Aquatic Neurorehabilitation

Neurocognitive disorder is a disease of a mental health due to which nerve cells – neurons – are damaged; as a result they are not able to function normally and die. People with this disease have troubles in everyday activities, because of decline in memory, behavior, bodily functions and other basic skills. Dementia, as a category of the neurocognitive disorder, maybe caused by depression, side effects from medications, delirium, using of alcohol, etc. According to Gaugler, James, Johnson, Scholz, and Weuve (2014) there are different types of dementia, such as Alzheimer’s disease, Parkinson’s disease, vascular dementia, Creutzfeldt -Jakob disease, dementia with Lewy bodies, Frontotemporal lobar degeneration, mixed dementia, pressure hydrocephalus, and others (p. 6-7).

Alzheimer’s disease is the most common type of dementia. It was first identified more than 100 years ago. According to statistic, about 5.2 million Americans of different ages have this disease in 2014 (p.16). In addition, “almost two-thirds of Americans with Alzheimer’s are women”(p. 17).  Alzheimer’s symptoms are “difficulty remembering recent conversations, names or events […]; apathy and depression […] impaired communication, disorientation, confusion, poor judgment, behavior changes and, ultimately, difficulty speaking, swallowing and walking” (p.6). However, “the brain changes of Alzheimer’s may begin 20 or more years before symptoms appear”. There are some risk factors. The first factor is age. People of 65 or older are susceptible to this disease. The second factor is family history. Individuals, who have parents or siblings with that disease, are at risk (p.9). Cardiovascular disease can be the other risk factor. “A healthy heart helps ensure that enough blood is pumped through these blood vessels, and healthy blood vessels help ensure that the brain is supplied with the oxygen and nutrient-rich blood it needs to function normally” (p.10). Scientist also discovered the link between education and the disease. “People with fewer years of formal education are at higher risk for Alzheimer’s and other dementias than those with more years of formal education” (p.11).

Parkinson’s disease is another type of dementia. It’s “a chronic and progressive movement disorder meaning that symptoms continue and worsen over time” (“What is Parkinson’s Disease?”, n.d.). There are about one million people with Parkinson’s disease in the US.  Zotz, T. G. G., Souza, E. A., Israel, V. L., and Loureiro, A. P. C. (2013) reported that:

With the clinical diagnosis of Parkinson’s disease, the individual may show an alteration in postural reactions such as straightening, balance, protective extension, difficulty in corporal rotation and reduced muscular strength. Such symptoms are accentuated when the patient is subjected to situations of stress, fatigue or pressure, which can exacerbate the freezing phenomenon and postural compromise, leading to a sudden loss of balance (p. 102).

According to Gaugler, James, Johnson, Scholz, and Weuve scientists reported two kinds of treatment for neurocognitive diseases: pharmacologic and non-pharmacologic. Pharmacologic treatment is based on drugs, which effectiveness may vary from patient to patient.”Non-pharmacologic therapies are those that employ approaches other than medication, such as physical therapy and reminiscence therapy (therapy in which photos and other familiar items may be used to elicit recall)” (p.14).

Physical activity plays a huge role in neurorehabilitation process. According to Bowes, Dawson, Jepson, and McCabe (2013) it positively affects “the cognition, activities of daily life and independence, functional ability, and mental health” (p.2). If physical activity is undertaken in a group then patients increase their social network, as a result, they don’t feel loneliness. It is also very important to choose the right type of physical activity:

For example, walking outdoors may help re-establish a connection with nature and the local community; dancing may provide enjoyment and feelings of wellbeing. Physical activity is also likely to have physical health benefits, helping maintain a normal lifestyle and reducing the risk of other disease (e.g. heart disease) (p.2).

Physical activity increases patients’ strength, improves their sleep quality, their balance becomes better too, and there are also significant reduction in falls and a reduction in wandering behavior. For example, “She’s developed a lot more strength and she now can get herself to the toilet and back. So that in itself is great. (Interview 9103)”. (p.7-8). Gardening, games and housework could also help patients to maintain or return skills:

I think it’s about maintaining skills as well, particularly with things like the gardening, which some of the men really enjoy. And they have a good workout sometimes… And it’s normality… and keeping the skills that they’ve got. (Interview 8682) (p.8).

Based on the researches made in Bowes, Dawson, Jepson, and McCabe it becomes clear that physical activity benefits patients and improve their overall quality of lives.  One of the best physical activities for patients with neurocognitive diseases is the aquatic therapy.

Water has a number of unique physical properties that are appropriate for various rehabilitation purposes. These properties include a relatively high specific thermal capacity and thermal conductivity, as well as the ability to provide resistance and the hydrostatical pressure on the body and its buoyancy. The two forces – the gravity and buoyancy act simultaneously on the human body in the water. Moreover, in the aquatic environment patients could perform movements in three dimensions, which are impossible in the air; it is a great social and psychological significance for people with disabilities. The buoyancy of the human body in the water is used in healing and rehabilitation practice for reducing stress, compression on joints, muscles, and connective tissue, as well as strain on the heart that is caused by the excessive body weight. The physical characteristics of the water allow patients to do a wide range of exercises more easily than it is possible on land. An important role for the recovery and rehabilitation does the hydrostatic water pressure. It increases proportionally to the depth of immersion of man. Immersion in water can be a supplement to circulation or peripheral edema due to venous or lymphatic insufficiency. Zotz, T. G. G., Souza, E. A., Israel, V. L., and Loureiro, A. P. C. reported that aquatic therapy can “improve the quality of life, reduce postural instability and the risk of falling in the elderly, and to enhance treatments for different disorders” (p.102).That is why hydrotherapy or aquatic therapy has positive effects on patients with neurologic and musculoskeletal conditions.

According to Myers, Capek, Shill, and Sabbagh (2013), “patients with decreased conditioning, cognitive impairments, reduced strength and endurance, head and spinal cord injuries, stroke, amputation, arthritis, osteoporosis, chronic back pain, and movement disorders may benefit from aquatic therapy”. There are also groups of patients for whom the aquatic therapy is contradicted. Such patients are persons with aquaphobia, fever, infections, cardiovascular disease, open wounds and incontinence. Patients with incontinence can be the “candidates for this therapy only if they are toileted before entering the pool and are provided with commercially available incontinence swim briefs” (p.4).

It is well known that the water influence positively on human’s body. Here emerges the question as to what effects the aquatic therapy has on patients with neurocognitive diseases? Because of the wide range of healing properties of water, the aquatic therapy benefits patients and can be an important part of the neurological rehabilitation.

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First of all, it has the effect on the musculoskeletal system. Zotz, T. G. G., Souza, E. A., Israel, V. L., and Loureiro, A. P. C. mentioned that aquatic therapy “may be an excellent alternative to land exercise for individuals who lack confidence, have a high risk of falling, or have joint pain that limits their ability to practice center-of-gravity shifts beyond the limits of their base of support” (p.104). Myers, Capek, Shill, and Sabbagh also reported that “Buoyancy in the water and the viscosity of water compared with air enable nonambulatory persons and those at high risk of falls to practice balancing skills while strengthening their lower extremity musculature without the risk of falling”. Patients with neurocognitive diseases and problems with movements can move freely in the water without fear of falling. As a result, water exercisers improve their postural and motor skills. “This study implies that while gait, balance, and lower body strengthening activities reduce fall risk, aquatic exercises are more effective” (p. 5). Therapist should also be careful with some patients who have increased adipose tissue or hypotonicity, because such patients may become unstable. Moreover, according to Morris (1995) “decreased weightbearing through the joints may further diminish sensory input for clients with sensory deficits”. But if the appropriate water depth is used, these problems can be avoided (p. 22). In addition, when a patient immerses in the water to a level of the neck, hydrostatic pressure of the water increases his blood flow in the non-working muscles. This kind of increasing in the muscle blood flow improves the muscular performance by oxygen saturation and removal of metabolic products. Thus, muscle training becomes more effective.

Aquatic therapy exercises, their duration and frequency should be also prescribed individually for every patient. In that way, patient of 89-year-old with Alzheimer’s disease, in Myers, Capek, Shill, and Sabbagh, was prescribed aquatic therapy “twice weekly for 30 minutes over a period of 3 months”. As a result, his fall risk scores trended downward (p.3).

The second example of the aquatic therapy’s effects is the cardiovascular effect. In many ways, this effect is caused by the influence of hydrostatic pressure. It causes a change in the functional state of the cardiovascular system, even in a motionless person who stands in the water. According to Hall, Swinkels, Briddon, and McCabe (2008) these “mechanisms are based around the effects of hydrostatic pressure, which by virtue of its effect on the cardiovascular system may relieve pain by reducing peripheral edema and, centrally, by dampening sympathetic nervous activity” (p.873). When a patient is immersed in the water in an upright position of the body, the hydrostatic pressure on the lower limbs contributes the transferring of the venous blood from the periphery to the heart, but this effect will only occur if the patient is in the water up to the neck. In that position central venous pressure increases to about 60%, and the heart volume and the stroke volume to about 30% (p.877).

The respiratory effect is the third advantage of the aquatic therapy. Ide, Belini, and Caromano (2005) told that “the aquatic respiratory exercise strengthened aspiratory muscles. We believe that this improvement occurred because of the influence of the physical properties of water which increase the volunteers’ respiratory efforts compared to exercising in air” (p.155). Moreover, water immersion of the body results transferring of blood from the periphery, increasing blood flow in the organs of the thoracic cavity, and the increment of hydrostatic pressure on the chest increases the resistance of its chest excursions, thereby reducing the vital capacity and enhancing the muscle work of apparatus of external respiration. Reduced weight bearing due to buoyancy and increased support of abdominals which is provided by the hydrostatic pressure of water, can help patients with a weak breathing diaphragm. Consequently, the load that falling on respiratory system during exercises in water can be used to improve the respiratory function and strength of respiratory muscles.  According to Becker (2009) “A review in 2006 concluded that respiratory muscle training tended to improve expiratory muscle strength, vital capacity, and residual volume” (p.863).

There are different breathing results depending on the temperature of the water. Еhe breath-holding occurred at the first minutes of the cold hydroprocedure, than the breathing becomes more frequent and, finally, deepens and slows down. Warm water therapy treatments don’t not significantly change the quality of breathing, but speaking about hot water therapy, it speeds up and reduces the depth of breathing.

The most significant example of positive effects of the aquatic rehabilitation is psychophysiological effect. According to Broach and Dattilo (1996), “psychological benefits of participants in aquatic therapy have been identified to include improved mood, enhanced self-esteem and body image, and decreased anxiety and depression” (p.212). Water immersion forms a powerful sensory inflow from skin receptors of different modalities that can radically change the functional state of the central nervous system and vegetative nervous system, significantly increase the energy potential of the brain and its plasticity, enabling the higher nervous activity. Hot water, increasing the sensitivity of the mechanical and thermal receptors of the skin, and making more frequent the number of afferent impulses, has a stimulating effect. Cold hydro procedures (the first phase of the reaction) leads to the similar effect. Prolonged use of procedures with both cold and hot water follows by the development of the second phase of the reaction – the depression of central nervous system (p.215).

Psychological effects are also dependent on water temperature. Immersion in warm water causes a general relaxation and comfort. On the contrary, cold water gives a flow of energy for most people. The neutral effect of the warm water can be used to create a feeling of comfort and reassurance of overexcited or aggressive patients, whereas the activating effect of cold water is used to increase the activity during exercises for those who usually have little activity.

It is believed that the observed psychological effects including mood improvement may be caused by the activation process in the reticular formation. When a patient takes a hot bath, the concentration of endorphins in his blood plasma increases and as a result can cause his or her euphoric reaction. For example, in Myers, Capek, Shill, and Sabbagh, the stuff noticed that their 89-year-old patient “was smiling more and talking more clearly without his usual trouble finding words. He even joked with the staff” (p.4).

To sum up, it is known from ancient times that water has healing properties and influences positively on human’s body. Thus, the aquatic therapy is used in neurological rehabilitation of patients with neurocognitive diseases. The aquatic therapy benefits patients on musculoskeletal and cardiovascular systems. Patients also have the respiratory and psychophysiological effects after the aquatic therapy. Aquatic therapy is one of the most effective methods of recovery and rehabilitation, only in the case when it is taken into account the functional condition of a patient and met the security measures for its implementation.

Author: Ekaterina Nikitina

References

Becker, B. E. (2009). Aquatic therapy: scientific foundations and clinical rehabilitation applications. PM&R1(9), 859-872. Retrieved November 26, 2014, from http://aquaticdoc.com/Aquaticdoc.com/Publications_files/Aquatic%20Therapy-%20Scientific%20Aspects.pdf

Bowes, A., Dawson, A., Jepson, R., & McCabe, L. (2013).  Physical activity for people with dementia: a scoping study, BMC Geriatrics, 13. Retrieved November 8, 2014, from http://www.biomedcentral.com/content/pdf/1471-2318-13-129.pdf

Broach, E., & Dattilo, J. (1996). Aquatic therapy: A viable therapeutic recreation intervention. Therapeutic Recreation Journal30, 213-229. Retrieved November 26, 2014, from http://www.bctra.org/wp-content/uploads/tr_journals/1204-4720-1-PB.pdf

Gaugler, J., James, B., Johnson, T., Scholz, K., & Weuve, J. (2014).  2014 Alzheimer’s Disease Facts and Figures, Alzheimer’s & Dementia, 10 (2), 4-15. Retrieved November 9, 2014, from http://www.alz.org/downloads/Facts_Figures_2014.pdf

Hall, J., Swinkels, A., Briddon, J., & McCabe C. S. (2008). Does aquatic exercise relieve pain in adults with neurologic or musculoskeletal disease? A systematic review and meta-analysis of randomized controlled trials, Archives of Physical Medicine and Rehabilitation, 89 (5), 873-883. Retrieved November 8, 2014, from http://www.archives-pmr.org/article/S0003-9993(08)00054-3/pdf

Ide, M. R., Belini, M. A. V., & Caromano, F. A. (2005). Effects of an aquatic versus non-aquatic respiratory exercise program on the respiratory muscle strength in healthy aged persons. Clinics60(2), 151-158. Retrieved November 27, 2014, from http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322005000200012&lng=en&tlng=en. 10.1590/S1807-59322005000200012

Morris, D. M. (1995). Aquatic neurorehabilitation. Journal of Neurologic Physical Therapy19(3), 22-28. Retrieved November 8, 2014, from, http://journals.lww.com/jnpt/Citation/1995/19030/Aquatic_Neurorehabilitation_.17.aspx

Myers, K., Capek, D., Shill, H., & Sabbagh, M. (2013). Aquatic therapy and Alzheimer’s disease. Annals of Long-Term Care: Clinical Care and Aging. Retrieved November 9, 2014, from http://hstrial-inertiatherapyse.homestead.com/Dr_Myers_Aquatic_Article.pdf

What is Parkinson’s Disease? (n.d). Parkinson’s Disease Foundation. Retrieved from http://www.pdf.org/about_pd

Zotz, T. G. G., Souza, E. A., Israel, V. L., & Loureiro, A. P. C. (2013). Aquatic physical therapy for Parkinson’s disease. Advances in Parkinson’s Disease, 2(4), 102-107. Retrieved November 9, 2014, from http://dx.doi.org/10.4236/apd.2013.24019

Positive Deviants and Their Medical Contributions

Gawande (2007) shows the relations between doctors and patients as well as the medicine behind the scene; it is like a separate world that is unseen to a regular person. In this world the doctor does his best to make the patient feel better, to prescribe a better medication, to become a good doctor and even better. This word “better” is going through the book from the beginning up to the end. Gawande identifies three topics: “Diligence”, “Doing Right”, and “Ingenuity”. He tells the readers about the importance of simple health care procedures like washing hands in order to drop in the epidemic rate in the hospitals, about the doctors who worked on mopping-up the polio among the Indian population, and about those who strived to save the lives of American soldiers in Iraq. Comfort level for the patients and cultural requirements are also discussed as well as insurance systems and service pricelists. The most significant problems that are mentioned by Gawande are the suing the doctors for their malpractices, and whether or not doctors should participate in executions by lethal injection. At the end the readers can learn more about how become a good doctor, how accept the failures, reflect on failures and find new solutions – even through creativity – to avoid these failures in the future.

Gawande hit upon a very important idea that “But making medicine go right is less often like making a difficult diagnosis than like making sure everyone washes their hands” (p.21). By this statement Gawande means that often people think that medicine is only about diagnosis, but in fact the health of an every single person is consists of thousands of steps, such as following health care rules, fighting till the end, and being creative.

First of all, following health care rules can prevent serious illnesses and diseases. According to Gawande, “Bacterial counts on the hands range from five thousand to five million colony-forming units per square centimeter. […]. The worst place is under the fingernails” (p.17). Doctors examine a lot of patients each day and if they don’t wash their hands, don’t use sterile gloves and don’t sterilize the instruments, they can easily communicate infection from one patient to another. Gawande acknowledges his possible mistakes in this passage:

Until that moment, when I stood there looking at the sign on his door, it had not occurred to me that I might have given him that infection. But the truth is I may have. One of us certainly did (p. 28).

Due to doctors either are lazy to follow hand hygiene rules or just forget about them, millions of patients are infected in the hospitals and as a result many of them die. Such doctors and nurses can be easily sued for malpractice. However, they all should understand that this simple step of washing hands can save a lot of lives and drop in the epidemic rate in the hospitals. Thus, lives of millions of patients are literally in the doctors’ hands.

Another instance of following the health care rules to avoid serious diseases is to be vaccinated when you should to be. When the epidemic breaks out, scientists do their best to find the vaccine for this or that disease.  Gawande gives us an example of polio – the disease that strikes children under age five in India (p. 35).  A huge campaign for polio immunization was launched there. Thousands of vaccinators went from house to house to inoculate children. It was up to parents whether or not do this vaccination to their children. But they had to understand that this simple process of immunization could save the life of their children and stop the spreading of the disease. Unfortunately, not all people realized that and as a result a lot of children became paralyzed because of not taking the drop. Gawande describes the conversation between mother and the doctor:

The mother said that a health worker had come around with polio drops a few weeks before her daughter became sick. But she had heard from other villagers that children were getting fevers from the drops. So she refused the vaccination. A look of profound sadness now swept over her (p. 50).

In that way, it is very important to follow health care rules, because these are what help people to stay healthy, prevent diseases and avoid terrible results, such as death.

Still another example of thousands of small steps that make the path to the success is fight till the end. Due to the progress in medicine, there are big chances for soldiers to survive after getting injuries during the war such as gunshot wounds to the stomach, liver, chest and others. One of the main important things is whether or not doctors start the treatment on time and whether or not they fight till the end to save the soldiers’ lives. In the war every minute and even every second has its own value. That’s why time is one of the cruelest things during the war. Colonel Ronald Bellamy claimed, “Civilian surgeons talk of having a “Golden Hour” during which most trauma victims can be saved”. But there are also “Golden Five Minutes” for soldiers with blood loss (as citied in Gawande, p. 57). If during these minutes the urgent treatment has started, probably, the soldiers would live. Moreover, it is also important what kind of treatment is provided and whether or not doctors put their whole soul, all their desires to save the soldiers. Life is priceless, that’s why doctors have to do their best to pull soldiers out of the death.

People also ask doctors very often questions like “Should they put her through yet more of this? Or should they take her home and let her die?” But where is the border between what doctors can do and what they can’t do (p. 159)? According to Gawande, “the truth is we want doctors who fight” (p. 159). “Even when we don’t know that a patient can be completely normal and healthy, we want doctors to fight” (p. 160).  Such a great responsibility lies with doctors. They should definitely fight. Only this kind of behavior can lead the doctors to the success, even if they were not able to save someone’s life. We never know what the last attempt can do. Maybe the last desperate attempt can lead the patient to the recovery. That’s why it is so important to fight till the very end, especially when the patients, their friends and relatives believe in doctors’ help so much.

The most significant example of how thousands of small steps make the path to the success is doctors’ ingenuity. Ingenuity is not less important than doctors’ skills and professionalism. Only due to all these things together, these simple steps, doctors can be successful in what they do. “Nonetheless, what I saw was: better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try” (p. 246). Doctors don’t have to be afraid of being creative and should give a try to something they have invented, even if it seems so simple and primitive. Who knows maybe exactly this innovation will improve the quality of the medicine and will help to save people’s lives. Gawande gives us an example of this kind of simple idea. It is a measurement of a newborn’s physical condition that was invented by Virginia Apgar – the first woman who was admitted to the surgical residency at Columbia University College of Physicians and Surgeons (p.185). “The Apgar Score, as it became universally known, allowed nurses to rate the condition of babies at birth on a scale from zero to ten” (p. 187). This innovation amazed doctors. It allowed them to give an immediate feedback to what they did. According to Gawande “The score also changed the choices they made about how to do better” (p. 190).

To sum up all above, Gawande considers that the ultimate success consists not only of difficult diagnosis, but it is the result of cooperation between doctors and patients. Moreover thousands of steps are essential to the way to the success. Following health care tips, fighting up to the end and doctors’ ingenuity these are what can save millions of lives and lead to the doctors’ professional triumph. However, not only in the medical field these steps are very important. Our whole life should be based on single steps that will lead us to the height of our success.

Author: Ekaterina Nikitina

Reference

Gawande, A. (2007). Better: A surgeon’s notes on performance. New York: Picador.