Water Works Wonders : Aquatic Therapy restores motion

Ken is a 51-year-old male who was diagnosed HIV positive in 1993. In November 1998, Ken began to experience low back pain and buttock pain. By October 1999, his pain was diffuse and seriously limiting his ability to walk and manage his daily activities. According to his rheumatologist, the most likely diagnosis was transient osteoporosis, although avascular necrosis and spondyloarthritis were possibilities.

He was experiencing more pain and stiffness with decreased range of motion in hip abduction, extension, and flexion. He reported weakness in both knees. The almost constant pain was now interfering with sleep and appetite, Resulting in further weight loss and atrophy which severely hampered his ability to perform daily activities of living. Ken became depressed and needed a wheelchair to move around his apartment.

His pain continued to the point where he was unable to lie down and in February 2000, he began sleeping in a lounger-recliner chair which was easier to get out of and less painful. The possibility of hip replacement and knee surgery was being considered. Ken sought a second opinion. The diagnosis came back as intermittent osteoporosis. In March 2000, he started new anti-HIV medication. In May his pain medication was increased and his pain levels began to improve. Soon he was ambulating with two canes but still suffered discomfort. With the encouragement of the massage therapist, he resumed sleeping in his bed.

Ken received support from a Casey House Home Hospice nurse and personal care attendant and received massage therapy weekly from a Registered Massage Therapist (RMT). The members of Ken's health care team, including the physiotherapist and massage therapist, were in regular communication regarding development of Ken's condition.

Treatment Protocol

Ken was referred by his rheumatologist to the Outpatient HIV Physiotherapy Service at the Wellesley Central Site of St. Michael's Hospital where he began a program of treatment with a physiotherapist on the HIV Team. He was simultaneously referred to Casey House Community Programs for massage therapy. Physiotherapy Objectives : Physiotherapy assessment revealed pain in his back, buttocks, and right knee, all of which worsened with changes in position and weight-bearing. Range of motion was limited in his thoracic and lumbar spine. Strength was decreased in his hips, knees, and ankles. His transfers were antalgic and his gait was extremely limited. He was not quite able to normalize his gait pattern with the use of two canes.

The physiotherapist gradually developed a stretching and strengthening exercise program that Ken could execute at home. The treatment plan focused on providing him with knowledge of the principles of exercise, as well as on the red flags that would indicate that he should slow down or stop. For two months, he tolerated these exercises surprisingly well. In February 2000, however, he suffered an acute inflammation of his knee that precluded any further activity until the condition cleared. Massage Therapy Objectives : When Ken was first referred to the Casey House Community Program he was having difficulty ambulating and reported pain when walking and getting out of bed or rising from a seated position. He reported the pain in his hips and lower back varied daily from four to seven on a pain scale of one to ten. Heat applications and light to moderate pressure massage were tolerated well. However, passive forced stretching and stage one traction was discontinued after an increase in pain was reported. As massage therapy treatments continued, he reported a decrease in pain to two out of ten. However, his relief would only last f or a day or two depending on his subsequent activity levels after the treatment.

In May 2000, Ken stated he still felt that his quality of life was affected because he was unable to walk for moderate periods of time and enjoy social outings. He was motivated to do more to improve his condition. A team decision was reached to offer Ken a newly introduced aquatic therapy to support Ken's ongoing physiotherapy and massage treatments.

Introducing aquatic therapy

In June, Ken was referred to the aquatic therapy program, to receive weekly 50 minute treatments over a 10 week period. After completing seven weekly treatments, massage therapy was every other week with the aquatic therapy.

Aquatic therapy is based on the techniques of WATSU and JAHARA combined with range of motion exercises and massage techniques in a warm (body temperature) pool of water. WATSU is derived from a contraction of the terms "water" and "Shiatsu" and is the technique founded by Harold Dull in 1980. The basic techniques were reworked by Mario Jahara in 1995 to incorporate biomechanics.

Treatment in the pool

The patient is floated in the water with the therapist supporting the head and neck. The ears are submerged while the nose and face remain on an even plane above the water line. A pool noodle is used to float one or both legs. Warm water (98 F) and the hydrostatic pressure exerted on the body are combined with constant speed and motion that is psychologically and physiologically relaxing. As the patient achieves this relaxation, range of motion exercises, passive stretching and gentle massage techniques are performed.

Significant improvement

In his first session, Ken presented ambulating with the aid of a cane. His presenting complaint was stiffness with little or no movement in the hips bilaterally, pain in the medial right knee, inability to abduct either leg and muscular stiffness through the low back. He indicated that MRI has shown disc degeneration at L3 and L4.

Post treatment, he reported that he slept better and had a noticeable increase in abduction of the legs and an increased flexibility in the low back and hips. He felt this contributed to a greater sense of stability when walking. After the second session Ken reported that he felt stable and secure enough to walk (with a cane) moderately daily. After three sessions Ken stopped using his cane for stability and support and carried it with him in his knapsack. After the ninth session the cane had been retired to his hall closet. One month following treatment, he continues to walk without a cane.

Ongoing cane

His improvement made it possible for bi-weekly massage therapy to advance from moderate to deep pressure techniques. Passive forced stretches are now tolerated well as are gentle resisted exercises for the hip. Range of motion is steadily improving as well. He reports his pain levels at three to four out of ten after a day of walking with recovery time decreasing each week. He continues to do a regular home exercise routine provided by the physiotherapist and is looking forward to joining a gym soon. He is elated to be able to walk again and said he feels he had dramatically improved his quality of life.

Stephanie Nixon, BA, BHSc (PT), MSC is a Physiotherapist, HIV Team, Wellesley-Central Site, St. Michael's Hospital and a Lecturer, University of Toronto, Faculty of Medicine, Department of Physical Therapy. She is also Co-Chair, Canadian Working Group on HIV and a Rehabilitation Doctoral Student, University of Toronto, Public Health Sciences.

Chris Godi, RMT, is a Registered Massage Therapist, Casey House Community Programs in Toronto, and is a part-time professor for the Centennial College Massage Therapy Program.

Claudia Salzmann, RMT, is a Registered Massage Therapist and Aquatic Therapist trained in Watsu and Jahara techniques in Toronto, On.