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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6011_Библиотеки_им_академика_М_И_Перельмана.pdf
C H A P T E R 1 6 Imaging of the Aging Spine
95
L2
L4
A
F IG UR E 1 6- 14 Severe spinal stenosis secondary to epidural lipomatosis and other degenerative changes. A, Sagittal T1-weighted image. B, Axial
T1-weighted image at L3-L4 level. C, Axial T1-weighted image at L4-L5 level. Excessive epidural fat (open arrows) in conjunction with facet hypertrophy, ligamentum
flavum hypertrophy (asterisks), and disc bulging and protrusion (white arrows) result in severe spinal stenosis. The thecal sac (S) is severely compressed.
B
S
S
*
*
C
solving in selective cases. Appropriate use and proper performance of the
imaging techniques are prudent to maximize the benefits of imaging.
Degenerative disease is the most common reason for spine imaging.
C3
Standardized nomenclature for description of degenerative spine disease
has been developed,
adoption of this nomenclature is encouraged to facilitate more effective
1
and further revision is now underway. A universal
communication among all who provide spine care to patients. Neoplasm,
infection, and trauma are also important indications for imaging. Imaging
is particularly important in patients presenting with the so-called red flags
that suggest a higher risk of these diseases, such as increasing age, osteoporosis, and persistent or progressive symptoms. In patients who have received
spine surgery, imaging is required to assess hardware placement, postsurgical
complications, and disease progression after surgery.
Many issues in spine imaging warrant further research. The correlation
between clinical presentation, imaging findings, and clinical outcomes is
still not well understood. In addition, continuing advances in imaging technology will provide increasingly explicit anatomical details of the diseased
spine, as well as new physiological and dynamic imaging data that have not
been captured by the more traditional imaging technology. Some of these
examples include high-resolution 3D MR imaging, special MR units that
allow patients to be imaged in different positions, and ultrafast volumetric
CT that can image the spine in flexion and extension. It is without doubt
F IG UR E 16 -1 5 Myelomalacia at level of C4-C5 to C5-C6 is seen as
increased T2 signal (long arrow) on this sagittal T2-weighted image. The cord
is atrophic with small areas of cystic changes. This patient had traumatic injury
and degenerative disease of the spine. Note the disc bulging and ligamentum
flavum hypertrophy at C4-C5 and C5-C6 levels (short arrows) resulting in spinal
canal stenosis. There is thinning of the ligamentum flavum at C5 level (open
arrow), probably from previous hyperflexion injury.
tethering of the cord to the dural sac may also be present. Differentiation
of myelomalacia from reversible edema or ischemia can be difficult when
atrophy associated with the myelomalacia is not evident.
SUMMARY
Imaging is an essential component of the evaluation of the aging spine.
Proper patient management hinges on correct diagnosis. Imaging facilitates
this by providing accurate depiction of the morphological changes associated with diseases. Plain film radiography, CT, and MRI constitute the
that imaging will play an ever-increasing role in the care of the aging spine.
References
1. D.F. Fardon, P.C. Milette, Nomenclature and classification of lumbar disc pathology, Spine 26
(5) (2001) E93–E113.
2. T.J. Masaryk, J.S. Ross, M.T. Modic, et al., High resolution MR imaging of sequestered lumbar
intervertebral discs, AJNR Am J. Neuroradiol. 9 (1988) 351–358.
3. M.T. Modic, P.M. Steinberg, J.S. Ross, et al., Degenerative disc disease: assessment of changes
in vertebral body marrow with MR imaging, Radiology 166 (1988) 193–199.
4. R . Rahme, R. Moussa, The Modic vertebral endplate and marrow changes: pathologic signifi-
cance and relation to low back pain and segmental instability of the lumbar spine, AJNR Am.
J. Neuroradiol. 29 (2008) 838–842.
5. G.R . Buttermann, K.B. Heithoff, J.W. Ogilvie, et al., Vertebral body MRI related to lumbar
fusion results, Eur. Spine. J. 6 (1997) 115–120.
6. A. Leone, G. Guglielmi, V.N. Cassar-Pullicino, L. Bonomo, Lumbar intervertebral instability,
Radiology 245 (1) (2007) 62–77.
7. R .S. Nizard, M. Wybier, J.-D. Laredo, Radiologic assessment of lumbar intervertebral instabil-
ity and degenerative spondylolisthesis, Radiol. Clin. North Am. 39 (1) (2001) 55–71.
8. I. Macnab, The traction spur: an indicator of segmental instability, J. Bone. Joint Surg. Am. 53
(1971) 663–670.
mainstay of imaging evaluation of the spine. Ancillary techniques such as
nuclear imaging, myelography, and discography are often used for problem
Land Based Rehabilitation and
the Aging Spine
Jack Miletic and Avrom Gart
17
k e y p o i n t s
Review the pathophysiology of the “degenerative cascade” in the aging spine.
Identify appropriate therapeutic movements for specific spinal pathology.
Understand patient comorbidities and how they affect the rehabilitation of
the aging spine.
Understand the physiology behind the stability of the lumbar spine.
Review the core stabilization exercises.
Before focusing on the rehabilitation essentials, we wil l dedicate some time
to reviewing the pathophysiologic basis of the degenerative spine, as has
been elegantly described by Kirkaldy-Willis.1 A thorough understanding of
spinal anatomy and the process of degeneration will better equip us to grasp
the focus of rehabilitation exercises tailored for specific pathologic findings
in the degenerated spine. Comorbidities are a significant factor influencing
the shape and depth of rehabilitation, therefore it is necessary to review
common comorbidities encountered when determining a rehabilitation
program, and how to adjust it based on these confounding factors. Finally,
before reviewing the essential core stabilization exercises, we would like to
touch on the normal physiology involved in stabilizing the spine. With this
background, we can better understand the kinematics and kinesiology of the
exercises reviewed.
THE “DEGENERATIVE CASCADE”
The spine is dynamic and is constantly modeling and remodeling, a process
greatly influenced by the physical stresses placed upon it. These changes can
positively or negatively impact neurological status and spinal biomechanics.
There are a certain set of conditions associated with degeneration of the aging
spine. Most commonly seen disorders include degenerative disc disease, segmental dysfunction or instability, zygapophyseal arthropathy, spinal stenosis,
cervical spondylotic myelopathy, and radiculopathy. To better understand
these conditions and which therapeutic approach would be most appropriate, we need to understand the pathophysiology of the degenerating spine.
Currently, the most widely accepted theory of intervertebral disc degeneration pathophysiology is a three-stage approach described by KirkaldyWillis.1 Stage I describes the acute pain of an initial insult occurring in the
early 20 to 30 years of life. This is the beginning of what Kirkaldy-Willis
described as the “degenerative cascade.” Repetitive microtrauma to the vertebral endplates results in ischemic events that can compromise the nutritional and metabolic transport to the disc. This microtrauma may also be
responsible for an alteration in proteoglycan content resulting in decreased
disc hydration and subsequent load-bearing capacity. Clinically, the patient
will present with intermittent and self-limiting pain. However, the pain
experienced may be extremely debilitating because of the innervation of the
outer third of the annulus by the sinuvertebral nerve.
Stage II, or the instability stage, represents continued disc dehydration
and loss of disc height. Increased force transfer to the annulus occurs with
the subsequent loss of disc height.1 This stage occurs later in life, between 30
and 50 years of age, and the patient presents with periods of low back pain
which is usually more intense and protracted in duration.
Stage III, known as the stabilization stage, usually occurs in the 60 and
older population. There is continued end-stage tissue damage and attempts
at repair. Disc resorption leads to disc collapse, endplate destruction, fibrosis, and osteophyte formation. The patient usually presents with symptoms
of neurogenic claudication or radiculopathy from central, lateral recess, and/
or foraminal stenosis.
1
THE FOCUS OF REHABILITATION
Aging is a normal process, and understanding the anatomic and physiological changes that occur with normal aging will allow for optimal rehabilitation. Some age-related bodily changes may be misunderstood and can
unnecessarily limit daily activities; however, when designing an exercise
program for older adults, the possibility of a latent or active disease process
must be taken into consideration. The exercise prescription must be individualized based on the health status and the goals of the individual.
The focus of rehabilitation in the aging population should consist of the
following: (1) increasing, restoring, or maintaining range of motion, physical strength, flexibility, coordination, balance, and endurance; (2) recommending adaptations to make the home accessible and safe; (3) teaching
positioning, transfers, and walking skills to promote maximum function
and independence within an individual’s capability; (4) increasing overall
fitness through exercise programs; (5) preventing further decline in functional abilities through education, energy conservation techniques, joint
protection, and use of assistive devices to promote independence; and finally,
(6) improving sensation, and joint proprioception, and reducing pain.
A conservative approach is usually warranted, considering the patient
population’s comorbidities. Any form of aerobic activity should be structured to provide adequate rest and minimal imposition of joint stress.2 Initiating resistance training under close supervision with the least amount of
resistance can provide significant benefit in the aging population.3 As with
younger individuals, functional range of motion is extremely important and
all aspects of physical therapy should be preceded by appropriate stretching
and warm-up to prevent further injury.
Much has been reported on the appropriate amount of rest a patient
with acute back pain should adhere to. What has become clear is that excessive immobility will translate to decreased aerobic capacity, impaired flexibility, loss of muscle strength, and promotion of bone demineralization,
all of which will exacerbate and promote further pain and disability.4 Ultimately limiting bed rest to a short period proves to be less detrimental than
extended periods of bed rest, even in the population of patients who exhibit
radiculopathic symptoms.
5
PATHOPHYSIOLOGIC BASIS FOR REHABILITATION
The goal of exercise for the treatment of acute back pain is pain control.
Therefore initiating exercises based on which direction of motion either
increases or reduces pain will provide more positive outcomes.
6,7
Movement
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P A R T I I I Conservative Treatment Modalities
into flexion or extension will centralize low back pain and reduce the
patient’s symptoms.
Extension-based exercises, or McKenzie exercises, may be effective in
reducing discogenic pain8 by alleviating pressure on the posterior annular
fibers and thereby altering intradisk pressure,9 which will concurrently allow
anterior migration of the nucleus pulposus10 and subsequent decreased tension on the nerve root.11 Contraindications to extension-based exercises
include segmental instability, bilateral sensory or motor deficits, large or
uncontained herniations, or an increase in radiculopathic symptoms. If the
patient responds well to extension exercises and demonstrates centralization
of his or her pain, repeated extension posturing while standing and use after
sitting or forward bending is stressed. If the patient does indeed have segmental instability, manual blocking of extension at that level can be achieved by the
therapist, and the patient can be educated on preventing segmental mobility.
Flexion-based exercises, or Williams exercises, may be effective in
decreasing zygapophyseal joint compressive forces, thus alleviating the compressive load to the posterior disc, decompressing the intervertebral foramen,
stretching hip flexors and paraspinal musculature, and strengthening core
stabilizers, such as the abdominals.12 Included in flexion-based exercises are
pelvic tilts, which can be performed either with bent knees, straight legs, or
standing, depending on the comfort level of the patient. These exercises will
help decompress the zygapophyseal joint and help mobilize the pelvis for
sacroiliac joint dysfunction.
When dealing with patients with idiopathic scoliosis it is widely understood that therapeutic exercises cannot prevent the progression of the curvature; however, there is a clear role for rehabilitation in this setting. The
fundamental goal is to prevent the progression of secondary morbidities. Exercises to restore range of motion and strength should begin early. The patient
will benefit from exercises that focus on improving trunk posture and alignment, which may prevent the development of a pathological curve. Abdominal
and gluteal strengthening helps prevent deconditioning and atrophy, whereas
lower extremity hip flexor stretching works well to prevent contractures.
13
COMORBIDITY INFLUENCE ON REHABILITATION
The key to a successful rehabilitation approach in any patient population
is conservatism and understanding the patient’s limitations. Interaction
between exercise and the medical condition is essential to grasp so that
deleterious exercise effects can be avoided, particularly when dealing with
patients that may have cardiac disease, diabetes mellitus, obesity, osteoarthritis, peripheral vascular disease, or cancer.
In patients who have cardiac comorbidities, a typical rehabilitation
approach would include isotonic, aerobic, and rhythmic exercises involving
large muscle groups, as well as isometric and resistive exercises, particularly for
patients with left ventricular dysfunction. Instituting heart rate and systolic
and diastolic blood pressure parameters varies depending on the pathology.
Patients that have pulmonary comorbidities such as chronic obstructive
pulmonary disease (COPD) respond to controlled breathing techniques
to improve pulmonary function parameters with diaphragmatic breathing
exercises. The need to monitor for hypercapnia is an essential indicator for
the need for muscle rest periods to be added to the exercise program. As
with cardiac precautions, pulmonary precautions are instituted with regard
to respiratory rate and oxygenation.
Osteoporosis must be considered when therapeutic exercises are instituted.
Physical therapy should be tailored to individual fitness level and anticipated
propensity to fracture or current fractures. Precautions include avoiding spine
flexion exercises, which may predispose to vertebral compression fracture.
muscles, which attach to the thoracolumbar fascia and provide for flexion,
extension, and rotation of the spine, is a key component to improving trunk
strength and preventing future exacerbation of pain.
Stabilization of the spine progresses through a sequ ence of events that
begins with strengthening of the smaller intersegmental local muscles of the
lumbar spine, such a s the multifidi and transversus abdominis. The multifidi usually span a few segments and thereby have a poor mechanical advantage as a significant mover of the spine, but they do play a role in rotational
movement and balancing of the shear forces of the spine.
15,16
Initial exercises
focus on obtaining isolated control of these muscles without substitution.
The next phase of stability training focuses on neutral spine stabilization
exercises, regarded as the “safe,” pain-free position.17 A neutral spine position
decreases tension on ligaments and joints, appropriate segmental forces with
respect to the disc, and the zygapophyseal joint provides optimal stability
with axial loading and gives the patient the greatest level of comfort. The
neutral spine is located through various body positions, which is followed
by lower extremity exercises initially without resistance, then with resistance
while maintaining a neutral spine. This approach will help facilitate coordination, endurance, and strength.
Finally, the prime movers, including the rectus abdominis, erector spinae, and latissimus dorsi, are strengthened. Traditionally abdominal exercises have been emphasized a s part of a low back exercise program, as well
as lower extremity strengthening because of their integral association with
the trunk. This is particularly important during lifting, where education in
proper bending and lifting techniques is stressed to prevent new-onset low
back pain. Lower extremity muscular flexibility is extremely important for
optimal physiologic lumbar motion. Hip flexors and extensors attach to the
pelvis and will essentially dictate lumbar positioning, which can result in
excessive stress on lumbar segments and the sacroiliac joint. If a patient has
tight hip flexors, this will result in extension of the lumbar spine and subsequent shear forces on the intervertebral disc. A slight alteration in the kinetic
chain biomechanics will promote pain and disability. Self-stretching techniques should be initiated as early as possible in the neutral pelvic position.
CORE STABILIZATION EXERCISES
The most common stabilization exercises incorporated in a routine rehabilitation program include (1) finding the neutral position, (2) sitting stabilization, (3) prone gluteal squeezing exercises, (4) pelvic bridging progression,
(5) kneeling stabilization, (6) wall slide quadriceps strengthening, (7) position transition with postural control, (8) curl-ups, (9) diagonal curl-ups,
(10) side bridging, and (11) straight leg lowering. Fitness programs that follow core-strengthening principles include Pilates, yoga, and taichi—all of
which must first be determined appropriate in the aging population with
certain limitations.
Figures 17-1 and 17-2 demonstrate abdominal strengthening exercises,
showing proper activation of the muscles around the abdominal area to
PHYSIOLOGIC FACTORS OF SPINAL STABILIZATION
Stability of the lumbar spine requires both passive stiffness, through the
osseous and ligamentous structures, and active stiffness, through musculature. Any injury to the passive supporting network of the spine will result in
instability.14 That is why optimal muscle strength can protect the damaged
spine from repetitive shear forces or nonphysiologic weight bearing. The
thoracolumbar fascia acts as a physiologic corset, in essence providing a link
between the lower limb and the upper limb, supporting the spinal segments
and providing proprioceptive feedback to the individual. Therefore a comprehensive stabilization or facilitation of the abdominal, pelvic, and trunk
F IG UR E 1 7- 1 Abdominal exercises: single leg curl.
F IG UR E 1 7- 2 Abdominal exercises: lying trunk twist.
C H A P T E R 1 7 Land Based Rehabilitation and the Aging Spine
support the low back in static and dynamic positions. Daily dynamic load
bearing causes the muscles to contract around the viscera to form a stable core
region against which the forces are balanced, in coordination with posture.
Figures 17-3 to 17-5 demonstrate back and buttock exercises, which
along with abdominal training help control movement, transfer energ y,
shift body weight, and move in any direction. Weak core muscles result in
loss of lumbar lordosis and postural deficiency. Stronger, more balanced
core musculature helps maintain appropriate posture and reduce strain on
the spine.
Figures 17-6 to 17-8 demonstrate trunk and full body exercises, which
are important for proper coordination patterns and abdominal and low back
endurance.
101
F IG UR E 1 7- 3 Buttock and back exercises: floor bridging.
F IG UR E 1 7- 5 Buttock, back, and abdominal exercises: horse stance.
F IG UR E 1 7- 4 Buttock and back exercises: single-leg bridging.
F IG UR E 1 7- 6 Trunk and full body exercises: modified weighted
lunges.
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P A R T I I I Conservative Treatment Modalities
F IG UR E 1 7 -7 Trunk and full body exercises: standing weighted
obliques.
The ultimate goal of core stabilization is to achieve optimal task performance while maintaining appropriate trunk position and control, which
will help ensure the prevention of recurrent injury. As always, consideration
must be given to individual musculoskeletal response to the exercise and the
overall metabolic demands.
References
1. W.H. Kirkaldy-Willis, et al., Pathology and pathogenesis of lumbar spondylosis and stenosis,
Spine 3 (1978) 319–328.
2. American College of Sports Medicine, ACSM’s guidelines for exercise testing and prescrip-
tion, sixth ed., Lippincott Williams & Wilkins, Philadelphia, 2000.
3. M.A. Fiatarone, et al., Exercise training and nutritional supplementation for physical frailty
in elderly people, N. Engl. J. Med. 330 (1994) 1769–1775.
4. V.A. Coveretino, et al., Symposium: physiological effects of bed rest and restricted physical
activity: and update, Med. Sci. Sports Exerc. 29 (1997) 187–206.
5. P.C.A.J. Vroomen, et al., Lack of effectiveness of bed rest for sciatica, N. Engl. J. Med. 340
(1999) 418–423.
6. R. Donelson, et al., Pain response to sagittal end-range spinal motion. A prospective, ran-
domized, multicenter trial, Spine 16 (1991) S206–S212.
7. R. Stankovic, et al., Conservative treatment of acute low back pain. A prospective randomized
trial: McKenzie method of treatment versus patient education in mini back school, Spine 15
(1990) 120–123.
8. R. Melzack, et al., Pain mechanism: a new theory, Science 150 (1965) 971–979.
9. A. Nachemson, et al., Intravital dynamic pressure measurements in lumbar discs: a study of
common movements, maneuvers and exercises, Scand. J. Rehab. Med. (Suppl. 1) (1970) 1–40.
10. R.A. McKenzie, The lumbar spine: mechanical diagnosis and therapy, Spinal Publications,
Waikance, New Zealand, 1981.
11. B.E. Schnebel, et al., The role of spinal flexion and extension in changing nerve root compres-
sion in disc herniation, Spine 14 (1989) 835–837.
12. P. Williams, Low back and neck pain: causes and conservative treatment, third ed., Charles C
Thomas, Springfield, Ill, 1974.
13. K.J. Noonan, Adolescent idiopathic scoliosis: nonsurgical techniques: The pediatric spine:
principles and practice, s econd ed., Lippincott Williams & Wilkins, New York, 2001,
pp. 371–383.
14. G.R. Ebenbichler, et al., Sensory-motor control of the lower back: implications for rehabilita-
tion, Med. Sci. Sports Exerc. 33 (2001) 1889–1898.
15. J.J. Crisco, et al., The intersegmental and multisegmental muscles of the lumbar spine. A
biomechanical model comparing lateral stabilization potential, Spine 16 (1991) 793–799.
16. M.M. Panjabi, et al., Spinal stability and intersegmental spinal forces. A biomechanical
model, Spine 14 (1989) 194–200.
17. J.A. Saal, Dynamic muscular stabilization in the non-operative treatment of lumbar pain
syndromes, Orthop. Rev. 19 (1990) 691–700.
F IG UR E 1 7 -8 Trunk and full body exercises: standing weighted
obliques.
Aquatic Physical Therapy
Thomas Cesarz and David Speach
18
k e y p o i n t s
Swimming skill is not required for patients to safely engage in water-based
therapies.
Aquatic exercises are generally as safe as land-based exercises but health
contraindications exist that may prohibit water-based therapy.
Aquatic physical therapy is indicated when an individual cannot tolerate
land-based therapies.
Pain relief and improved function are the most common reasons for
prescribing aquatic-based physical therapy.
Scientific literature supporting purported benefits of aquatic therapy is
limited. Extrapolated research in patients with knee arthritis and ankylosing
spondylitis do demonstrate modest benefits in pain reduction and well-being
following aqua therapy.
For millennia people have used water for healing and for rituals, traditions continuing through the present. Today, water is applied in a variety of
therapies, with proponents of each often making broad and unsubstantiated
claims of health benefits. Commonly used terms for water-based therapies
include hydrotherapy, aquatic therapy, balneotherapy, and spa therapy.
Hydrotherapy and aquatic therapy are often used interchangeably to
refer to physical therapy performed in water. Spa therapy refers to physical
modalities applied in a relaxing atmosphere that may be purely commercial, devoid of oversight from a licensed practitioner at point of delivery.
Spa therapies can include land-based modalities such as massage and
electrotherapy, as well as water-based forms such as balneotherapy and
whirlpool. Spa treatments, even when water-based, are typically passive.
Studies of spa interventions prove difficult. Balneotherapy refers to the
immersion of patient or limb in a natural thermal mineral water, defined
as at least 20° C, and containing a concentration of specific salts in excess
of 1 g/L.
land-based physical therapy. It will cover the theoretical underpinning of
aquatic exercise with appropriate indications and contraindications.
1
This chapter focuses on aquatic therapy exercises that are analogous to
CLINICAL CASE EXAMPLES
A 78-year-old woman with advanced bilateral knee osteoarthritis and leg
and back pain occurring only when walking and standing has been unable
to tolerate land-based aerobic exercise due to pain.
A 68-year-old obese male smoker with chronic axial low back pain and
poor endurance presents to a chronic pain center with markedly reduced
daily function and pain with any movement or prolonged positioning.
BASIC SCIENCE
For such a widely used and presumably safe activity, immersion in water
has far-reaching physiological effects that help explain the patient’s relief
of symptoms but also raise the flag of specific contraindications. Water
differs from air in density, buoyancy, and viscosity, rendering it of different
therapeutic value.
Water is nearly 800 times as dense as air.
material exerts a pressure based on the density of the material. For example,
at sea level, effectively at the “bottom” of the earth’s atmosphere, patients are
exposed to the pressure of air. When a patient enters a body of water, be it
a hot tub, swimming pool, or ocean, the water exerts pressure that increases
with increasing depth. Water affects the cardiovascular and renal systems.
Water’s hydrostatic pressure compresses veins, increasing venous return and
pushing blood centrally, leading to a rise in central blood volume, cardiac
blood volume, and cardiac output.
Healthy individuals seated for 2 hours in water from the renowned spa at
Bath, England, showed a doubling of diuresis and 50% increase in cardiac
index. The increase in diuresis is not due to an increase in creatinine clearance, though alteration of renally active hormones may play a role.
unclear if hydrostatic pressure is the primary mechanism underlying all of
these systemic effects.
Water is a viscous substance that resists movement. The resistance
offered by the water increases as speed of movement increases, so when the
patient first starts exercising in water, a slower velocity is naturally used. As
strength and endurance improve, faster movement is possible with greater
challenge. Because of the mechanics of fluid, resistance is maximized if the
patient performs exercises in a continuous movement in which the limb
is kept below the water surface. Resistance can be strategically lessened
to accommodate the patient’s strength level with partial submersion and
pausing during the movement. For the stronger patient, water mitts and
hand paddles can be added to increase drag of the limb.
has several advantages compared to land. Movements against water are
inherently more difficult than identical movements against air because of
1
water’s viscosity, making virtually any movement against water a resistance
training exercise. Performing resistance training movements in water puts
less stress on joints because they are unloaded of gravitational forces compared to land.
Pain decreases in water through several mechanisms. The natural
buoyancy of water unloads joints and supports the body so less muscle
activation and coordination is required to maintain balance. Standing
upright with water up to the neck, the upward buoyant force counteracts
gravity so that about 10% of the normal gravitational force is exerted on
the body. Discs, facets, and peripheral joint structures are unloaded allowing for functional movements such as walking with less stress.
of muscle activity to maintain balance allows for easier control of proper
pelvic tilt and lumbar curvature. Body support from buoyancy in positions of spinal flexion and extension means the patient can actively range
through normally painful spinal load movements with less compression
on the spine. Normal range of motion may be achieved in a pain-free
manner in the aquatic environment before trying similar exercises on
5
land.
A negative effect of buoyancy is a decrease in body stability with
water levels above the T8 spinal level. Shallower water may be indicated
if the patient has difficulty keeping his or her feet planted on the pool
5
floor.
An additional factor in aquatic therapy pain relief is that water
acts as a diffuse sensory stimulus that can alter or suppress the typical
pain experience.
5
3
Compression of veins can reduce edema.
2
The bottom of a mass of
5
Training in water
4
It is
6
Reduction
103
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P A R T I I I Conservative Treatment Modalities
Case Studies
TREATMENT, CLINICAL CHALLENGES,
AND FUTURE TREATMENTS
A 78-year-old woman with bilateral knee osteoarthritis and leg and back
pain occurring only when walking and standing has been unable to tolerate land-based aerobic exercise. For this individual, her knee arthritis
interferes with her ability to bear weight and train her spine on land.
Evidence exists showing that aquatic exercises decrease pain from peripheral joint arthritis. e unloading effect that occurs in water allows for
strength training and aerobic conditioning while in a supportive environment that protects from falls. Her history is suggestive of neurogenic claudication from lumbar spinal stenosis, a condition where the
patient often obtains relief while in positions of flexion. In water a flexion
posture is achieved with less compressive force on the vertebral bodies,
limiting the risk of an exercise-induced osteoporotic compression fracture or aggravation of mechanical low back pain. Eventually, this patient
can try transitioning to a land-based program with the goal of improving
her walking tolerance.
CLINICAL PRACTICE GUIDELINES
Physician Evaluation and Prescription
While obtaining the history and physical the practitioner will pay special
attention to factors that will make aquatic therapy uniquely beneficial, as
well as to contraindications. Evaluation includes a focused neurologic
and musculoskeletal examination with a focus on spinal range of motion,
strength, sensation, and gait. A common example of an aquatic therapy
regimen is that outlined by Dr. Andrew Cole.
of progressive difficulty are used for development of spinal stabilization.
Examples include sitting against the pool wall with neutral spine posture,
walking forward and backward, abdominal crunches, a host of exercises
designed for the facilitation of neutral spine posture, flexibility, conditioning
and core strength.
7
Static and dynamic exercises
A 47-year-old obese male smoker with chronic axial low back pain and
poor endurance presents to a chronic pain center with markedly reduced
daily function and pain with any movement or prolonged stationary position. Chronic low back pain is very challenging to treat. Once an individual
becomes deconditioned, land-based exercises can be too challenging, particularly in patients with limited pulmonary capabilities as in obstructive pulmonary disease. Water is an ideal environment to begin recovery of strength,
endurance, and flexibility. e prescribing physician must pay attention to
any contraindications for aquatic therapy that are present in this patient,
such as comorbid severe heart disease or open wounds. e primary goal
for this patient will be to decrease the pain associated with movement. e
buoyant aquatic environment reduces axial load on his spine. Limb exercises performed quickly under water will be more difficult than on land.
An aquatic-based conditioning program must be titrated to his endurance,
which will increase over the course of therapy.
therapy in the treatment of pain for neurologic or musculoskeletal conditions.
The authors distilled the 793 identified studies down to 19 that were of adequate quality with sufficient data to analyze. Three of the included studies
were of chronic low back pain, while the remaining were of rheumatoid arthritis, osteoarthritis, fibromyalgia, and multiple sclerosis. The authors found that
in aggregate there was no additional pain-relieving effect of aquatic therapy
compared to land-based therapies. When compared with no treatment at all,
aquatic therapies provide a small amount of pain relief.
8
These results do not
eliminate the possibility of water-specific pain-relieving properties. The painrelieving effect may be the same for land- and water-based therapies yet their
mechanisms may differ. For the individual unable to tolerate land-based therapies aquatic therapies are a means to seek a pain-relieving effect.
A useful resource for clinicians interested in exploring the evidence base
for water therapies is http://aquaticnet.com/index.htm, an online repository
of references for scholarly and non-scholarly writings on water therapies.
Indications
Indications for water therapy are similar to those for land-based therapies
with the most important criterion being unsuitability for a fully land-based
program. The patient may need extra support due to weakness or proprioceptive loss and concurrent land-based spinal rehabilitation is possible if the
patient can tolerate some land-based exercises.
7
Ultimately the patient needs
to function on land in an air atmosphere without the support and comfort
of water. Aquatic therapy can be used to decrease pain, and improve gait,
strength, endurance, or coordination. In water, skills can be simulated in
a less challenging setting than land with the ultimate goal being improved
function and pain level while on land. The water milieu can serve as a bridge
to improved land function.
5
Contraindications
There are general contraindications for use of any form of water immersion
including home bathing. These include open wounds, fever, severe heart
disease, bowel or bladder incontinence, open ports such as tracheostomy,
feeding tube, or colostomy, and extreme cognitive or functional impairment
rendering a water environment unsafe.
5
Evidence Base
High quality evidence supporting the efficacy of water therapy for pain relief
and functional restoration in patients with spinal disorders has been limited,
with the practice supported primarily by anecdotal reports and extrapolation from studies of peripheral joint arthritis. The purported special ability of
aquatic therapy to reduce pain has been challenged in a recent meta-analysis.
Hall et al.
8
conducted an exhaustive search of 18 databases for studies of water
CONCLUSIONS AND DISCUSSION
Aquatic therapy is an alternative form of physical therapy that is indicated
when land-based exercises are prohibitively challenging. Exercise in water
can be performed with lower requirements of strength, balance, and coordination. Buoyancy reduces forces across joints, making movement less painful. Despite these theoretical advantages there has been limited literature
evidence especially in the form of randomized controlled trials to show that
exercising in water translates to decreased pain and improved function on
land. For special populations, however, such as those with peripheral joint
comorbidities, severe edema, and deconditioning, water-based therapy is
useful when land-based exercise is intolerable.
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