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Taking It Easy: Encouraging patients with rheumatologic disorders

Byline: Andrea Salzman, MS, PT

Therapists who work in the water have a difficult task. Not only must they understand the nuances of their

patients' diagnoses, but they must understand all the technical distinctions that come from working in a

unique environment: the pool. In addition, there is more of a call for justification for aquatic therapy than for garden-variety physical therapy. Payers look at the pool and think of synchronized swimming, of water aerobics, of learn-to-swim lessons, of just about everything but skilled intervention. Consequently, they want therapists to make a strong case for taking a patient into the water.

Definition of Terms

Always describe rheumatologic language in lay terms to patients to increase their understanding of their condition. Specifying specific conditions also helps.

Fibromyalgia is a group of nonspecific illnesses characterized by pain, tenderness and stiffness of joints, capsules and adjacent structures. Focal trigger points may be identified. Systemic symptoms such as fatigue, insomnia and depression may be present.

Osteoarthritis is a chronic disease involving the joints, especially those bearing weight. It is often characterized by destruction of articular cartilage, overgrowth of bone with lipping and spur formation and impaired function.

Rheumatoid arthritis is a form of arthritis with inflammation of the joints, stiffness, swelling, cartilaginous hypertrophy and pain.

Precautions and Contraindications

Next, identify precautions and contraindications to exercise in a therapy pool for patients with rheumatologic problems. (Note that precautions and contraindications that are general to the public at large are not listed here.) If the patient has arthritic hands, avoid the use of equipment that requires strong grip. If the patient is easily fatigued, progress exercise intensity, frequency and duration cautiously.

In addition, identify techniques and specific treatment parameters for designing an aquatic therapy program for patients with rheumatologic problems. Provide more warm-up time to increase time for joints to "loosen up" (from the synovial fluid bathing the joint). Include warm-up, socializing (games), balance and reaction time training, gross and fine motor skills tasks, aerobic exercises, flexibility exercises and cool-down. Increase progressive resistive exercise (PRE) gradually to prevent delayed onset muscle soreness. Remember that the goal is function, not necessarily "normal limits." Flexibility necessary for one patient may be unnecessary for others.

Try to emphasize functional movement patterns (e.g., PNF, transfers) during exercise instead of multiple straight plane to conserve energy while exercising all muscle groups. Water temperature should be at least 92 degrees Fahrenheit (thermoneutral) to be soothing for patients.

Goals for Aquatic Therapy

Overall goals for aquatic therapy for patients with rheumatologic problems should include:

• Improvement in cardiopulmonary fitness;

• Improvement in flexibility;

• Improvement in strength;

• Improvement in fine motor skills;

• Improvement in balance, reaction time, and safety during ambulation;

• Improvement in gait parameters;

• Improvement in posture;

• Improvement in ability to perform ADLs;

• Improvement in exercise tolerance;

• Improvement in work tolerance or duration;

• Decrease in complaints of pain and stiffness;

• Compliance with attendance and willingness to learn and execute an aquatic program.

Benefits of Aquatic Therapy

Always take the time to identify the benefits of aquatic therapy for patients with rheumatologic problems, including:

• Reduction in weight bearing during exercise;

• Reduction in gravitational pull on posture, which permits more spinal extension than possible on land;

• Promotion of synovial fluid bathing of the joint, which decreases joint stiffness and pain;

• Retardation of muscle atrophy that often accompanies immobility;

• Increase in proprioceptive awareness during exercise and functional task simulation;

• Increase in amount of time to recover from loss-of-balance episodes;

• Provision of soothing environment in which to perform exercises with a reduction in pain.

Providing PT in an aquatic environment becomes logical when you can break it down into component parts.

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