The specialist team at Neurokinex look at how water-based therapy can help to support people with spinal cord injury to achieve their ambitions in neuro-rehab
Rehabilitation in water can have a synergistic effect when combined with land-based exercise. Water provides unique advantages for rehabilitating people with a spinal cord injury (SCI) owing to the principles of hydrodynamics whereby when someone is immersed in water, the weight on their joints is offloaded. This is because of the buoyant force present in water which counteracts the effects of gravity.
Working with clients in water enables the focus to be more on balance and gait training patterns and less on weight bearing (Ellapen et al., 2018). Water is not inclined to move out of the way when swimmers apply a positive force to it as they move in a desired direction, which creates resistance without needing to be weight bearing.
Safe, multi-sensory space
Unlike land-based tasks, exercise in water provides a safe, multi-sensory experience for people to work on their proprioception: self-awareness when moving through space (Ellapen et al., 2018). Furthermore, hydrostatic pressure is associated with preventing low blood pressure and reducing swelling which is usually caused by a lack of mobility in affected limbs in people with a SCI (Silva et al., 2005).
Interestingly, research also suggests that water therapy helps with spasticity and pain, but evidence for this is still enigmatic. Water is also an excellent conductor of heat so it enhances clients’ ability to effectively thermoregulate their bodies when exercising and maintains a low core temperature (Gass & Gass 2001; Gass et al. 2002). Hence, they are able to exercise safely for longer, improving cardiorespiratory function and energy expenditure.
Jasper about to head into the pool for hydrotherapy
Aquatic therapy explained
There are various types of aquatic therapy. These include swimming, hydrotherapy and underwater gait training.
Research in swimming indicates that it could be used as a novel model for locomotor training, the process in which therapists aim to retrain clients to stand and walk again. It is argued that swimming appears to be task-specific because of the lack of limb loading in water (Smith et al., 2006; 2009). It also lacks plantar cutaneous feedback, which consists of the sensory cues which send signals to the brain to initiate the next step in the gait cycle.
Whilst swim training does not seem to transfer to overground stepping, it does enhance functional independence, motor recovery and postural control in people with a SCI (Silva et al., 2005).
Benefits of buoyancy
During underwater gait training, buoyancy and hydrostatic pressure help raise the contralateral hip during the stance phase, thereby reducing the muscle contraction force required to elevate it. Buoyancy also negates the effects of gravity, enhancing the swing phase of the ipsilateral hip.
While current research suggests little to no transfer to overground stepping, it can be argued that the underwater gait training can serve to condition the lower limb neuromuscular system as well as improve cardiorespiratory function. Importantly, exercise in the water also has positive psychological benefits as being in the water can feel really relaxing thus it canhelp with various mental health outcomes. Swimming has been shown to help with mental stability and self-confidence which has a knock-on effect on quality of life (Smith et al., 2006).
Hydrotherapy client case study
Jasper, 10, sustained a lower motor neuron spinal cord injury at the age of one and has attended therapy sessions at Neurokinex twice a week since 2016. The aim of his sessions is to get as much weight bearing as possible combined with wide pulse stimulation (WPS) – a form of electrical stimulation which enhances contractions superficially to promote increased central activation.
Neurokinex also challenges Jasper’s trunk and core control through varied activity-based rehabilitation (ABR). These include low kneel and high kneel work, crawling, tasks on unstable surfaces and varying sitting positions. While these therapies are highly beneficial, Jasper is usually restricted within a harness and being held by trainers to ensure his safety and proper alignment of joints. Swimming, on the other hand, provides Jasper with the unique opportunity to have complete freedom of movement.
By combining ABR and WPS with swimming, Jasper enhances his potential to achieve greater therapeutic benefits. Jasper’s swimming classes focus on improving the core aquatic skills (CAS). Two of the main CASs involve buoyancy and balance and rotation and orientation. Jasper’s teacher encourages them to experiment with water’s buoyant and resistance forces with simple tasks like attempting to sit on the pool floor, star floats and tuck floats. Each body shape has a different centre of gravity, and swimmers are encouraged to practice floats to effectively match their centre of gravity with their centre of buoyancy.
These tasks are highly beneficial as they help improve core and trunk control and overall muscle strength. Most importantly, it encourages Jasper to use his neuromuscular movement to its full potential and build increased awareness about body positioning (proprioception).
Free to move
Jasper’s swimming teacher states that while she provides her physically disabled swimmers with a rough framework on how to execute the four strokes, she also provides space for the swimmers to get creative. This is because she believes that every SCI is different so the swimmers can use trial and error to find the most effective way to propel themselves in the water.
This flexibility to try different techniques and positioning is not possible overground due to the increased risks of falls and injury. The freedom to move independently and enjoy some autonomy on how he chooses to position himself not only works wonders for Jasper’s physical rehabilitation, it also encourages his self-esteem, self-reliance and reliance and independence – three essential outcomes we aim for SCI clients to achieve.
