AQUATIC SPORTS INJURIES AND REHABILITATION 0278-5919/99 $8.00 + .

OO

AQUATIC THERAPY IN
THE REHABILITATION
OF ATHLETIC INJURIES
Jan Prins, PhD, and Debra Cutner, MPT, ATC

hcreasing interest in aquatic physical therapy can be attributed in part to

its evolution from the limited confines of spas and “Hubbard tanks,” to the
larger venues of swimming pools. These larger exercising areas accommodate a
greater variety of exercises, including those that require sustained propulsive
movements.
Using the water to regain lost mobility and strengthen weakened muscles
has been described by a number of authors?, 19, 20, 31, 35 The purpose of this article
is to discuss the manner in which aquatic physical therapy is used for the
treatment of common athletic injuries.

PHYSICAL PROPERTIES OF WATER AFFECTING AQUATIC

PHYSICAL THERAPY

Two important physical properties of water, buoyancy and viscosity, are

key elements in designing effective exercises for treating athletic injuries. The
advantage of buoyancy is direct: When a person enters the water, there is an
immediate reduction in the effects of gravity on the body. The advantage of
viscosity of water is indirect: When the person moves through the water, resis-
tance is felt. The degree of effort is determined by the size of the moving body,
or limb, plus the speed or velocity of the movement.

From the Department of Kinesiology and Leisure Science, University of Hawaii at Manoa,
Honolulu UP); and Prins Aquatherapy, Incorporated, Honolulu UP, DC), Hawaii

CLINICS IN SPORTS MEDICINE

-
VOLUME 18 NUMBER 2 APRIL 1999 447
448 PRINS 81 CUTNER

Force of Buoyancy and Its Effect on Weightbearing During

Immersion

The buoyant force of water decreases the effective weight of an individual

in proportion to the degree of immersion. Axial loading on the spine and weight-
bearing joints, particularly the hip, knee, and ankle, is reduced with increasing
depths of immersion (Fig. ,).I4 When standing in chest-deep water, the weight-
bearing load is approximately 40% of the total body weight, whereas stepping
on a submerged step (waist-deep water) increases the weight-bearing value to
approximately 60%.14
The ability to control joint compression forces by varying degrees of immer-
sion is of primary benefit in the design and prescription of therapeutic exercises.
By monitoring the depths at which functional movements, such as walking
and stepping, are performed, the effect of gravity can be reintroduced and,
consequently, gradual strengthening is 41 When floating in prone,
supine, or vertical positions, the effects of gravity are eliminated.

Muscle Strengthening Using the Viscosity of Water

Although traditional modes of strength training have been used successfully

in clinical settings, there are three primary advantages for using water resistance
to promote strengthening.

Water Acts as an Accommodating Resistance

The advantage of accommodating resistance is that it matches the patient’s
applied force or effort. Because the resistance of the water equals the force
exerted, the likelihood of exacerbation or reinjury is reduced dramatically.

Figure 1. Subject’sweight-bearing load is 40% (chest depth) and increases to 60%’ (waist
depth) when standing on the step.i4(Courtesy of Prins Aquatherapy, Inc., Honolulu, HI.)
Figure 2. Buoyant force of foam bell is used to assist with increasing shoulder range of
motion. (Courtesy of Prins Aquatherapy, Inc., Honolulu, HI.)
 AQUATIC THERAPY IN THE REHABILITATION OF ATHLETIC INJURIES 449

Water Acts as a Variable Resistance

The term variable refers to being able to change the speed or velocity of the
movement. Unlike isokinetic strength-training apparatus, which limit exercises
to a preset velocity, it is possible to change limb speeds during each repetition
in the water. Because most human motion is variable in nature, functional gains
are more likely to be made.

Strengthening Exercises in Water Are Unrestricted in Direction

and Limited Only by the Mobility of the Joints Being Used
One limitation of conventional strength-training apparatus is that joint activ-
ity is isolated?' Many exercise machines are designed with rigid bars that guide
the resistance; this limits the user to exercising in fixed planes of movement. In
contrast, aquatic strengthening exercises can be designed to closely match every-
day movements and, as a result, provide neuromuscular adaptations better
suited to the activities of daily living. In an attempt to quantify the applied
muscular forces in water, pressure-sensitive sensors have been designed to
measure the patient's progress. The results of monitoring lower extremity
strength during the course of aquatic therapy treatment following anterior cruci-
ate ligament (ACL) surgery are listed in Table 1.

BENEFITS OF AQUATIC REHABILITATION

In addition to points discussed in the previous section, there are other

applications of properties of water used in treating athletic injuries.

Using Buoyancy to Increase Range of Motion

An array of clinical conditions, such as subacromial bursitis, calcifying

tendinitis, and partial rotator cuff tears, are included in the term "frozen shoul-
der syndrome."z6These conditions, which restrict active and passive glenohu-
meral and periscapular shoulder motion, can be treated in water by taking
advantage of the force of buoyancy to promote both active and passive move-
ment?, 15, 26, 35 Varying the standing depth controls the amount of movement of
the upper extremity (Fig. 2). Other types of flotation equipment can be used to
assist with movements of the lower extremity.

Table 1. RESULTS OF AN &WEEK AQUATIC PHYSICAL THERAPY PROGRAM FOR

RECOVERY FROM LEFT ANTERIOR CRUCIATE LIGAMENT (ACL) INJURY

Left
Right (injured) % Deficit
Test 1: (12 weeks postsurgery) 87.8 N 69.2 N 21.9
Test 2: (20 weeks postsurgery) 85.6 78.8 7.9

Peak forces in Newtons (N) against water was measured for single-leg standing flutter kick using
pressure sensors. A reduction in the deficit for peak force between the injured and noninjured knee is
seen after the 8-week program.27
450 PRINS&CUTNER

Cooperative Movements of Upper and Lower Extremities

An often overlooked advantage of aquatic physical therapy is the extensive

range of exercises that require alternating or symmetric movements of the limbs
and associated joints. These movements encourage increased involvement of the
affected limbs by inducing the injured side to match the effort and range of
motion of the uninjured side. The propulsive movement patterns of formal
swimming strokes require arm and leg actions that combine symmetric or
alternating patterns of motion.

Cardiorespiratory Fitness in Water

The loss of cardiorespiratory fitness can be significant during recovery after

injury; early resumption of exercise, therefore, now is considered essential to the
successful return to preinjury activity. Aquatic therapy allows the injured athlete
to begin exercising earlier. Deep-water running has been shown to compare
favorably with land-based e~ercise.~, 30, 34* 40 Maximum oxygen uptake (VO-,)
values for aquatic running. range from 83% to 89% when compared with the
values obtained from runnmg on land. Maximum heart rate values for aquatic
running ranged from 89% to 95% of values measured on land?, 4, 34, 36
Aquatic running, when supported by a floatation device, offers additional
benefits, most notably the maintenance of quick turnover (rapid gait cycling),
and coordinated movements between the arms and legs. These aspects facilitate
the return to land-based training.

Early Restoration of Joint Mobility

Prolonged rest or inactivity following injury is no longer recommended for

patient recovery. The therapeutic advantages of early restoration of joint mobility
are well documented.2,14* 18, 21, 4o The inactive injured athlete is predisposed to
muscle atrophy, soft tissue weakness, decreased joint mobility, and possible
increases in pain.17,24, 35* 38, 39 Also, functional deficits may be addressed sooner
with early mobilization.l6S21
Water provides a low-stress physical environment where axial and compres-
sive forces are reduced; thus, a case can be made for early prescription of aquatic
therapy1', 17, 31 When full weight-bearing activities are premature but closed
kinetic chain exercises are recommended, exercising in the water at graduated
depths is ideal.17,31 Individuals recovering from back, hip, and knee injuries or
surgery can benefit from beginning therapeutic exercises in the supportive
aquatic environment.20, 23 Patients with multiple injuries also benefit from starting
a strengthening and joint mobilization program in the water, making a later
transition to land-based physical therapy, to continue their prescribed rehabilita-
tion program.

OVERVIEW OF AQUATIC EXERCISES

A wide variety of aquatic exercises are employed for strengthening and

increasing joint range of motion. When designing an exercise program it also is
important to consider such factors as pathology, age, body type, and the patient's
comfort level in the water.
 AQUATIC THERAPY IN THE REHABILITATION OF ATHLETIC INJURIES 451

Primary Body Positions Used in Aquatic Rehabilitation

A typical aquatic exercise program combines exercises that are performed

in several body positions.

Standing on the Bottom of the Pool

Most standing exercises are performed at depths between midchest (xy-
phoid) and the top of the shoulder (coracoid process). Two factors to be consid-
ered when designing exercises in the standing position are
The depth of water in which exercises are performed. This determines the
degree to which buoyancy will affect the percentage of weight bearing on joints
and range of motion.
Buoyancy. There is a positive force when moving toward the surface of
the water and an opposing or negative force when moving away from the sur-
face.

Walking and Associated Stepping Patterns

Walking at different depths provides an invaluable method of reintroducing
the mechanics of gait while varying the axial loads on the spine, hip, and joints
of the lower extremities. The mechanics of gait can be simulated without the
risks associated with gravitational forces and the loss of balance. A n added
benefit is the increased muscular effort needed to move through a denser me-
dium.
Differences in the gait phases are apparent when patients of different body
densities walk at varying depths. Decreased stride lengths often characterize
initial gait patterns. A decrease in hip and knee flexion results in a shuffling of
the feet during the swing phase of the gait cycle. In some cases, exaggerated hip
and knee flexion may occur.
It must be remembered that the degree of ground reaction force that can be
maintained when submerged at different depths will establish the amount of
contact between the foot and pool bottom. In turn, the amount of contact will
determine the effectiveness of the propulsive phase of each stride.

Floating on the Surface

Flotation devices allow the body to remain motionless, eliminating the need
to apply propulsive forces to remain on the surface. This allows the gradual
introduction of upper and lower extremity movements for both flexibility and
strengthening.
Floating vertically in the water. For most individuals, a floatation vest is
necessary to float vertically in deep water. Therapeutic exercises in this position
range from passive vertical traction with weights attached to the ankles, to a
variety of exercises involving movements at the hip, knee, and ankle joints. Hip,
knee, and ankle movements in the cardinal and oblique planes can be performed
in the absence of all gravitational forces. Running movements of varying stride
lengths and frequencies can be simulated. Alternating leg movements that re-
semble the "flutter kick" of the front crawl are also performed in this position.
This kick pattern strengthens the quadriceps muscles and promotes strengthen-
ing of the hip and lower lumbar regions.
Floating prone or supine. Floating horizontally with the aid of floatation
452 l'RINS&CUTNER

and breathing devices (mask and snorkel) can be used to reduce the tension
accompanying soft tissue injury, principally in the neck and lower back.
Floating prone. Exercises for strengthening both upper and lower body
segments can be performed in the prone position, that is, floating face down in
the water, wearing a mask and snorkel. Selected arm and neck movements can
be prescribed for cervical, glenohumeral, and shoulder girdle strengthening.
Specific kicking movements are used when the focus is the lumbar spine, hip,
and lower extremities. Also, there are many variations of formal swimming
strokes that can be performed when lying prone in the water.
Floating supine. Although upper extremity movements in this position are
limited in comparison to floating prone, lower extremity kicking patterns are
somewhat similar. The major advantage of floating in the supine position is the
ability to place the body in varying degrees of extension or hyperextension.
Spine specialists have noted that the preferred position for persons with disco-
genic pain is in a slight "extension bias."9 With proper adjustment of the
floatation vest, the degree to which the spine is placed in extension can be
adjusted (Fig. 3).

DESCRIPTION OF INJURIES AND RECOMMENDED AQUATIC

REHABILITATION EXERCISES

Each anatomic area covered below includes a list of typical athletic injuries,
descriptions of aquatic rehabilitation exercises recommended as part of treat-
ment, and equipment suggestions.

Shoulder Girdle and Glenohumeral Joint

The complexity of the shoulder joint, together with its importance in most
athletic endeavors, leaves it vulnerable to injury. Injuries at this joint result from
single traumatic events or repetitive overuse situations.', 32 The most common
traumatic injuries are fractures, tears, subluxations, and dislocations. Rotator
cuff impingement, inflammation of the tendons and bursa, and joint instabilities
are the primary consequences of excessive use of the shoulder.6,22 Swimming,

Figure 3. Positioning of flotation vest will determine degree of spinal extension in supine
floating position. (Courtesy of Prins Aquatherapy, Inc., Honolulu, HI.)
 AQUATIC THERAPY IN THE REHABILITATION OF ATHLETIC lNJURIES 453

tennis, and throwing activities, such as baseball pitching, are listed as activities
that are likely to cause these conditions.**,29
Strengthening of the shoulder girdle and glenohumeral joint can be per-
formed in the water, using a variety of body positions (Table 2). The available
planes of movement and the desired range of motion determine the choice of
body position. Resistive force is a function of the cross-sectional area of the
limbs and resistive device, if used, and the speed at which the movement
takes place.

Equipment for Shoulder Exercises

Hand paddles and hand-held three-dimensional resistive devices commonly
are used for strengthening the upper extremities. These devices come in a wide
range of shapes and sizes and help .increase the cross-sectional area of the
moving limb.

Elbow and Radioulnar Joint

The combination of weak lateral bony arrangements and a broad range of

motion predisposes the elbow and radioulnar joints to injury in many different
sports. Injury to the elbow from direct blows can cause contusions, dislocations,

Table 2. EXERCISES FOR INCREASING JOINT MOBILITY AND RANGE-OF-MOTION

OF THE SHOULDER

1. Passive stretching exercises in the water

2. Active range-of-motionexercises
Standing upper extremity
movements
- Flexion extension
Abduction/adduction
Intemal/extemal rotation
Horizontal abduction/adduction
Floating prone Flexion/extension
PNF patterns
Horizontal abduction/adduction
Exercises for increasing strength of the shoulder
Standing upper extremity Flexion/extension
movements Abduction/adduction
Intemal/external rotation
Horizontal abduction/adduction
Floating prone Flexion/extension
PNF patterns
Horizontal abduction/adduction
Swimming strokes Breaststroke pull patterns performed at
different depths with respect to the surface
Underwater freestyle (alternating front-
crawl pull patterns without overarm
recovery)
Elementary backstroke starting at varying
degrees of abduction
Formal swimming strokes can be introduced
or reintroduced in the case of persons
returning to training in the water
Table 3. EXERCISES FOR INCREASING JOINT MOBILITY AND RANGE-OF-MOTION
OF THE ELBOW AND RADIOULNAR JOINT

1. Passive stretching exercises in the water

2. Active range-of-motion exercises
3. Exercises for increasing strength of the elbow and radioulnar joint
Standing upper extremity movements Push/pull action
Flexion/extension
Pronation/supination (Fig. 4)
Floating prone Flexion/extension
PNF patterns
Horizontal abduction/adduction

fractures, and soft tissue damage. Overuse injuries to the elbow area are often a
result of excessive throwing activities and sports that require swinging of bats,
clubs, and rackets.', 32 Table 3 lists exercises for increasing mobility, range, and
strength of this area.

Equipment for Elbow and Radioulnar Joint Exercises

Hand paddles and hand-held three-dimensional resistive devices may be
used for these exercises (Fig. 4).

Wrist and Hand

Wrist injuries are common in sports, such as football, basketball, soccer, and
volleyball. Repetitive pushing, blocking, spiking, or falling on an outstretched
arm are common causes of these injuries. Recommended aquatic physical ther-
apy exercises for the wrist and hand are similar to those used for the elbow.

Figure 4. Pronation/supination exercise, performed using spatulas. (Courtesy of Prins

Aquatherapy, Inc., Honolulu, HI.)
 AQUATIC THERAPY IN THE REHABILITATION OF ATHLETIC INJURIES 455

Cervical Spine

Injuries to the cervical spine can occur from direct trauma and range
from fractures to sprains and strains. These injuries usually involve forceful
hyperflexion and extension, rotation, and lateral flexion. Collisions, as in tack-
ling, spearing, and diving, and combinations of twisting and lateral flexion, are
seen in sports, such as football, wrestling, soccer, and the martial
At present, aquatic exercises for strengthening the cervical and thoracic
regions are those that involve concomitant strengthening of scapula stabilizers
and glenohumeral musculature. In addition to exercises performed in the pri-
mary planes of motion, movements in oblique planes of motion, such as the
sculling pull patterns seen in selected swimming strokes, are ideal (Table 4).
An added advantage of the water is the option of performing many neck
strengthening exercises while floating in the prone position. When a mask and
snorkel are used for breathing in the prone position, the buoyant force of the
water can be relied on to support the weight of the head. This relieves injured
muscles and associated soft tissue from the responsibility of counteracting antici-
pated gravitational forces (Fig. 5 ) .

Equipment for Cervical Exercises

Hand paddles and hand-held three-dimensional devices also are used for
strengthening the upper extremities. Many of the available resistive devices can
be modified to increase the amount of resistances.

Table 4. EXERCISES FOR INCREASING CERVICAL JOINT MOBILITY AND RANGE-

OF-MOTION

1. Passive stretching exercises in the water

2. Active range-of-motionexercises
Standing on the bottom of the pool
-
Cervical flexion/extension
Cervical rotation
Cervical lateral flexion
Chin-tuck exercises
Suspended vertically in deep water -Cervical traction
Exercises for increasing cervical strength
Standing A series of unilateral and bilateral arm
exercises with and without the use of
resistive apparatus. Exercises similar to
those used in shoulder strengthening
Floating prone Flexion/extension
PNF patterns
Horizontal abduction/adduction (Fig. 5)
Swimming strokes Breaststroke pull patterns performed at
different depths with respect to the surface
Underwater freestyle (alternating front-
crawl pull pattern without overarm
recovery)
Elementary backstroke starting at varying
degrees of abduction
Formal swimming strokes can be introduced
or reintroduced in the case of persons
returning to training in the water
456 PRINS & CLJTNER

Figure 5. Upper extremity abduction/adduction exercises, using resistive hand paddles,

performed in the stationary prone position, provide maximum resistance in both directions
of the movement. (Courtesy of Prins Aquatherapy, Inc., Honolulu, HI.)

Figure 6. Isometric spine stabilization exercise, using a tray. (Courtesy of Prins Aquather-
apy, Inc., Honolulu, HI.)

Lumbar Spine

As in the case of the cervical spine, injuries to the lower back can be
attributed to repeated stresses or a single traumatic occurrence. Congenital
conditions also may play a role in these events; however, almost all athletic
activities place demands on the lower back and consequently can precipitate in-
jury.
When dealing with injuries to the spine, particularly the intervertebral disks,
aquatic treatment must focus on effective spine stabilization protocols.8, Aquatic
stabilization techniques help the patient regain dynamic control of segmental
spine forces and eliminate repetitive injury to the motion segments? Exercising
at different standing depths provides an important process for adjusting the
compressive and shear forces on the spine.
The effectiveness of aquatic spine stabilization exercises (Table 5) is based
on the premise that in order for the upper and lower extremities to generate
muscular forces, the axial skeleton, particularly the lumbar spine, must provide
a stable base of support. This fulcrum, or stable base, is produced by isometric
contractions of the abdominal and spinal muscles, with corresponding tension
provided by the ligaments and associated structures, such as the thoracolum-
bar fascia.

Equipment for Lumbar Spine Exercises

Resistive fins, preferably of short-blade design, provide moderate increases
in resistance. Trays of different sizes can be used for standing and walking
exercises (Fig. 6). Although a number of patterns for flotation vests are available,
those that are rectangular in shape are recommended.
 AQUATIC THERAPY IN THE REHABILITATION OF ATHLETIC INJURIES 457

Table 5. EXERCISES FOR INCREASING LUMBAR SPINE JOINT MOBILITY AND

RANGE OF MOTION

1. Passive stretching exercise in the water

2. Active range-of-motionexercises
Standing on the bottom of the Gluteus maximus stretch
pool Adductor stretch
Hamstring stretch
Firiformis stretch
Gastrocsoleus stretch
Floating prone Selected stretches may be performed while
floating prone, for example, double knee-to-
chest stretch
Floating vertically Vertical traction with ankle weights attached
to the ankles
Exercises for increasing lumbar spine strength
Standing against or away from Unilateral hip flexion/extension
wall Unilateral leg movements simulating the
flutter-kick
Unilateral abduction/adduction
* Push/pull and/or sideways movements
using a tray (Fig. 6 )
Walking on the bottom of the Forward/backward walking
pool at different depths
Floating vertically, body position A series of lower extremity movements,
maintained with the aid of a similar to those performed while standing.
floatation device However, the exercises now can be
performed with both legs working
simultaneously, as in the case of the flutter-
kick or abduction/adduction
Swimming strokes * Swimming and kicking in the prone and/or
supine body positions, maintaining a
neutral spine.
Stroke mechanics must be modified to fit
patient’s experience and tolerance

Knee

Much has been written about stresses placed on the knee joint in athletics.’S3*
Because joint reaction forces on the knee can reach several times body weight,
aquatic rehabilitation reduces negative consequences of gravitational and com-
pressive forces, allowing safe and effective therapy.35,37 Studies have recom-
mended a combination of open- and closed-chain exercises for increasing quadri-
ceps and hamstring strength during acute and intermediate postoperative
periods following ACL reconstmction.ls An 8-week study comparing aquatic
physical therapy with traditional land-based therapy was conducted for patients
recovering from ACL reconstructive surgery. Although no difference in passive
range of motion was found between the two groups, the group treated in the
water showed less joint effusion, reported greater functional improvement, and
recorded higher scores on the Lysholm scales (a measure of functional stability
of the knee j ~ i n t ) . ” ~
In the water, functional activities, such as walking at varied depths, that
affect the percentage of weightbearing, can be started earlier than on land. When
458 PRINS&CUTNER

open-chain exercises are prescribed, using water as an accommodating resistance

medium eliminates risks associated with excessive muscle force or loading of
the joint. The strengthening exercises in Table 6 can be accompanied by normal-
ization of range-of-motion by taking advantage of the buoyant force of water.

Equipment for Knee Exercises

Resistive fins, preferably of short-blade design, provide increases in resis-
tance.

Hip, Thigh, and Foot

Aquatic treatment of injuries to the hip, thigh, and foot incorporate those
exercises described for rehabilitation of the knee. The effectiveness of closed-
chain activities in the pool depends upon adequate traction between the foot
and the pool surface.

RECOMMENDATIONS FOR IMPLEMENTING AN AQUATIC

PHYSICAL THERAPY PROGRAM

For effective therapy, objective measurement of progress is essential. This is

accomplished as follows:
1. An initial evaluation is conducted by a licensed physical therapist. This

Table 6. EXERCISES FOR INCREASING KNEE JOINT MOBILITY AND RANGE OF

MOTION
1. Passive stretching exercises in the water
2. Active range-of-motion exercises
Standing on the bottom of the Quadriceps stretch
pool Hamstring stretch
Gastrocsoleus stretch
Exercises for increasing knee strength
Standing against or away from Unilateral knee flexion/extension
wall Unilateral leg movements simulating the
flutter kick
Step-ups, minisquats, and single-leg balance
Walking on the bottom of the
pool at different depths - Forward/backward walking
Marching
Floating vertically Aqua-jogging
Body position maintained with Vertical bicycling
the aid of a floatation device Vertical flutter kick
Vertical abduction/adduction
Swimming strokes Swimming with the emphasis on kicking
action, in the prone and/or supine body
positions. The resistive force can be
increased by increasing rate or cadence, and
bv using resistive fins
 AQUATIC THERAPY IN THE REHABILITATION OF ATHLETIC INJURIES 459

evaluation provides objective measurement of strength, range of motion,

posture, neurologic integrity, and function.
2. Following the initial evaluation the patient is given an aquatic assess-
ment. The patient performs an established sequence of movements in the
water, which are closely observed from the pool deck and recorded with
underwater video equipment. The use of video technology provides a
means for recording and analyzing subtle changes in movement mechan-
ics, which can dramatically affect a patient’s condition.
3. Changes in strength may be monitored by measuring the applied forces,
using specially designed pressure-sensitive sensors.27This new technol-
ogy is useful particularly for evaluating the efficacy of rehabilitation
and the expected strength changes following surgery or injury induced
inactivity.
4. The exercises, number of repetitions performed, or duration of the exer-
cise effort is recorded at each therapy session to monitor increases in
volume and intensity of the prescribed exercise workloads.
5. The therapist continually supervises and evaluates patient performance
and status as a means of determining when to increase the exercise
workload.

WHEN IS IT APPROPRIATE TO SELECT AQUATIC

PHYSICAL THERAPY?

In determining whether aquatic or land-based therapeutic exercises should

be prescribed, three options have been described?

“Wet-to-Dry” Transition

Starting with aquatic therapy and then transferring to land-based therapy

is recommended when strengthening joint areas are affected by axial and com-
pressional forces. For example, aquatic therapy can be used when one is recov-
ering from back, hip, and knee injuries. Strengthening can be accomplished
more gradually in the water, in preparation for resuming land-based activity.

“Dry-to-Wet” Transition

Therapy is initiated with land-based exercises, and then the patient is

transferred to aquatic therapy. This scenario is necessary when land-based exer-
cises exacerbate the patient’s condition. Once sufficient strength gains are real-
ized, land-based activity can be resumed.

“Wet Only”

Exclusive use of aquatic therapy is recommended for patients who have an

inability to tolerate land-based strengthening exercises, or by personal choice,
prefer aquatic therapy.
460 PRINS & CUTNER

CONCLUSIONS

The key to effective rehabilitation is the return to desired functional activity

as soon as possible. Aquatic therapy provides a unique environment for promot-
ing normal movement patterns and building strength early in the course of
treatment. These changes usually are accomplished in the water, where the risk
of further injury is reduced. This frequently is accompanied by a reduction in
pain and perceived discomfort. Aquatic therapy in many cases is the only option
for rehabilitation when land-based programs have not provided satisfactory re-
sults.

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