Byline: Andrea Salzman, MS, PT
Improvement in balance is caused by the ability to make movement errors and correct for them and the water provides an environment in which this can be attempted safely. Hypothesized benefits are improved balance and improved sensory awareness.
Hypothesis: Patients may be challenged beyond limits of stability in the water without the fear of consequences of falling which are often present with land-based balance training. The environment leads to improvement in balance reactions which are translatable to land.
Building an Argument
I. Hydrodynamic principles
Movement through water is affected by turbulence and viscosity. Water is more viscous than air, and resistance to flow through water is greater than resistance to flow through air. Thus, it takes more force to push through water molecules than to push through air molecules. Additionally, the faster an object is pushed through the water, the more turbulence is created and this creates additional resistance to movement.
Richley Geigle et al argue that somatosensory input is increased more by moving an object through a viscous liquid than by moving through a less viscous gas (air). They postulate that resistance to movement may "cause distention or stretch of the skin resulting in stimulation of rapidly adapting mechanoreceptors, perhaps contributing to better proprioception." [7] A body immersed is surrounded by a viscous fluid which retards the speed of movement. This viscosity prevents rapid falling and elongates the period of time in which a patient can respond to a shift of his center of mass outside his base of support. Additionally, the natural end result of a loss of balance which is not corrected is a fall into a compliant fluid (water) and not a fall to a noncompliant solid (the ground).
Thus, the patient may be challenged to move outside his base of support without fear of traumatic consequences. This reduction in patient anxiety may encourage the patient to attempt tasks which he would not attempt on land. It becomes possible to elicit balance challenges which the patient has both time and mental confidence to combat. On land, without the assistance of such aquatic properties, the resultant balance responses may be incomplete or absent. Water offers a three dimensional environment of both support and resistance. Any object with a specific gravity of less than one will tend to float toward the surface of the water. Alternatively, any object with a specific gravity less than one will sink.
According to Richley Geigle et al, these forces combine to "create multiple combinations of joint angles and planes of motion which are assisted, supported or resisted to various degrees. The therapist may use these combinations in the water to challenge the patient beyond his or her limit of stability, without the fear of the consequences of falling which are often present with land-based balance training." [7]
II. Clinical Research
To support the use of aquatic therapy (performed by a therapist) for improving balance and sensory awareness in patients with rheumatologic disorders, the following five recent systematic reviews provide robust evidence:
1. Medrado et al. (2022): This systematic review investigated the effectiveness of aquatic exercise in the treatment of inflammatory arthritis, including rheumatoid arthritis and spondyloarthritis. The review found that aquatic exercise significantly improved physical function and reduced pain and disease activity, indicating benefits for balance and sensory awareness.[1]
2. Pieniążek et al. (2021): This study assessed the impact of rehabilitation in the aquatic environment on patients' balance compared to rehabilitation at a gym. The results showed that patients undergoing aquatic therapy experienced a greater improvement in balance, highlighting the effectiveness of aquatic therapy in enhancing neuromuscular communication and movement coordination.[2]
3. Zhao et al. (2020): This meta-analysis focused on the effectiveness of aquatic physical therapy interventions on disease activity and function in patients with ankylosing spondylitis. The findings demonstrated significant reductions in pain and improvements in balance and functional mobility, supporting the use of aquatic therapy for sensory awareness and balance enhancement.[3]
4. Faíl et al. (2022): This systematic review with meta-analysis evaluated the benefits of aquatic exercise in adults with and without chronic diseases, including rheumatologic conditions. The review found that aquatic therapy significantly improved balance, flexibility, and strength, making it a valuable intervention for enhancing sensory awareness and balance in patients with rheumatologic disorders.[4]
5. Verhagen et al. (2012): Although slightly older, this best-evidence synthesis provides a comprehensive summary of the effectiveness of aquatic exercises in treating musculoskeletal conditions, including rheumatoid arthritis and osteoarthritis. The review highlighted that aquatic exercises are beneficial for reducing pain and disability and improving balance and physical function.[5]
These systematic reviews collectively provide strong evidence supporting the use of aquatic therapy for improving balance and sensory awareness in patients with rheumatologic disorders.
References
Medrado LN, Mendonça MLM, Budib MB, Oliveira-Junior SA, Martinez PF Effectiveness of Aquatic Exercise in the Treatment of Inflammatory Arthritis: Systematic Review.
Rheumatology International. 2022;42(10):1681-1691. doi:10.1007/s00296-022-05145-w.
Pieniążek M, Mańko G, Spieszny M, et al. Body Balance and Physiotherapy in the Aquatic Environment and at a Gym. BioMed Research International. 2021;2021:9925802. doi:10.1155/2021/9925802. Copyright License: CC BY
Zhao Q, Dong C, Liu Z, et al. The Effectiveness of Aquatic Physical Therapy Intervention on Disease Activity and Function of Ankylosing Spondylitis Patients: A Meta-Analysis.
Psychology, Health & Medicine. 2020;25(7):832-843. doi:10.1080/13548506.2019.1659984.
Faíl LB, Marinho DA, Marques EA, et al. Benefits of Aquatic Exercise in Adults With and Without Chronic Disease-a Systematic Review With Meta-Analysis. Scandinavian Journal of Medicine & Science in Sports. 2022;32(3):465-486. doi:10.1111/sms.14112.
Verhagen AP, Cardoso JR, Bierma-Zeinstra SM.Aquatic Exercise & Balneotherapy in Musculoskeletal Conditions. Best Practice & Research. Clinical Rheumatology. 2012;26(3):335-43. doi:10.1016/j.berh.2012.05.008.
Simmons, V., & Hansen, P.D. (1996). Effectiveness of water exercise on postural mobility in the well elderly: An experimental study on balance enhancement. Journal of Gerontology, 51A(5), M233-M238.
Geigle, P.R., Cheek, W.L., Gould, M.L., Hunt, H.C., & Shafiq, B. (1997). Aquatic physical therapy for balance: The interaction of somatosensory and hydrodynamic principles. Journal of Aquatic Physical Therapy, 5(1), 4-10.
Conclusion
In addition to the above, Simmons and Hansen found that the water exercisers adhered to their program, as evidenced by better attendance rates [6]. The authors postulate that the improvement shown by the water exercisers was due to their ability to make and correct for movement errors in a viscous, safe environment which provided proprioceptive feedback to movement. The authors felt that land-based exercise may be too intimidating for those with balance deficits; the cost of loss of balance is much greater than it is in water. The water's turbulence, inherent destabilizing effect, and depth-dependent buoyancy effect may enhance the variability of practical effect needed to learn compensation for loss of balance.
Comments