Innovative Aquatic Therapy. Aquatic Therapy. Innovative. 1

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1 Innovative Aquatic Therapy for Low Back Pain: Ideas from the Trenches Welcome the webinar will start at 12:02ish If you will be listening by phone, make sure to call in as directed. In the meantime, grab a latte and put your feet up. Lab demonstrations excerpted from ATU manuals: Kim Gordon, MPT, Beth Scalone, DPT, & ATU class participants Innovative Aquatic Therapy for Low Back Pain: Ideas from the Trenches Instructor: Lab demonstrations excerpted from ATU manuals and feature: Kim Gordon, MPT, Beth Scalone, DPT, & ATU class participants University of Alabama at Birmingham grad Awarded APTA s highest honor for aquatic PTs in 2010 Aquatic Therapy University, Director of Programming Founder and Owner, AquaticResources Network Has served as: Editor-in-Chief, Journal Therapy Pool Manager Adjunct Faculty, PT School Functional Design Consultant Instructor, over 200 conferences Aquatic Health Research Database (AHRD) Creator Author, 5 aquatic therapy-related texts Columnist, 6 magazines, over 300 articles Instructor: Contact.. asalzman@aquaticnet.com 1

2 A sample of our live instructionals Justifiable Aquatic Therapy Strategies for the Client with Cardiopulmonary Compromise (Phoenix, AZ Aug 3-4 ) Aquatic Therapy Options for the Low Back, Neck and Chronic Pain Client (Mpls, MN October 11-12) Aquatic Therapy Options for CP, DD & the Medically Fragile (Mpls, MN Nov 8-9) Novel Aquatic Balance, Proprioception & Fall Prevention Strategies (Bham, AL April 2014) Objectives 1. Examine the 10 most common aquatic exercises performed for LBP and why therapists fall into a rut treating this disorder so frequently. 2. Compare and contrast 12 evidence-based ways to quickly bring innovationto these same stale aquatic routines. Includes: adding a cognitive overlay, creating unpredictablility, altering the environment, sensory overload, teach the teacher, four-walls concept and more. 3. Integrate the "power of touch" into common exercises to transform exercise into THERAPY. 4. Examine a new way to document progression (other than reps and sets). 5. Recognize 5 ways toidentify the "skill" that went into each treatment through daily documentation. Contact.. asalzman@aquaticnet.com #1. Examine the 10 most common aquatic exercises performed for LBP and why therapists fall into a rut treating this disorder so frequently. 2

3 10 most common 1. Water walking 2. Straight plane UE patterns 3. UE PNF patterns 4. Straight plane LE patterns 5. LE PNF patterns 6. Squats & lunges 7. Pelvic circles/ tilts 8. Standing trunk + hip stretches 9. Deep water aerobic exercise 10.The unloaded hang Contact.. asalzman@aquaticnet.com #2. Compare and contrast 12 evidence-based ways to quickly bring innovationto these same stale aquatic routines. 3

4 #1.Water walking Forward walking Velocity Unpredictability 4

5 Build a move #2. Shoulder Straight plane UE patterns Flexion and Extension Shoulder Abduction and Adduction Shoulder Horizontal Abduction and Adduction Contact.. asalzman@aquaticnet.com #3. UE PNF patterns PNF D1/D2 Contact.. asalzman@aquaticnet.com 5

6 Regional focus #4. Straight plane LE patterns Hip Flexion and Extension Hip Abduction and Adduction #5. PNF LE PNF patterns D1/D2 6

7 Teach the teacher Correct the teacher #6. Open Squats & lunges Pelvis Squats Front Lunges 7

8 Points on a clock #7. Pelvic circles/tilts Pelvic circles combined with scapular retraction Contact.. asalzman@aquaticnet.com Sensory increase 8

9 Assistance #8. Standing trunk + hip stretches Hamstring Stretch Gluteal Stretch #8. Standing trunk + hip streches Trunk Extension Contact.. asalzman@aquaticnet.com 9

10 Elevator floors #9. Deep water aerobic exercise Courtesy AquaJogger 4 walls concept 10

11 Pyramids #10. Unloaded hang Hanging in deep water (apologies for the world worst photoshop) Contact.. Sensory decrease 11

12 Integrate the "power of touch" into common exercises to transform #3.exercise into THERAPY. Tiffany Field * Touch for socioemotional and physical well-being: A review. Developmental Review; 30(4): December 2010;

13 Touch Activates OrbitofrontalCortex and Caudate Cortex Touch Increases Serotonin Touch Decreases HR, BP, Cortisol 13

14 TouchEnhancesImmune Function Including Natural Killer Cells POWER OF TOUCH Example: Your goal is to open thoracic outlet/ increase trunk extension 14

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16 POWER OF TOUCH Example: Your goal is to encourage neutral spine during movement 16

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18 Examine a new way to document progression #4.(other than reps and sets). Traditional documentation showing progress: Reps 10x 15x 18

19 Traditional documentation showing progress: Sets 1 sets 2 sets This is what they think you do: There are a limited number of therapeutic exercises generally performed in the water. These exercises become repetitive quickly. Once a patient can demonstrate an exercise safely, you may no longer bill Medicare for the time it takes the patient to perform this now independent exercise. If the same exercise is performed over a number of sessions, the documentation must describe the skilled nature of the qualified professional s/auxiliary personnel s intervention during the therapeutic exercise to support the ongoing medical necessity. (Medical Necessity document; National Government Services) Variability The degree to which performance of repetitions or sets of an activity or exercise varies or changes over treatment sessions. 19

20 Component Parts Individual tasks can be broken up into component parts and could include trials of part-task training in preparation for attempts at performing the whole task New Skill: Patient demonstrates closed chain upper extremity sequencing necessary to independently push to stand (or to initiate roll, etc) New Skill: Patient properly sequenced 5 component parts necessary for successful sit to stand transfer (use of arms, forward lean, proper positioning of legs, use of momentum and initial standing balance) 20

21 Task Attention By merely adjusting the degreeto which the patient is allowed to attend to the function to be performed, the task becomes more difficult. New Skill: Patient able to maintain neutral spine without verbal cueing while performing secondary task (folding sheet) New Skill: Patient able to ambulate without step hesitation or path deviation while performing a cognitive task (which research shows decreases balance and reaction time) 21

22 Feedback A conscious effort (over time) to decrease external feedback and allow patient to substitute his own internal cues New Skill: Patient able to properly perform XYZ exercise as taught without using external support or cues. Skill necessary as patient will be discharged to independent exercise program within 4 sessions. New Skill: Patient able to ambulate without step hesitation or path deviation while performing a cognitive task (which research shows decreases balance and reaction time) 22

23 Environment Environmental progression can include modificationof any of the surrounding conditions. The pool setting can be adjusted to increase (or decrease) auditory, visual, proprioceptive, vestibular and tactile information. New Skill: Patient able to perform single limb stance x 30 seconds demonstrating proper ankle and hip strategies standing in waist deep water (50% body weight) New Skill: Patient able to perform upper extremity sequence (see chart) at 90 degrees/second or faster pace without increase in pain > 3/

24 Regional Focus A regional approach to progression includes a purposeful shift of focus from one anatomical region or area to another. New Skill: Patient able to execute median nerve stretch properly without cues New Skill: Patient able to perform segmental spinal rotation while immersed to chest level (25% spinal loading) without movement of feet (log roll motion) 24

25 Assistive Device Another method of withdrawing assistance and thus progressing a task is the removal of support from an assistive device. New Skill: Patient able to stabilize spine in neutral position while supported on unstable surface (moved from stable pool wall to unstable buoyant surface) New Skill: Patient able to ambulate 10 immersed to waist deep (50% weight bearing) without use of parallel bars 25

26 Assistance Given Another common way to think of progression in exercise or activity is the gradual withdrawal of the amount of assistance given or required. New Skill: Patient able to hold forward lunge position without therapist s physical assistance New Skill: Patient able to perform 10 exercises which will comprise independent pool program without verbal cues. Ready for d/c to independent status. 26

27 Recognize 5 ways toidentify the "skill" that went into each treatment through daily #5.documentation. Safety Ex. progression 27

28 Education Hands-on Tx Reassessment 28

29 Library Language Source: Innovative Aquatic Therapy for Low Back Pain: Ideas from the Trenches Thanks for attending, Andrea QUICK LINKS: Phone: (800) Downloads at: Post-test instructions: will be ed to you 29