Hydrotherapy or Aquatic therapy

People use hydrotherapy to treat many illness and conditions such as acne, arthritis, colds, depression, headache, stomach problems, joint pain, muscle spasm, nerve problems, sleep disorders and stress

Hydrotherapy (Aquatherapy) is any activity performed in water to assist in rehabilitation and recovery from eg.hard training or serious injury.It is a form of exercise in warm water and is a popular treatment for patients with neurologic and musculoskeletal conditions. The goals of this therapy are muscle relaxation, improving joint motion and reducing pain. This therapy is been used for thousands of years.

Physiotherapists are often involved in hydrotherapy in a rehabilitation setting. Client satisfaction and adherence to this form of exercise are often high. The therapeutic effects are often enhanced by the social setting of the sessions.

Hygiene and infection control needs to be closely monitored.

Physical properties of water

In common with other forms of matter, water has certain physical properties which include mass, weight, density, relative density, buoyancy, Hydrostatic pressure, surface tension, refraction and reflection.

Of the physical laws of water that the physiotherapist should understand and apply when giving Aquatherapy, those of buoyancy and hydrostatic pressure are the most important. The lateral pressure exerted and the effect of buoyancy together will give the feeling of weightlessness.

Buoyancy:-

Buoyancy is the force experienced as an upthrust which acts in the opposite direction to the force of gravity. A body in water is therefore subjected to two opposing forces. When the weight of the floating body equals the weight of the liquid displaced, and the centres of buoyancy and gravity are in the same vertical line, the body is kept in stable equilibrium. If the centres are not in the same vertical line the two forces acting on the body will cause it to roll over until it reaches a position of stable equilibrium.

Hydrostatic pressure 

The molecules of a fluid thrust upon each part of the surface area of an immersed body. Pascal's law states that fluid pressure is exerted equally on all surface areas of an immersed body at rest at a given depth. Pressure increased with the density of the fluid and with its dept. This means that swelling will be reduced more easily if exercises are given well below the surface of the water where the increased pressure may be used.

The hydrostatic pressure place on the outside of the body causes a decrease in Blood Pressure (BP) peripherally and an increase in the BP in and around the heart. This can cause potential problems for eg Chronic Heart Failure (CHF) and Coronary Artery Disease CAD) clients and needs to be taken into consideration. The greater the depth the greater the changes described above would be.

Physiological Effects

The physiological effects of water therapy combine those brought by the hot water of the pool with those of the exercises. The extent of the effects varies with the temperature of the water, the length of the treatment and the type and severity of the exercise.

The physiological effects of exercise in water are similar to those of exercise on dry land. The blood supply to the working muscles is increased, heat is evolved with each chemical change occurring during the contraction, and the muscles temperature rises. There is an increased metabolism in the muscles resulting in a greater demand for oxygen and increased production of carbon dioxide. These changes augment the similar changes brought about by the heat of the water, and both contribute towards the final effect. The range of joint movement is either maintained or increased, and muscle power increases.

During the immersion, the physiological effects are similar to those brought about by any other form of heat but less localized. A rise in body temperature is inevitable because the body gains heat from the water and from all the contracting muscles performing the exercises. As the skin becomes heated the superficial blood vessels dilate and the peripheral blood supply is increased. The blood flowing through these vessels is heated and by convection, the temperature of the underlying structures rises.

The relatively mild heat of the water reduces the sensitivity of sensory nerve endings and the muscle tone will diminish when the muscles are warmed by the blood passing through them.

Therapeutic Effects 

Relieve pain and muscle spasm

To gain relaxation 

To maintain or increase the range of joint movement

To re-educate paralyzed muscles

To strengthen weak muscles and to develop their power and endurance

To encourage walking and other functional and recreational activities.

To improve circulation ( trophic condition of the skin ) 

To give the patient encouragement and confidence in carrying out his exercises, thereby improving his morale

The warmth of water blocks nociception by acting on thermal receptors and mechanoreceptors, thus influencing spinal segmental mechanisms

Warm water stimulates blood flow positively, which leads to muscle relaxation

the hydrostatic effect may relieve pain by reducing peripheral oedema and by dampening the sympathetic nervous system activity.[3]

The study by Ahmed SAMHAN et al. suggests that monitored aquatic-based exercises effectively improve muscle strength, fatigue, and quality of life, and skin disease activity than land-based exercises in children with juvenile dermatomyositis

Clinical Contraindications 

Serious ContraindicationsAbsolute Contraindications

Cardiovascular disease

cardiopulmonary disease

Diabetic

Balance disorder

History of CVA, Epilepsy

Incontinence

Labyrinthitis

a cold

Influenza

Fever

skin conditions

Chemical allergies (Chlorine)

Contagious diseases

Hepatitis

Tracheotomy

Urinary tract infection

Serious Epilepsy

Urinary incontinence

Open Wounds 

Recently Surgery 

Hydrophoby

Difference Between Aquatic Exercise and Balneotherapy

Balneotherapy is hydrotherapy but without exercise and is also called “Spa therapy”. It is frequently used in alternative medicine as a disease cure and is very popular for treatment of all types of arthritis.

There are not many studies that describe the difference in therapeutic effects between aquatic exercise and balneotherapy without exercise. In the following review article, ‘Effectiveness of Aquatic Exercise and Balneotherapy’, results show that Aquatic exercise had a small significant effect on pain reduction, improvement of function, quality of life and mental health. Compared to balneotherapy, an exercise in water is more effective for the treatment of musculoskeletal diseases than passive immersion. There are no long-term effects, so to keep the disease stable, it is necessary to frequently participate in water exercises.

It is not clear what exactly the effect is of balneotherapy in musculoskeletal diseases because the studies involving this subject have poor methodological quality, which makes it difficult to determine the individual effect in this therapy.

Examples of Alternative Methods  of Hydrotherapy

The "Watsu Method"

Also called “water Shiatsu", is a combination of Aquatherapy and Shiatsu. Watsu is based on stretching the body in the supportive, relaxing medium of warm water. Beside the physical aspect, also the mental aspect has a great importance during this therapy. The Watsu method has a general relaxation and calming effect that soothes the muscle tension and stimulates all of the body systems and organs by nourishing the energy flow.

The "Bad Ragaz Ring Method"

This is an aquatic treatment approach based on proprioceptive neuromuscular facilitation.

The "Feldenkrais Method"

This method promotes teaching individuals about the quality of their movements and how to move effortlessly with ease and efficiency.

The "Halliwick Method"

This method takes a holistic approach using Aquatherapy as a learning activity for all people, particularly those with physical or learning difficulties, to be confident to move independently and become a part of a group setting involving water activities.[13]

The "Burdenko Method"

A method of Aquatherapy designed to address the 6 precepts of fitness: strength; flexibility; balance; co-ordination, endurance and speed. It is promoted as a great way to recover from injury or surgery

Related articles

Hydrotherapy for Children with Cerebral Palsy - Physiopedia

Description 'Hydrotherapy' also known as 'Aquatic Therapy' involves therapeutically immersing the body in water where the physical properties of altered density and gravity, hydrostatic pressure, buoyancy, viscosity and thermodynamics can be used to promote physiological change[1]. The buoyancy and turbulence of water facilitates weight relief and ease of movement during rehabilitation to promote safe movement exploration, strengthening, and functional activity training[2]. Benefits Hydrotherapy is indicated in children with cererbal palsy. The main benefits of aquatic therapy are: Water provides resistance in all planes and directions Encourages a wider range of movement and opposition Alleviates stress and tension Reduces pain and tension in muscles and joints Protects against injury Improves cardiovascular conditioning since the heart pumps more blood per beat when body is submerged in water Decreases post exercise discomfort Safety Considerations and Outcome Measures Absolute Contra-indications [3] Acute vomiting / diarrhoea Medical instability Chlorine / Bromine allergy Resting angina Shortness of breath at rest Uncontrolled cardiac failure High BMI limiting exit from pool Relative Contra-indications Acute illness Irradiated skin Known aneurysm Open infected wounds Poorly controlled epilepsy Unstable diabetes Exercise dependent O2 demand increases Outcomes should be meaured in dimensions outlined by the International Classification of Functioning, Disability and Health for Children and Youth (ICF-CY) [4]. Common motor function meaures utilised in Aquatic Therapy research: [5] Gross Motor Function Measure (GMFM) Paediatric Evaluation of Disability Inventory - functional skills Dynamometer - muscle strength Energy Expenditure Index (EEI) - energy efficiency 3/5/6 minute walk tests Timed up and Go (TUG) Vital Capacity Goniometry - range of movement Ashworth Scale - spasticity Swimming based measures: Aquatics Independence Measure Water Orientation Test-Alyn 2 (WOTA) Social function measures: PEDI - social function domain Pictoral scale of perceived competence Canadian Occupational Performance Measure Key Evidence Administered correctly, aquatic therapy can: Improve muscle tone Increase core strength Enhance circulation Improve cardiovascular functioning Improve flexibility Increase endurance Extend range of motion Reduce muscle spasticity Elevate metabolism Reduce sleep disturbances Relieve joint stress Improve muscle tone Increase stability Decrease pain and discomfort Physiopedia

: Introduction: Aquatherapy and Hydrotherapy are terms used interchangeably to indicate a modality of treatment performed in an aquatic environment. This page will attempt to assimilate the current literature for incorporating hydrotherapy into conventional rehabilitation of Anterior Cruciate Ligament (ACL) Injury, conservatively or alongside Anterior Cruciate Ligament (ACL) Reconstruction (ACLR). Outcome measures of ACL rehabilitation: Instability episodes [1] Pain [1] Issues with: Swelling, walking, climbing, stairs, kneeling, squatting, running, lateral motion, cutting, jumping [1] Measures of knee function: Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36)  International Knee Documentation Committee (IKDC) form, Lysholm and Tegner scores Knee Injury and Osteoarthritis Outcome Score (KOOS4) Graft rupture (post-ACLR only)  Contralateral ACL injuryLachman and pivot-shift Passive range of motion (knee flexion & extension), muscle strength, thigh circumference (thigh girth, thigh muscle mass, knee joint swelling) [5][6] Active range of motion (knee flexion & extension) [7] 6 minute walk test (6MWT) [7] Advantages of Hydrotherapy in ACL/R Rehabilitation In principle: Early weightbearing [7] Postural and gait exercises in a supported environment [8] Water resistance induced muscular conditioning [8] Outcomes of Hydrotherapy + Conventional Rehabilitation vs. Conventional Rehabilitation Only: After 2 weeks post-ACLR, patients who underwent 3 weeks of combined hydrotherapy with conventional rehabilitation, had superior outcomes in proprioception, walking, muscle strength in the short and medium term, compared to participants exclusively in conventional rehabilitation programme [9]. Another trial found that ACLR patients placed through 9 weeks of aquatic rehabilitation immediately post-surgery had better clinical parameters in muscle strength and mass circumference, pain, swelling, and range of motion compared to those on land rehabilitation [5]. A smaller case study of 3 subjects demonstrated no risk of harm in utilizing hydrotherapy to accelerate rehabilitation of ACLR [7]. Considerations for ACL hydrotherapy rehabilitation design: Accelerated Hydrotherapy Programme [7] Goal: Treatment: Gait Retraining Gait training Quadriceps and hamstring strengthening Closed kinetic chain exercises, Open kinematic chain exercises Strengthening & endurance training Running, Cycling, Deep-water running techniques Hip and calf maintenance and strengthening Hip exercises and calf raises, kicking and vertical kicking Balance and proprioception (perturbation protocol) Balance and proprioception exercises Plyometric training Jumping, running, shuttle runs, side steps with increased speed Sports-specific rehabilitation Agility exercises making use of a ball Video Examples of Hydrotherapy Protocols & Case Studies: ACL Hydrotherapy Rehabilitation Progression Timeline, Principles, & Advantages - Hydroworx Acute Partial ACL & PCL Injury in Male Recreational Basketball Player (conservative management) - Hydroworx ACL-R Patellar Autograft (5.5 weeks post-op with regression) - Hydroworx ACL-R in Female Soccer Goalie (4 weeks post-op with delayed rehabilitation) - Hydroworx Unhappy Triad in Female Volleyball Player (8 weeks post-op) - Hydroworx Gait Retraining and Lower Limb Mobility Exercises - Sports Med Mumbai

Thermotherapy - Physiopedia

Definition/Description Thermotherapy consists of application of heat or cold (cryotherapie) for the purpose of changing the cutaneous, intra-articular and core temperature of soft tissue with the intention of improving the symptoms of certain conditions. Cryotherapy and thermotherapy are useful adjuncts for the treatment of musculoskeletal injuries and soft tissue injuries. Using ice or heat as a therapeutic intervention decreases pain in joint and muscle as well as soft tissues and they have opposite effects on tissue metabolism, blood flow, inflammation, edema and connective tissue extensibility. Thermotherapy can be used in rehabilitation facilities or at home.  Purpose The goal of thermotherapy is to alter tissue temperature in a targeted region over time for the purpose of inducing a desired biological response. The majority of thermotherapies are designed to deliver the thermal therapy to a target tissue volume with minimal impact on intervening or surrounding tissues. Heat: By increasing the temperature of the skin/soft tissue, the blood flow increases by vasodilatation. The metabolic rate and the tissue extensibility will also increase. Heat increases oxygen uptake and accelerates tissue healing, it also increases the activity of destructive enzymes, such as collagenase, and increases the catabolic rate. Cold: By decreasing the temperature of the skin/soft tissue, the blood flow decreases by vasoconstriction. It will be followed afterwards by a vasodilatation which will prevent against hypoxic damage (hunting reflex: If the cold pack is left on the skin for more than 10 minutes, the blood vessels will dilatate). The tissue metabolism will decrease just like the neuronal excitability, inflammation, conduction rate and tissue extensibility. At joint temperatures of 30°C or lower, the activity of cartilagedegrading enzymes, including collagenase, elastase, hyaluronidase, and protease, is inhibited. the decreased metabolic rate limits further injury and aids the tissue in surviving the cellular hypoxia that occurs after injury. Figure 1:Pathophysiologic effects of topical modalities Both applications can reduce the pain, but when we need to use which application is still the question. Therefore, patient’s preference can be taken into consideration when deciding which thermotherapy tool to use.  Application Heat: Heating of superficial tissues can be achieved using hot packs, wax baths, towels, sunlight, saunas, heat wraps, steam baths/rooms. We can also get the heat in the deeper tissues through electrotherapy (ultrasound, shockwave and infrared radiation). Cold: Cooling is achieved using ice packs, ice baths, cooling gel packs, cold air and sprays.  In the literature, they describe cryotherapie (ice application) as an effective treatment for soft tissue injuries. It reduces the swelling, and it will improve the range of motion. However, there are still some doubts if it is actually effective for pain relief. So the application of ice may be useful for a variety of musculoskeletal pains, yet the evidence for its efficacy should be established more convincingly. [10] [11] Exercise in warm water, usually called hydrotherapy or balneotherapy, is a popular and effective treatment with a pain relief effect for many patients with painful neurologic or musculoskeletal conditions. The warmth of water may block nociception by acting on thermal receptors and mechanoreceptors, thus influencing spinal segmental mechanisms. It gives positive effects on cutaneous barrier homeostasis and a anti-inflammatory activity. In addition, the warmth may enhance blood flow and muscle relaxation. The hydrostatic effect may also relieve pain by reducing peripheral edema and by dampening sympathetic nervous system activity.  Mechanism of Action Skin blood flow is controlled by two branches of the sympathetic nervous system: a noradrenergic vasoconstrictor system and a cholinergic active vasodilator system. These dual sympathetic neural control mechanisms affect the major aspects of thermoregulatory responses over most of the human body’s surface. Figure 2:Skin blood flow responses to cold stress and heat stress. [5] VC = vasocondtriction, VD = vasodilatation During periods of hypothermia, falling core and skin temperatures lead to reflexive increases in sympathetic active vasoconstrictor nerve activity to reduce skin blood flow and conserve body heat. During periods of heat stress, increasing core and skin temperatures lead to reflexive increases in sympathetic active vasodilator nerve activity to increase skin blood flow. The effect of heat on pain is mediated by heat sensitive calcium channels. These channels respond to heat by increasing intracellular calcium. This generates action potentials that increases stimulation of sensory nerves and causes the feeling of heat in the brain. These channels are part of a family of receptors called TRPV receptors. TRPV1 and TRPV2 channels are sensitive to noxious heat, while TRPV4 channels are sensitive to normal physiological heat. Their multiple binding sites allow a number of factors to activate these channels. Once activated, they can also inhibit the activity of purine pain receptors. These receptors, called P2X2 and P2Y2 receptors, are mediated pain receptors and are located in the peripheral small nerve endings. For example, with peripheral pain, heat can directly inhibit pain. However, when pain is originating from deep tissue, heat stimulates peripheral pain receptors which can alter what has been termed gating in the spinal cord and reduce deep pain. Previous studies have suggested that temperature can affect the exchange between Ca2+ and Na+ in neural cells. They have documented an increase in both pain threshold (PTH) and pain tolerance (PTO) with the use of cooling.  True or not true?Disadvantage: when you heat skin, vasodilatation (VD) distracts blood from soft tissue underneath and poor muscle circulation decreases metabolism in the muscles… Increased superficial tissue temperature results in the release of chemical mediators, such as histamine and prostaglandins, which result in vasodilation. These vasodilatory mechanisms do not significantly affect blood flow in skeletal muscle since skeletal muscle blood flow is heavily influenced by other physiologic and metabolic factors. Exercise is the best means to increase blood flow to skeletal muscle. Treatment The treatment depends on the type of application and the type of disease. There are 3 phases of the healing process: the inflammatory phase, the proliferation phase and the remodeling phase. The first phase, known as the inflammatory phase, protects the injured area from further injury while the body contains the damaged tissue. During this phase, cryotherapy can help to reduce swelling. Never use heat during this phase because heat increases the blood flow into the injured area and increases the amount of swelling. The inflammatory phase has a duration of 2 days. During the second phase, the proliferation phase, new tissue and scar tissue are formed. Heat can now be applied to the injured area to facilitate the healing process. The third and final phase, the remodeling phase, is the process of returning to health: the restoration of structure and function of injured or diseased tissues. The healing process includes blood clotting, tissue mending, scarring and bone healing. Heat therapy can also be used during this phase. Physiological Effects Many of the local physiologic effects of heat and cold have been studied thoroughly. For instance, heat increases skin and joint temperature, improves blood circulation and muscle relaxation and decreases joint stiffness. Cold will numb the pain, decrease swelling, constrict blood vessels and block nerve impulses to the joint. Deep heating is thought to lessen nerve sensitivity, increase blood flow, increase tissue metabolism, decrease muscle spindle sensitivity to stretch, cause muscle relaxation, and increase flexibility. Heat stimulates the cutaneous thermo receptors that are connected to the cutaneous blood vessels, causing the release of bradykinin which relaxes the smooth muscle walls resulting in vasodilation. Muscle relaxation occurs as a result of a decreased firing rate of the gamma efferents, thus lowering the threshold of the muscle spindles and increasing afferent activity. There is also a decrease in firing of the alpha motorneuron to the extrafusal muscle fibre, resulting in muscle relaxation and decrease in muscle tone.  Precautions A very important note that needs to be made is that thermotherapy is safe for people with a normal skin sensation. When a patient has problems with thermal sensitivity, it could be dangerous. They cannot feel if they are being burned due to the application.  Effectiveness Effectiveness There are still a lot of contradictions if the use of thermotherapy is effective; however, worldwide it is used to reduce the pain. While there is good evidence that exercise relieves pain, improves function, and is cost-effective, evidence supporting the use of non-exercise physiotherapeutic interventions is much weaker. There is some support for the efficacy of thermotherapy, transcutaneous electrical neuromuscular stimulation (TENS), and massage. But there is little evidence to support the efficacy of electrotherapy, acupuncture or manual therapy. For knee osteoarthritis (OA), ice massage is reported to improve joint movement, pain and function; ice packs can reduce swelling and improve movement but may not relieve pain. In rheumatoid arthritis (RA), heat or cold packs are reported to have no effect on edema, pain, movement, strength or function. Cost effectiveness  Despite conflicting evidence, the simple form of thermotherapy is widely recommended for many musculoskeletal conditions because it is a safe, effective, easy-to-apply and well-liked therapy based on anecdotal reports, expert opinion and patient preferences. Interventions that can be self-administered (thermotherapy, TENS, massage) are more likely to be cost-effective and less burdensome and hence much more attractive long-term management options. Complex thermal therapeutic modalities (heating deeper tissues) require special equipment, supervision and need to be delivered by a therapist, making them less accessible, more costly and higher risk. Figure 3:Short- and long-term effectiveness, cost-effectiveness and clinical practicability of commonly ' used physical therapy modalities utilized in the management of musculoskeletal conditions.  level of evidence: 1C

Fibromyalgia - Physiopedia

Definition/Description Fibromyalgia Syndrome is a disease characterized by chronic pain, stiffness, and tenderness of muscles, tendons, and joints, without detectable inflammation. Fibromyalgia does not cause body damage or deformity. Fatigue affects 90 percent of patients and sleep disorders are common. Fibromyalgia can be associated with other rheumatic conditions, and irritable bowel syndrome (IBS). There is no definitive medical test for the diagnosis of fibromyalgia and fibromyalgia symptoms can come and go over time. Diagnosis is made by eliminating other possible causes of the symptoms. It can take time to tease out which symptom is caused by what problem. FMS is NOT just one condition; it's a complex syndrome involving many different factors that can severely impact and disrupt a person’s daily life. Fibromyalgia Syndrome (FMS) is considered as a systemic problem involving biochemical, neuroendocrine, and physiologic abnormalities, leading to a disorder of pain processing and perception (i.e. allodynia, hyperalgesia). The symptoms associated with FMS may originate from primary or secondary/reactive causes. [2] The most effective treatment is a combination of education, stress reduction, exercise, and medication. The below video gives a good summary of FMS [3] Prevalence FMS occurs in more than 6 million Americans, or 4% of the population, causing it to be the most common musculoskeletal disorder in the U.S. It affects mainly women (90%) more often than men. Symptoms typically present between the ages of 20-55 years, but individuals have been diagnosed as young as 6 years and as old as 85 years of age. Pathophysiology The pathogenesis of FMS is theorized to be a malfunctioning of the central nervous system (CNS), characterized by central sensitization, which is a heightened pain perception accompanied by ineffective pain inhibition and/or modulation. This increased response to peripheral stimuli causes hyperalgesia, allodynia, and referred pain across multiple spinal segments, resulting in chronic widespread pain and decreased tolerance to sensory input of the musculoskeletal system. FMS systemically causes a dysregulation : : neurologic; immunologic; endocrinologic; and enteric organ systems[2]. 1. Autonomic Nervous System The Autonomic Nervous System (ANS) is responsible for regulating the Sympathetic (“fight or flight”) and the Parasympathetic (“rest and digest”) responses. With FMS, patients experience a systemically heightened sympathetic (SNS) response with a diminished parasympathetic (PNS) modulation. Continuous over activation of the SNS results in increased heart rate, excessive gastric secretions and contractions, abnormalities of smooth muscle contraction throughout the digestive tract, rapid and shallow respiration, and vasoconstriction. This can lead to malnutrition due to absorption and digestion disruptions. Prolonged inhibition of PNS alters the neuroimmunoendocrine systems, directly affecting growth hormone secretion by the pituitary gland. This can result in nonrestorative sleep, pain, fatigue, and cognitive/mood symptoms.  2. Immune System The immune response to infection, inflammation, and/or trauma is a release of cytokines for local healing, which trigger the CNS to release glial cells within the brain and spinal cord for healing support and pain response. With FMS, this auto-immune response is heightened, causing an excess of glia in the body which creates an exaggerated state of pain (chronic).Causes There are many hypotheses of how multiple factors play a role in the development of FMS. The exact etiology of FMS is still being researched; however, there are several potential causes and risk factors, listed below, that are currently associated with, or increase one’s risk for developing this condition. Diet Viral Occupation, seasonal, environmental influences Adverse childhood experiences (i.e. PTSD) Psychological and cognitive/behavioral factors Other conditions: RA, systemic lupus erythematosus, or AS Current research remains inconclusive regarding the genetic or hereditary cause of sMS. A family history of FMS is a risk factor. Characteristics/Clinical Presentation Muscle pain is characterized as the major symptom of FMS, often described by patients as “aching or burning” regardless of physical activity. Other symptoms or associated problems occur, with various reports of frequencies, that can also affect function. FMS may cause residual pain sensations at a lower intensity due to repetitive exposure to peripheral stimuli or activity, also known as the “Wind-up Response.” Symptoms are often exacerbated by: Stress Overloading physical activity Overstretching Damp or chilly weather Heat exposure of humidity Sudden change in barometric pressure Trauma Another illness A recent study carried out by Sempere-Rubio et al found out that functional capacity, upper limb muscular strength, postural maintenance, pain threshold, and anxiety are important predictive factors of QoL in women with FM.Associated Co-morbidities Those with FMS are likely to present with several co-morbidities. It is important that a diagnosis of FMS is not overlooked given the presence of additional co-morbidities more commonly diagnosed. Below is a list of common co-morbidities associated with FMS[2]: Sleep disturbances / apnea Depression Anxiety PTSD Rheumatoid arthritis Systemic Lupus Erythematosus Ankylosing Spondylitis (Axial Spondyloarthritis), Fibromyalgia Diagnostic Criteria (2016) There is no definitive diagnostic test currently available to determine the presence of FMS. A diagnosis of FMS is generally made based upon the results of a physical examination and ruling out other similar conditions. No special laboratory or radiologic testing is necessary for making a diagnosis; however, some recommended lab tests can be performed in order to rule out other conditions. These tests used to rule out include: CBC, ESR, basic chemistry (blood urea nitrogen, creatine, hepatic enzymes, serum calcium), thyroid levels (TSH, T3, and T4), and Rheumatoid factor. Fibromyalgia may now be diagnosed in adults when all of the following criteria are met[6]: Widespread pain index (WPI) ≥7 and symptom severity scale (SSS) score ≥5 OR WPI 4–6 and SSS score ≥9. Generalized pain, defined as pain in at least 4 of 5 regions, is present. Symptoms have been present at a similar level for at least 3 months. A diagnosis of fibromyalgia is valid irrespective of other diagnoses. A diagnosis of fibromyalgia does not exclude the presence of other clinically important illnesses. Management Medication Active rehabilitative approaches have primacy in management, but drugs can help to control symptoms. There is evidence to support the use of amitriptyline, duloxetine, milnacipran or pregabalin, but pure opioids should be avoided. Physical Therapy Management & Exercise Education about the pathophysiology and the neuroscience behind the condition is the most effective method in reducing catastrophizing pain symptoms in patients experiencing FMS according to current research. Simple acknowledgement and explanation of symptoms and relaxation strategies can alter a patient’s ability to cope with their condition. Explanation of disorder Reassurance of condition and symptoms Activity management - Pacing, self-monitoring, rest breaks, AVOID exacerbations, set realistic activity goals, etc. Relaxation Techniques - Minimize environmental stress, deep breathing, healthy & active lifestyle habits, adequate sleep, therapeutic massage, etc.  [Example of a Physical Therapist providing a patient with the educational tools to manage their condition and rehabilitation process.] Aerobic and Resistance Exercise According to the Ottawa Panel evidence-based clinical practice guidelines (2008), supervised light aerobic exercise and strength/resistance training is highly recommended for the management of patients with chronic pain, like those with FMS. It has been found to increase their capacity for activity while minimizing their symptoms associated with FMS. Specifically, aerobic activity has been shown to improve psychological symptoms associated with depression, cognitive decline, and sleep disturbances. Exercise also improves patient’s cellular metabolism and respiratory capacity, increases lean muscle mass and tone, and increases oxygen uptake within the body’s system(s), which ultimately minimizes their complaints of chronic pain and fatigue. Manual / Passive Therapy Some studies support that TENS and joint mobilizations foster the reduction of pain as short-term relief in patients with FMS. Specifically, patients with chronic back pain due to FMS may benefit from spinal manipulations with limited evidence to support this modality. Moderate evidence shows that the use of passive STM is helpful with pain regulation. In addition, diffuse chronic pain presentations are less likely to be reliable for medical management with TENS compared to localized pain. Passive therapy should not be the foundation of FMS medical management due to the maladaptive illness beliefs and coping strategies for patients’ pain.[10][2][4] Manual lymph drainage therapy and connective tissue massage have also been studied in women with fibromyalgia. Researchers used the Fibromyalgia Impact Questionnaire and the Nottingham Health Profile to measure the impact of the treatment. Their research suggests that both manual lymph drainage therapy and connective tissue massage show improvements in both the FIQ and the Nottingham Health Profile. However, there were significantly greater improvements in the group that received manual lymph drainage therapy, suggesting that manual lymphatic drainage therapy may be preferred over connective tissue massage. Aquatic Therapy & Balneotherapy Recent research has proven that aquatic therapy is a more tolerable workout for people with FMS pain. The water’s buoyancy allows the patient to maintain active movement without exerting excessive energy and/or increasing pressure on their joints. Furthermore, evidence has shown that aquatic therapy and hydrotherapy help in improving the quality of life of those with FMS long term.

The underlying symptom(s) of fibromyalgia, central hypersensitivity and pain, may be alleviated by the hydrostatic pressure and the effects of soothing temperature on the nerve endings, along with general muscle relaxation Ideal pool temperature for aquatic therapy sessions are between 84o F and 90o F 82o F and 84o F for the general population 90o F and 94o F for people with arthritic conditions An exercise-education program showed a small significant improvement in health status in patients with fibromyalgia and chronic widespread pain, compared with education only. Patients with milder symptoms improved most with this treatment. Moreover, it has been shown that thermal mud baths (and other balneotherapy methods) increase plasma levels of beta-endorphins, thus explaining their analgesic and anti-spastic effects, which is particularly important in patients with FMs. Other Types of Management Occupational Therapy Treatment focuses on activity modification principles, such as working at a moderate pace, frequent positional/postural changes, and resting before fatigue sets in. Patients are encouraged to incorporate regulating principles into all areas of life including self-care, work, and leisure. Proper body mechanics and posture related to home management and work activities are evaluated and adjusted per individual. Cognitive Behavioral Therapy Research performed by Moseley supports the relationship between pain association and beliefs with physical performance. There is evidence that supports the consideration of cognitive behavioral therapy (CBT) to be implemented in the assessment and plan of care of patients with chronic pain. Growing evidence continues to demonstrate that CBT shows improvement in reports of pain, reduces hyperalgesia, and chronic pain-related brain response in FMS. One study found that behavioral insomnia therapy for patients with FMS may have a promising impact. The study incorporated patient education on sleeping habits and proper sleeping schedules to reduce the bouts of insomnia experienced by those with fibromyalgia. The researchers concluded that patients who received the behavioral therapy experienced improvement in how long they slept and in their general condition compared to other groups Emotional Awareness and Expression Therapy A group intervention focusing of emotional awareness and expression of emotions was found to be more effective than cognitive behavioral therapy in reducing pain for up to 6 months.[17] Chiropractic care & Massage [9] There is no evidence to support chiropractic care nor therapeutic massage are effective in pain management. Acupuncture [10] While many patients explore this option for relief of pain and fatigue, acupuncture techniques have weak evidence to support their effectiveness in current literature. Alternative/Holistic Management No evidence to support alternative/holistic management. Differential Diagnosis The following are all differential diagnoses for FMS. It is possible for several to be present concurrently. Moreover, it is important to determine the presence of all potential facets and diagnoses in order to successfully treat a patient with suspected fibromyalgia.[2] Case Reports Fibromyalgia Case Study A case-control study examining the role of physical trauma in the onset of fibromyalgia syndrome (Full Text Here) Tailored cognitive-behavioral therapy for fibromyalgia: Two case studies. (Abstract Here) Insular hypometabolism in a patient with Fibromyalgia: A case study. (Abstract Here) Resources National Fibromyalgia Association FibroCenter.org APTA Conservative PT Management for Fibromyalgia APTA Recommendation for "Best Workout Options" for Chronic Pain Fibromyalgia Network Ted Talk - A short lecture discussing the perception of pain can pose as an example of how to approach educating patients with chronic and/or catastrophizing pain symptoms, like Patient with FMS.

The Halliwick Concept - Physiopedia

Introduction The Halliwick Concept was developed by the swimming instructor and engineer of hydromechanics James McMillan MBE and his wife Phyl McMillan, MBE in the late 1940s and early 1950s. The International Halliwick Association (IHA) defines the Halliwick Concept as "an approach to teaching all people, in particular, focussing on those with physical and/or learning difficulties, to participate in water activities, to move independently in water, and to swim.  Philosophy The Concept is based on hydrostatics, hydrodynamics, and body dynamics. The main goal is to encourage participation in water activities, to encourage independent movement, to teach swimming. The concept combines the area of mental and physical adaptation to water, relaxation, breathing control, balance, and the acquisition of basic motor skills in the water. The Haillwick concept is based on the following: introduction to water, motor learning, holistic learning, awareness of abilities and achievements in water instead of disability on land, improving the quality of life, integrating children and people with and those without disabilities.Ten Point Programme The concept is implemented according to a ten-point program that is the basis of the Halliwick Concept. Those ten points follow a logical sequence of progress in water, from initial sensorimotor experiences in the aquatic environment to master the elements of the art of swimming. 1. Mental Adjustment During this stage, the swimmer must learn to respond appropriately to the water, and its situations or tasks also need to master breath control which is a crucial step in this program. Mental adjustment enables swimmers to react independently and appropriately during activities in the water. 2. Disengagement This process allows the swimmer to become more physically and mentally independent in the water. Instructors help swimmers to become more independent by ensuring they only offer the support that is needed and work towards reducing this support and their verbal instructions to the swimmer. 3. Transversal Rotation Control (formally Vertical Rotation) Transversal Rotation Control is the ability to control movements around the frontal-transverse axis of the body. It enables swimmers to be in the vertical position, to lean forward and blow water bubbles, or to maintain a standing position without losing balance.[2][3] 4. Sagittal Rotation Control Sagittal Rotation is the rotational movement around an axis passing from the front to the back of the body. This rotation is involved when walking sideways in the water or just maintaining an upright position with turbulent water on one side. 5. Longitudinal Rotation Control Longitudinal Rotation is the rotational movement around an axis passing from the head down to the feet. This rotation allows swimmers in the vertical position to turn around on the spot or enables swimmers to lie on back in the water in the horizontal position and rolling over. A swimmer needs to learn rotating through longitudinal rotation to achieve a safe breathing position on their back and be able to stay in this position.

6. Combined Rotation Control Combined Rotation Control allows the swimmer to control any combinations of the above rotations in one fluid movement. For swimmers with poor breath control, these rotation is crucial. If a swimmer is falling forwards from a standing position swimmer can rotate the head, by doing that swimmer creates a combined rotation and avoids putting face directly in the water. For advanced swimmers, Combined Rotation Control is needed to perform tumble turns. 7. Upthrust Upthrust is a property of water that allows the swimmer to float in the water. It is also called ˝mental inversion˝ because the swimmer needs to reverse their thinking and accept they will float not sink in the water. The instructor can use activities such as diving down to retrieve objects to help swimmers become aware of this effect of water. 8.Balance in Stillness Balance in Stillness is when a swimmer can maintain floating in the water without excessive movements. It depends on both physical and mental balance control. When a swimmer learns these skill he can perform other tasks in water more easily.9. Turbulent Gliding Turbulent Gliding is when the instructor moves a floating swimmer through the water without any physical contact by creating turbulence under the swimmer´s shoulders as he or she moves backward. While the instructor does that swimmer is required to control unwanted rotations without making any propulsive movement. Simple Progression and Basic Swimming Stroke This is the development of simple propulsive movements made by the swimmer to a Basic swimming stroke. Basic swimming stroke is when the swimmer is lying on ack and brings both arms low over the water to shoulder level and then brings arms back to the side creating propulsion.Through these points, the goals of the program in the water are achieved, which are: improvement of breathing control, rhythmic coordination of movements, sensory integrations, body awareness, independence in the activities in daily life, improvement of the general physical fitness and health, self-esteem and interpersonal communication, and abilities to create and participate in the game. Water as a medium provides children with freedom of movement, greater self-confidence, and satisfaction. Haillwick concept is a great method to teach swimming through games and various activities the main idea is to make swimmers happy and adapt to aquatic activities it is a great method to consider when it comes to creating a therapy approach to children with disabilities.