Webinar Recap: Aquatic Therapy for Knee Replacement
We recently hosted a webinar on Total Knee Aquatic Therapy Progressions for Low to High Level Patients presented by Olmer Cruz, PTA, Peak Performance Physical Therapy in Lynbrook, NY. In this webinar, Olmer takes the viewer through a host of protocols that are beneficial for those with a total knee replacement or other knee injuries. Having used aquatic therapy at Peak Performance Physical Therapy for many years, he mentions how the use of aquatic therapy has grown a lot over the years. And that doctors are now even prescribing aquatic therapy because of the results they have seen.
With total knee replacements growing rapidly and more being performed on younger patients (50% are younger than 65), there is a need to get people back to their pre-surgery activities, which can include work, household and even athletic activities. Although many physical therapists and physical therapist assistants are not getting a lot of class time on aquatics, Peak Performance Physical Therapy is sure to educate all of their new PTs on aquatic therapy by getting them into the pool and demonstrating how aquatic therapy can help their patients. This drives many referrals from physical therapy.
A key point that Olmer shared is that aquatic therapy is not just for low-functioning patients. While it is great for that type of patient, and used often, there are a lot of benefits for high-level patients also. Olmer prefers to get high-level patients back into the pool for high level training at the end of their rehabilitation in order to better prepare the patient for full return to functional activities.
Olmer provided a multitude of protocols along with things to watch for and ways to progress a patient to the next level. A few of the protocols Olmer uses with progressions include:
- Warm up
- Toe raises
- Heel raises with increased lumbar flexion and extension
- Weight bearing – simple exercises to remove fear of putting weight on it.
- Underwater treadmill activities
- Forward ambulation – being to build confidence as the patient begins doing something they haven’t been able to do on land.
- Forward marching – use this to stretch their end ranges. Patients go further without feeling the pain they do on land.
- Goose steps – great for discussing the importance of firing the quad and maintaining core stabilization.
- Run/sprint – patients love getting back to things they haven’t done in years.
- Low skipping – can add upper extremity activities to distract them.
- Backward ambulation
- Marching backwards – simply use the pool floor instead of the treadmill if some patients aren’t as coordinated on the treadmill.
- Backward running with ball toss – this is great for sport-specific training and for a little added fun
- Side to side ambulation – can be done with treadmill and jets off
- Shuffling on the underwater treadmill
- Steps or platform activities
- Step progressions – this helps to decrease fear in a safe environment since patients are often afraid to step down.
- Quick steps
- Eccentric taps progression
- Step up with medicine ball
- Squats – this is a great place to teach proper form and the importance of hip muscles during squats.
- Plyo jumps – this is an ideal environment for teaching the importance of proper landing.
- Side to side jumps
- Split jumps to increase range of motion in the hips
- Prop kicks
- Floating exercises – such as bike, flutter kick and scissor kicks can also improve range of motion.
This is a large list of possible protocols that provide a framework for rehabilitation after a total knee replacement. A patient can progress through the protocols based on indicators such as:
- Following established protocols
- Experiencing no pain during a protocol
- Proper body mechanics
Olmer also states it is always important to be specific to the needs of the patient. Pay attention to pain areas, concern areas and their goals for returning to daily life activities. The physical therapists at Peak Performance Physical Therapy in Lynbrook, NY have seen tremendous results from using aquatic therapy throughout patients’ rehabilitation progress.
After the webinar, Olmer answered some questions from the attendees. A few are below:
How do you maintain strength and balance between both of the patient’s legs while strengthening the injured leg?
A) Olmer uses the varying depths of the pool to accommodate both. You can maintain strength in the uninjured leg by doing more activities in shallower water. Deeper water can be used to gradually strengthen the injured leg.
What are specific things you do to assure they’re getting full range of motion?
a) Range of motion is always assessed via measurement like on land. The aquatic therapist will communciate with the PT on what they are lacking. It is ideal to measure flexion at the beginning, do their pool session and then remeasure. This is often very encouraging to the patient because they can immediately see how the water helped. The advantage to working on range of motion in the pool rather than on the table is that you can avoid muscle guarding from the patient and they are able to really relax.
How do aquatic therapy sessions fit in with land therapy sessions from scheduling standpoint?
a) If they are scheduled for a session it is almost always either a strictly land or strictly pool session. If the patient arrives early, they might do the bike a little to warm up. We always work on patients after the pool with manual stretching and then they will get ice and stim. As for a weekly schedule, they may start with 2x a week in pool and 1x on land. Then they will progress to 1x in pool then 2x on land. In the past, it was common to simply progress them just to land. They are now seeing a shift to when the patient is ready to leave, the PT will bring them back to the pool to challenge them beyond what they can do on land 1x per week.
Do you use weights in the pool?
a) Sometimes. Some patients are easy floaters, so it’s a good way to bring them down. For goose steps or marching, adding weights makes it a little more challenging. I don’t tend to use weights as often as others, because the water is so useful by itself. I use other ways to challenge them with the treadmill, resistance jets or paddles.