CLINICAL REASONING AND

EVIDENCE BASED
PRACTICE IN AQUATIC
PHYSIOTHERAPY

Sophie Heywood
Lecture Aquaevidence, Leuven 2009
[email protected]
 CLINICAL REASONING
Definition:

•! “a process in which the clinician, interacting with

significant others (client, care givers, health care
team members), structures meaning, goals and
health management strategies based on clinical data,
client choices and professional judgement and
knowledge.”
(Higgs and Jones, 2000)

 CLINICAL REASONING IN
AQUATIC THERAPY

•! What are the additional considerations

related to an aquatic environment?
AQUATIC THERAPY AND LAND
THERAPY

•! Direct comparison
•! Added benefit
•! Key part of multimodal intervention
 TREATMENT

 
  
  
"


 

 
   

 







 !

  
 


 "






 

  


   
 
 "



 
  
  

 


 

FUNCTION AND ACTIVITIES OF
DAILY LIVING (ADL)

What are the considerations for the patient

related to the relationship of aquatic therapy
to their normal daily function?

 SCREENING AND
PHYSIOLOGY OF
IMMERSION








•! Physiological or screening considerations

•! Relevance

•! Impact on planning

•! How will you monitor?

REFERRAL AND SCREENING
Date of Assessment:________________________________
CURRENT HISTORY: (Include reasons for referral to Aquatic Phys/ Hydrotherapy)
Weight Bearing Status : __________________
Medications (include dosage):

PAST MEDICAL PROBLEMS:

_______________________________________________________________________________________________
______________________________________________________________________
Previous Aquatic Physiotherapy/HydrotherapyYes/No
Level of Assistance required in the water
•! Maximal ! Moderate ! Minimal !
PROBLEM OBJECTIVE MEASURE
___________________________________________________________________________________________________
_________________
SMART GOALS FOR AQUATIC PHYSIOTHERAPY
•! _______________________________________________________________________________________________
__________________________
CommunicationNAD ! Impaired !Comments
Primary Language ________Interpreter RequiredYes/No
Cognition/Behaviour NAD ! Impaired !Comments
Assistance RequiredTransfers, Mobility, Dressing
DISCHARGE PLANNING FOR SELF MANAGEMENT:
•! Chronic condition requiring self management strategies !
•! Any issues with transport or support !
•! Attended local pool previously !
•! Which pool _________________________________
•! Land physio discussed local pool attendance after AqPT!
REFERRAL AND SCREENING
YES NO Comments
•! CNS Epilepsy ! !
Headaches/Dizziness ! !
•! CVS Hyper/Hypotension ! !
Cardiac Condition ! !
Peripheral Vascular disease ! !
•! R.S. Respiratory Condition ! !
•! G.I.T. Incontinence: Faeces ! !
•! G.U.T. Incontinence: Urine ! !
•! SKIN Open Wound ! !
Sensitivity to Chlorine ! !
•! EARS Infections, Hearing Impairment/Hearing Aids, !
•! EYES Infections/Discharges, Visual Impairment
•! FEET Tinea, Papilloma, Warts ! !
•! OTHER Febrile Condition Renal Problem Acute Inflammatory Condition
Swallowing Problems Deep radiotherapy in past 3 months Infectious diseases
•! Diabetes Pregnant
•! Gait: Independent ! Assisted ! Supervised ! Non ambulant !
•! Gait Aids
•! Recommended mode of entry to Pool: Steps ! Over side ! Hoist !
•! Is the patient a swimmer?
•! Is the patient afraid of water?
 OUTCOME MEASURES
SUBJECTIVE AND
OBJECTIVE MEASURES
•! Outcome measures are important to show
change over time
•! To assist with determining the patient’s
function and with guiding therapy are there
any relevant subjective information or
objective measures you can use
–! In the land based assessment?
–! Poolside?
–! In the pool?
 AIMS OF TREATMENT

•! Aims of treatment
•! Treatment techniques/ exercises including
progression
•! Hydrostatic/dynamic principle underlying
technique
 SMART GOALS
•! Specific
•! Measured
•! Agreed
•! Realistic
•! Timed
 EVIDENCE BASED PRACTICE

What is evidence-based practice?

Physiotherapy PRACTICE based on the
application of interventions and management
acknowledged as efficacious by a process of
analysis and critique.
 EVIDENCE
•! EVIDENCE may include the scrutiny by
peers of clinical research, published opinion
in journals and texts, and clinical treatment
supported by outcome measurement

•! What type of evidence is better than another

type of evidence?
 SYSTEMATIC REVIEWS THAT
INCLUDE AQUATIC THERAPY

•! Sub-acute low back pain. (Pengel et al 2002)

•! Fibromyalgia. (Adams & Sim 2005)
•! Pre-operative physiotherapy for lower limb joint
replacement surgery (Ackerman & Bennell 2004)
•! Physiotherapy interventions for ankylosing
spondylitis (Dagfinrud et al 2004)
 SYSTEMATIC REVIEWS
FOCUSED ON AQUATIC
THERAPY
•! Children with neuromotor impairments
(Getz et al 2006)
•! Fibromyalgia (Gowans and deHueck 2007)
•! Pain in adults (Hall 2008)
•! Aquatic exercise in the LBP (Waller 2009)
 SYSTEMATIC REVIEW:
HYDROTHERAPY
•! 1984 to 2001: 34 trials
•! Moderate quality evidence supports the effectiveness of
hydrotherapy
–! pain
–! joint mobility
–! function
–! self-efficacy
–! affect
–! fitness
–! balance
•! in patients with
–! rheumatic conditions,
–! chronic low back pain and
–! older adults (Geytenbeek 2002)
 AQUATIC PHYSIOTHERAPY
EPB GUIDE 2008
•! 1997-2007
•! Reference to 154 published papers
–! 11 systematic reviews
–! 42 randomised controlled trials
–! 101 reports of lower levels of evidence
•! Summarized into diagnostic categories
–! What evidence?
–! What treatment?
–! What effect? (Geytenbeek 2008)
 AQUATIC PHYSIOTHERAPY
EPB GUIDE 2008
•! Systematic review of aquatic physiotherapy
•! Key words
–! “aquatic physiotherapy”, “hydrotherapy”,
“aquatic therapy”, “aquatic exercise” and
“water exercise”
•! Databases
–! CINAHL, MEDLINE, EMBASE, PEDro,
AMED, Ageline, Sports Discuss, Cochrane
Library
 AQUATIC PHYSIOTHERAPY
EPB GUIDE 2008
•! Appraisal included
–! trial type and level of evidence
–! Subjects
–! frequency and duration of intervention
–! description of the intervention
–! outcome measures.
 AQUATIC PHYSIOTHERAPY
EPB GUIDE 2008
Aquatic therapy in areas of physiotherapy practice:
•! musculoskeletal
•! neurology
•! paediatrics
•! womens health
•! cardiorespiratory
•! sports
 AQUATIC PHYSIOTHERAPY
EPB GUIDE 2008
Conditions included:
•! OA, RA, FMS, AS, TKR, THR
•! Back pain, lower- and upper limb conditions
•! CVA, ABI, SCI, Adult CP, MS, PPS, GBS
•! CP, MD, juvenile arthritis, Rett, CRPS, autism
•! Peri-natal, post-menopause, OP, obesity
•! COPD, heart failure
 AQUATIC PHYSIOTHERAPY
EPBG OUTCOME DOMAINS
•! Function and ambulation
•! Strength
•! Range of movement, flexibility
•! Pain
•! Balance
•! well-being, depression, quality of life
•! health status, activity and participation
•! athletic performance
•! body composition
•! cardiac and respiratory function, fitness
•! Spasticity
•! medication use
•! cost-effectiveness
 AQUATIC PHYSIOTHERAPY
EPB GUIDE 2008
•! Musculoskeletal aquatic physiotherapy
–! 69 of 151 articles (45%)
–! 2606 of 3227 subjects (81%) s
•! Individual, one-to-one, or manual aquatic physiotherapy
practice remains understudied
–! passive joint mobilisation
–! therapist observation and correction of preferred
movement patterns
–! movements based on hydrodynamic variations and
patient performance
–! Halliwick, Watsu and Bad Ragaz Methods
 AQUATIC PHYSIOTHERAPY
EPB GUIDE
Evidence is growing

Clinicians should apply self-reflection and

personal critique, using outcome measures
and making regular attempts to keep abreast
of new research evidence (Geytenbeek 2008)
 JOINT ARTHROPLASTY
AQ PT EPB GUIDE 2008
•! 9 papers
•! 176 subjects
•! Levels of evidence
–! I, II, III-3, IV
•! Outcome domains
–! func, amb, strgth, pain, ROM (supported by
Level II/RCT evidence)
 WHAT EVIDENCE?
•! 9 articles for patients undergoing lower limb joint
arthroplasty were identified
•! 1 RCT (Gilbey 2003) n= 57

Gilbey HJ. Ackland TR. Tapper J. Wang AW (2003)

Perioperative exercise improves function
following total hip arthroplasty: A randomized
controlled trial. Journal of Musculoskeletal
Research. 7(2):111-123
 WHAT TREATMENT?
•! 30 minutes 2 x /week with additional land and home-based
components for 20 weeks
•! Warm up - walking 3 sets of 10 widths (7m) of the pool (forwards,
backwards, side-stepping
•! Muscle strengthening exercises - partial squat and hip hike
•! Ankle weights were introduced where appropriate to increase the
resistance when water cycling while the patient was supported in a
flotation device (5 minutes)
•! Step-up activities (increasing height)
•! Balance activities with eyes open and eyes closed
•! Water running with the water level approximating the xiphoid process
and the use of flippers were also introduced into the program for some
of the younger patients
 WHAT EFFECT?
•! Improved
–! Ambulatory function (6 minute walk test)
–! Lower limb strength (isokinetic hip strength)
–! Range of movement of the hip
Hinman RS, Heywood SE, Day AR (2007) Aquatic
Physical therapy for hip and knee osteoarthritis:
Results of a single-blind randomized controlled trial.
Physical Therapy. 87:32-43

Centre for Health, Exercise &

Sports Medicine, School of Physiotherapy,
The University of Melbourne
&
Physiotherapy Department, Sunshine
Hospital, Western Health, Melbourne
 Volunteers screened

Baseline assessment &

0 weeks randomisation
(n=71)

Supervised aquatic No intervention control

physiotherapy (n=35)
(n=36)

Primary outcomes:
Re-assessment
6 weeks (n=66)
•!Pain on movement (VAS)
•!Global change in pain &
function

Unsupervised aquatic Secondary outcomes:

physiotherapy •!WOMAC (pain, stiffness,

function)
(n=35)
•!Muscle strength
(dynamometer)
Follow-up •!Quality of life (AQoL)
12 weeks (n=33) •!Physical function (6 minute
walk, TUG)
 Aquatic physiotherapy
•! Group sessions 2 x week, 6 weeks
•! Supervised by physiotherapist
•! Progressive 12 phase program
•! Individual progression through phases
 Aquatic physiotherapy
•! Group sessions 2 x week, 6 weeks
•! Supervised by physiotherapist
•! Progressive 12 phase program
•! Individual progression through phases
 Aquatic physiotherapy
•! Group sessions 2 x week, 6 weeks
•! Supervised by physiotherapist
•! Progressive 12 phase program
•! Individual progression through phases
 Aquatic physiotherapy
•! Group sessions 2 x week, 6 weeks
•! Supervised by physiotherapist
•! Progressive 12 phase program
•! Individual progression through phases
 Aquatic physiotherapy
•! Group sessions 2 x week, 6 weeks
•! Supervised by physiotherapist
•! Progressive 12 phase program
•! Individual progression through phases
 Aquatic physiotherapy
•! Group sessions 2 x week, 6 weeks
•! Supervised by physiotherapist
•! Progressive 12 phase program
•! Individual progression through phases

2 sets of 3 sets of 4 sets of 5 sets of

10 reps 10 reps 10 reps 10 reps
 6 week results: secondary
outcomes
Control APT p value

WOMAC (mm)
–!Pain (0-500) 12 (50) -58 (97) <0.001
–!Stiffness (0-200) -1 (19) -22 (39) <0.01
–!Function (0-1700) 43 (168) -135 (319) <0.001
Muscle strength (kg)
–! R quads -0.4 (6.7) 2.1 (8.7) 0.04
–! L quads 1.3 (5.8) 2.0 (8.1) 0.23
–! R hip abductor -0.7 (3.5) 2.1 (5.9) <0.01
–! L hip abductor
-1.8 (5.3) 1.7 (6.7) 0.01
6-min walk (m) 0 (28) 20 (48) <0.01

AQoL (-0.04-1.00) 0.00 (0.09) 0.01 (0.05) 0.01