the body in a unique way that leads to increased safety for those with osteoporosis. Buoyancy and hydrostatic pressure decrease the force that is transmitted through joints, therefore decreasing the sense of body weight when performing mobility tasks. Viscosity enables patients to perform resistive activities, increasing muscle use. Like weight training, it gives the benefits of increased bone density with decreased joint stress and decreased risk of fracture. In addition, maintaining elevated pool temperatures between 90-94 degrees allows patient muscles to relax, in order to maximize the benefit of their therapy.
Another beneficial property of the aquatic environment is a decreased fall risk, which results from resistance to movement provided by viscosity acting in combination with buoyancy. On land, when a person experiences a loss of balance, gravity acts quickly and provides forces that accelerate a fall, and increase risk of injury to the patient. In the aquatic environment, these forces are altered, allowing the patient increased time to react to a loss of balance and recover with or without therapist assistance.
When a patient is recovering following spinal cord injury, the ability to participate in activities that promote improved mobility is incredibly important. However, the common diagnosis of osteoporosis places many patients with SCI at increased risk of fracture when performing these tasks, compounding with an increased fall risk. A therapeutic pool has the ability to provide patients with a safe, controlled environment to work toward challenging therapeutic goals.
"Joe" was a 60-year-old male whose primary goal for therapy included improving his walking skills and learning to complete floor to stand transfers. Floor to standing transitions are an important skill for patients who often experience falls, in order to recover safely. During land-based therapy, Joe's hypertonicity, lower extremity tightness, weakness and balance deficits led to a challenging transfer that required more than one therapist to assist him through positions that would not place torque through his joints.
Prior to entering the pool, Joe was thoroughly evaluated by his rehab therapists and physician at Kennedy Krieger Institute's International Center for Spinal Cord Injury. Key components were assessed in his evaluation in order to determine if the pool setting would be a reasonable therapeutic environment. Joe's bone density test was examined for a baseline. A thorough evaluation of his current mobility function and goals were also evaluated. On land, he presented as a high fall risk and fracture risk secondary to a diagnosis of osteoporosis.
In the aquatic environment, however, he had been able to participate in tone reduction and stretching interventions in the warm water, prior to participating in mobility training both in and out of the pool. The therapists and the patient were then able to work together to problem solve through the difficult transfer from the floor, while optimizing the patients safety. The patient has had great success with transfer and gait training in this unique environment, which has translated to his improved everyday function outside of the pool.
Overall, the aquatic environment is an excellent place to address mobility, range of motion and strength limitations in patients who have a concurrent diagnosis of osteoporosis. It is a safe and optimal environment to allow patients to strengthen their body and improve their mobility skills, with a significantly decreased risk of injury.
1. The National Osteoporosis Foundation: www.nof.org/articles/7. Accessed Dec. 11, 2012.
2. Smith ÉM. Treatments for osteoporosis in people with a disability. PM&R. 2011: 3 (2): 143-152.
3. Recio, A, et al. Movement Restored. Using aquatics for physical and psychological restoration. Advance for Occupational Therapy Practitioners. Dec. 14, 2010.
Kimberly Obst is a senior occupational therapist and Lauren White is a PT clinical specialist working at Kennedy Krieger Institute's International Center for Spinal Cord Injury (ICSCI), Baltimore. Albert Recio is a physician and medical director of ICSCI's aquatics program, and Christy Sachs is the manager of the aquatics and wellness program at Kennedy Krieger Institute.