Crushing Pain

A blast from the past. Here is one of the 300+ aquatic articles our team has written for Advance magazine over the last 10 years. The Advance magazine archives are no longer available online, so we are preserving them here. Enjoy!

Byline: Andrea Salzman, MS, PT

     It's no secret that exercise is one of the most effective treatments to manage the symptoms of rheumatologic disorders. But weight-bearing exercise—even "normal" exercise—can aggravate pain and further promote degeneration in patients with abnormal joints. This is particularly true if the joints have incongruous articular surfaces, poor alignment, ligamentous instability, or altered muscleor joint innervation.

     Unfortunately, these problems diminish exercise options for patients with joint degeneration. As a result, many simply discontinue exercising altogether. Ironically, the ensuing immobility and lack of dynamic joint loading further damage joint surfaces, leading to a downward spiral of immobility and degeneration.

     Aquatic therapy, however, is an effective treatment for the impairments,functional limitations and disabilities commonly associated with rheumatic diseases. In particular, it can increase aerobic capacity and endurance, as well as improve ventilation, respiration (gas exchange) and circulation.

     Aerobic exercise is an important treatment for patients with rheumatic disorders. Many of these patients tend to be physically deconditioned, which promotes a continued cycle of pain, fatigue and decreased motivation. This, in turn, leads to inactivity, which further exacerbates the cycle.

     The therapeutic pool offers a reduced weight-bearing environment in which patients can still achieve cardiopulmonary rewards associated with aerobic conditioning.

The hydrodynamic properties of water, in particular, have an important effect, among them:

• Buoyancy.The therapeutic pool offers an environment for aerobic exercise that's no-impact or low-impact. Therefore, people can engage inaerobic exercise without experiencing the negative consequences of excessive joint compression. So how does buoyancy create a therapeutic environment? Archimedes'principle states: "When a body is wholly or partially immersed in a fluid, it experiences an upthrust equal to the weight of fluid displaced." This upthrust, or buoyancy, counterbalances gravity and supports the body, reducing weight bearing through the spine and lower extremities. Therefore, exercise in water can produce less spinal and lower extremity joint compression than the identical exercise performed on land, offering patients with rheumatologic disorders an environment to exercise aerobically.
  

• Hydrostatic pressure. As already established, the therapeutic pool offers an environment for aerobic exercise that's no- or low-impact. Interestingly, we can argue that this environment also can provide cardiopulmonary training effects that are similar to, or better than, those achieved on land. Why? In part, this is due to the effects of hydrostatic pressure. Pascal's Law states: "Fluid pressure is exerted equally on all surfaces of an immersed body at rest at a given depth." Therefore, we know that pressure increases as depth increases. Because the density of the fluid in most therapeutic pools is fixed and unalterable,this pressure gradient can be used therapeutically. In essence, hydrostatic pressure increases the pressure on the outside of an immersed standing body, producing the following benefits: A reduction in edema and an offsetting of blood pooling in the lower extremities (by providing graduated pressure at greater depths). As lowing of the heart rate during exercise in water (especially in cooler water) by increasing the shift of blood to the thorax. This,in turn, increases pre-load of the heart, which increases stroke volume. This produces a greater perfusion of coronary arteries and a more efficient cardiopulmonary system during exercise. Hydrostatic pressure also can restrict chest wall expansion in people with compromised pulmonary systems and, thus, serve as a progressive resistive exercise program for respiration.
  

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What the Research Shows

Although the beginnings of a solid case can be made based on hydrodynamic principles alone,research has examined whether aquatic therapy can benefit the cardio pulmonary fitness of rheumatologic patients. The following studies demonstrate that it does have a powerful impact on fitness levels:

1. Jentoft, et al. examined the effects of pool-based and land-based exercise programs on patients with fibromyalgia.1 The outcomes were assessed by the Fibromyalgia Impact Questionnaire, the Arthritis Self-Efficacy Scale and tests of physical capacity. After 20 weeks, researchers found statistically significant improvements in both groups in cardiovascular capacity, walking time and daytime fatigue.The results were mainly unchanged at six months follow-up. The researchers concluded that physical capacity can be increased by exercise, even when the exercise is performed in a warm-water pool, and that pool programs may have some additional effects on symptoms.
   

2. Melton-Rodgers, et al. compared the aerobic effects of land-based biking vs. water-based running for subjects with a diagnosis of class II or III adult-onset rheumatoid arthritis.2 No significant differences existed between the two training environments for the following factors: peak VO2, maximum heart rate, perceived exertion (RPE) at 60 percent peak VO2, or pain. Peak minute ventilation on the bike was 26 percent higher and peak tidal volume was 48 percent greater than that achieved during water running (significantly different). Conversely, peak RPE was 7 percent higher and peak respiration rate was 22 percent greater in the water than during land-based bicycling (significantly different). The authors concluded that it was possible to achieve training effects during water running for the population and parameters studied.
   

3. Minor, et al. examined a group of patients with rheumatoid arthritis or osteoarthritis who volunteered to be subjects for this study of aerobic vs. non-aerobic exercise.3 Patients were randomly assigned to an exercise program of aerobic walking, aerobic aquatics or non-aerobic range of motion (controls). The researchers found a significant training effect over controls by having rheumatologic subjects participate in either land- and water-based aerobic exercise. Aerobic capacity, 50-foot walking time, and physical activity improved after subjects participated in the 12-week exercise trial. Their findings document the feasibility and efficacy of conditioning exercise for people with rheumatoid arthritis or osteoarthritis.
   

4. Danneskiold-Samsoe, et al. examined the effect of exercise therapy performed in a heated swimming pool for patients in a non-acute stage of rheumatoid arthritis.4 After two months of exercise therapy, the researchers noted a significant improvement in aerobic capacity in patients with class II or class III rheumatoid arthritis after they participated in a twice weekly, eight-week aquatic exercise program.
   

5. Bacon, et al. examined the effects of aquatic therapeutic exercise on lower extremity range of motion, gait, balance and functional mobility in children with juvenile arthritis.5 In this pilot study, patients ages 4 to 13 with lower-extremity joint involvement, diagnosed as functional class I-III, completed a six-week program of aquatic exercise aimed at increasing lower extremity range of motion and strength. The researchers found a significant reduction in post-exercise recovery heart rate after patients with juvenile rheumatoid arthritis participated in a  six-week aquatic exercise program, twice weekly. Further investigation was warranted, however, to determine fully the effects of aquatic therapeutic exercise on mobility and fitness in children with juvenile arthritis, the researchers noted. Hundreds of scientific articles chronicle the cardiopulmonary benefits of non-swimming aquatic exercise for "normal populations."6 It's no longer a question of "if" aquatic exercise can improve cardiovascular fitness. It's now just a question of whether the same holds true for patients with compromised health, such as patients with osteoarthritis or fibromyalgia.
   

Based on the above studies, we can conclude that aquatic exercise can have a powerful effect on people with rheumatic conditions.

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References

1. Jentoft, E., Kvalvik, A., & Mengshoel, A. (2001). Effects of pool-based and land-based aerobic exercise on women with fibromyalgia/chronic widespread muscle pain.Arthritis Rheumatology,45(1), 42-47.

2. Melton-Rogers, S., Hunter, G.,Walter, J., & Harrison, P. (1996). Cardio respiratory responses of patients with rheumatoid arthritis during bicycle riding and running in water. Physical Therapy, 76(10),1058-1065.

3. Minor, M., Hewett, J., Webel,R., Anderson, S., & Kay, D. (1989). Efficacy of physical conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis Rheumatology, 32(11),1396-1405.

4. Danneskiold-Samsoe, B.,Lyngberg, K., Risum, T., & Telling, M. (1987). The effect ofwater exercise therapy given to patients with rheumatoid arthritis.Scandinavian Journal of Rehabilitative Medicine,19(11), 31-35.

5. Bacon, M., Nicholson, C.,Binder, H., & White, P. (1991). Juvenile rheumatoid arthritis:Aquatic exercise and lower-extremity function. Arthritis Care Research, 4(2),102-105.

6. Salzman, A. (2002). Aquatic therapy research bibliography. Aquatic Resources Network: Amery, WI.