Loading of the Lower Limb when Walking Partially Immersed: Implications for Clinical Practice

Magnitude of vertical ground reaction force during water-based exercises in women with obesity

Individuals with obesity are recommended to practice physical activity with reduced weight bearing, such as water-based exercises. However, the magnitude of the vertical ground reaction force (Fz) during these exercises is unknown in this population. This study aimed to verify the magnitude of peak Fz (Fzpeak) in women with obesity during different exercises performed in water and on land and at different intensities. Ten adult women with obesity class 1 (body mass index: 31.6 ± 0.57 kg·m-2) completed two randomised sessions, one performed on land and other in water, composed by three exercises (stationary running, frontal kick, butt kick) performed at cadences of 80 b·min-1, 100 b·min-1 and maximal. Fzpeak value was determined in each situation. Data were analysed using repeated-measures three-way ANOVA (α = 0.05). Significant lower Fzpeak values were observed in water (p < 0.001), with no significant differences between the exercises. A significant difference in the Fzpeak was verified between maximal cadence and 80 b·min-1 (p = 0.01). Water-based exercises performed by women with obesity revealed a Fzpeak reduction from land to water corresponding to 41-67%. Also, the three water-based exercises resulted in similar Fzpeak values, while an increase was observed 80 b·min-1 to the maximal cadence.

The effects of water-based exercise on body composition: A systematic review and meta-analysis

AIMS

This study aimed to investigate the effects of water-based exercise (WBE) on body composition.

METHODS

Trials published up to October 28, 2022 were searched using the PubMed, EMBASE, Web of Science, Cochrane, Scopus, and Ovid databases. Randomized controlled trials of healthy adults published in English, comparing WBE and control groups, were included. Other studies with different research designs and participants with medical diagnoses were excluded. The main outcome measures were body weight (BW), body fat mass (BFM), body fat percentage (BFP), lean mass (LM), and skeletal muscle mass (SMM).

RESULTS

Overall, 17,458 potential studies were identified. After a closer inspection, 79 full-length articles were considered for further screening. Finally, 20 studies, involving 565 participants, were included in the meta-analysis. The WBE was beneficial in reducing BW, BFM, and BFP and increasing LM and SMM. Subgroup analyses were conducted based on different exercise intensities and times per week. Moderate- or moderate-vigorous-intensity exercise helped improve body composition, while lower-intensity WBE or aquatic high-intensity interval training (HIIT) seemed less helpful. Training for <120 min/week was insufficient to improve body composition. Training for >120 min/week was associated with improvements in body composition.

CONCLUSIONS

Moderate- or moderate-vigorous-intensity WBE helps improve body composition. Adults are encouraged to exercise for >120 min/week.

Lower Limb Muscles' Activation during Ascending and Descending a Single Step-Up Movement: Comparison between In water and On land Exercise at Different Step Cadences in Young Injury-Free Adults

(1) Background: Forward step-up (FSU) simulates the stance phase in stair ascension. With the benefits of physical properties of water, aquatic FSU exercise may be more suitable for patients with lower limb weakness or pain. The purpose of this study is to investigate the effect of progressive steps per min on the surface electromyography (sEMG) of gluteus maximus (GM), biceps femoris (BF), rectus femoris (RF), and gastrocnemius (GA), when performing FSU exercise with different steps per min in water and on land. (2) Methods: Participants (N = 20) were instructed to perform FSU exercises at different steps per min (35, 60, and 95 bpm) in water and on land. The sEMG of the tested muscles were collected. The percentage maximum voluntary isometric contraction (%MVIC) of GM, RF, GA and BF at different environments and steps per min was compared. (3) Result: There was a statistically significant difference of %MVIC of RF at all steps per min comparisons regardless of the movement phases and environments (p < 0.01, except for descending phases of 35 bpm vs. 60 bpm). All tested muscles showed a statistically significant lower muscle activation in water (p < 0.05) (4) Conclusion: This study found that the %MVIC of the tested muscle in both investigated environments increase as steps per minute increases. It is also found that the movement pattern of FSU exercise activates RF the most among all the tested muscles. Muscle activation of all tested muscles is also found to be smaller in water due to buoyancy property of water. Aquatic FSU exercise might be applicable to patients with lower limb weakness or knee osteoarthritis to improve their lower limb strength.

Effects of Acute Aquatic High-Intensity Intermittent Exercise on Blood Pressure and Arterial Stiffness in Postmenopausal Women with Different ACE Genotypes

The present study investigated the effects of acute aquatic high-intensity intermittent jumping (HIIJ) on blood pressure (BP) and arterial stiffness in postmenopausal women with different angiotensin-converting enzyme genotypes (ACE). We recruited 12 postmenopausal women carrying the ACE deletion/deletion (DD) genotype and 61 carrying the insertion/insertion or insertion/deletion (II/ID) genotype. The participants performed 12 trials of 30 s, 75% heart rate reserve (HRR) jumping, and 60 s, 50% HRR recovery, and 3 trials of 40 s upper limb resistance exercises were performed as fast as possible. The heart rate (HR) and BP were measured before exercise, immediately, 10 min, and 45 min after exercise. The brachial-ankle pulse wave velocity (baPWV) was measured before and after exercise. The systolic blood pressure (SBP) of the DD genotype increased more significantly than those with the II/ID genotype post-exercise (30.8 ± 4.48 vs. 20.4 ± 2.00 mmHg, p = 0.038). The left and right sides of baPWV increased significantly after exercise (1444.8 ± 29.54 vs. 1473.4 ± 32.36 cm/s, p = 0.020; 1442.1 ± 30.34 vs. 1472.0 ± 33.09, p = 0.011), and there was no significant difference between the two groups. The HIIJ increased baPWV. The postmenopausal women with the DD genotype have a higher SBP increased post-exercise than those with II/ID genotype. These findings suggest that the aquatic exercise program has better effects in decreasing blood pressure in postmenopausal women with the II/ID genotype. Those with the DD genotype should pay attention to the risk of increasing blood pressure after aquatic HIIJ exercise.

A Study Comparing Gait and Lower Limb Muscle Activity During Aquatic Treadmill Running With Different Water Depth and Land Treadmill Running

Aquatic treadmill running is a partial weight-bearing exercise for rehabilitation. The purpose of this study was to investigate the surface electromyography activities of the rectus femoris, tibialis anterior, biceps femoris and medial head of gastrocnemius, and gait kinematics during aquatic treadmill running in water levels at waist, mid-thigh and mid-shin and on land. Seventeen healthy subjects (9 males and 8 females) were recruited by convenience sampling. Participants performed 2-min aquatic treadmill running at a specific speed for each water depth. The test speed was selected based upon the speed that elicited 110 steps per min. The surface electromyography data of lower limb muscles and the joint angles at three different water depths and on land were collected to evaluate the muscle activity and gait kinematics using a waterproofed surface electromyography system and inertial measurement unit for each muscle. Results showed that rectus femoris electromyography was different between depths during the swing and stance phases. Likewise, biceps femoris and tibialis anterior electromyography were different between depths for the swing phase. However, it was not the case for gastrocnemius electromyography. Peak flexion angles in both left and right hips were different between depths. A significant increase in a stance/swing ratio was observed with rising water depths. Water depth influenced muscle activity as well as kinematics. Aquatic treadmill running in the mid-thigh level should be further evaluated for its effectiveness, training value and applicability.

The effect of aquatic High Intensity Interval Training on cardiometabolic and physical health markers in women: A systematic review and meta-analysis

Background

We performed a meta-analysis of randomized controlled trials (RCTs) assessing the effect of Aquatic High Intensity Interval Training (AHIIT) on cardiometabolic and physical health markers in women.

Methods

Systematic search used 7 databases (MEDLINE, PubMed, SPORTDiscus, Cochrane, Embase, CINAL complete, PsycINFO). The Physiotherapy Evidence Database (PEDro) score was used to evaluate the methodological quality of the studies. Clinical trials compared AHIIT with a control group that receive no exercise training. We integrated randomized controlled trials published in English, and participants were women aged ≥18 years. The outcome of interest was the change in cardiometabolic and physical health markers.

Results

Among 242 articles screened, 18 articles (13 trials) were included in this meta-analysis comparing AHIIT (n = 261) with a control group (n = 215). The median PEDro score was 5.5 out of 10 (range, 4–8). AHIIT significantly improved peak oxygen uptake (Hedges' g 0.610; 95% CI 0.277–0.943; P < 0.001), reduced resting heart rate (Hedges' g −0.495; 95% CI -0.866 to −0.124; P < 0.05), as well as chair to stand test. (Hedges’ g 0.548; 95% CI 0.019 to 1.077; P < 0.05).

Conclusion

AHIIT has a moderate effect in improving cardiometabolic and physical health markers in women.

A review on muscle activation behaviour during gait in shallow water and deep-water running and surface electromyography procedures

BACKGROUND

Surface electromyography (sEMG) can provide information on muscle activation patterns during gait.

OBJECTIVES

To characterize electromyographic activity during gait in shallow water and during deep-water running compare to on land and to review and analyse underwater surface-electromyographic (sEMG) procedures.

SEARCH METHODS

Eight databases (MEDLINE, EMBASE, WEB OF SCIENCE, SPORT Discus, CINAHL, SCOPUS, SCIELO, and LILACS) were searched from their inception to the December of 2019.

SELECTION CRITERIA

The selected studies had to be related to electromyographic analysis of gait in an aquatic environment.

DATA COLLECTION AND ANALYSIS

The studies that met the inclusion criteria were reviewed by two independent reviewers and divided into four groups.

RESULTS

Ten studies met the inclusion criteria. Lower muscle activation was found with treadmill water walking compared to treadmill land walking. With deep-water running, the leg muscles (tibialis anterior and gastrocnemius lateralis) have lower muscle activation when compared to on land running, but the trunk and thigh muscles have higher activation.

CONCLUSION

If gait is performed on an aquatic treadmill, the muscles assessed had lower muscle activation when compared to land. During deep-water running activities, lower activation of the distal leg muscles and a higher activation thigh muscles were found when compared to on land. Studies did not follow standard processes in sEMG procedures.

Internet of Things (IoT) System and Field Sensors for Exercise Intensity Measurements

Although exercise training according to individual peak aerobic capacity ( V ˙ o_2peak ) has been recommended at all ages, sensors available in the field are limited. The most popular sensors in the field are pedometers, but they cannot be used to monitor exercise intensity. Instead, although heart rate (HR) monitors are broadly available in the field to estimate exercise intensity, HR responses to exercise vary by individual according to physical fitness and environmental conditions, which hinders the precise measurement of energy expenditure. These issues make it difficult for exercise physiologists to collaborate with geneticists, nutritionists, and clinicians using the internet of things (IoT). To conquer these problems, we have developed a device that is equipped with a triaxial accelerometer and a barometer to measure energy expenditure during interval walking training (IWT) in the field with inclines. IWT is a training regimen to repeat fast and slow walking for 3 min each, equivalent to greater than 70% and approximately 40% of individual V ˙ o_2peak , respectively. Additionally, we developed an IoT system that enables users to receive instructions from trainers according to their walking records even if they live far away. Since the system is available at low cost with minimum personnel, we can investigate any factors affecting the adherence to and effects of IWT in a large population for a long period. This system was also used to verify any effects of nutritional supplements during IWT and to examine the value of applying IWT to clinical medicine. © 2020 American Physiological Society. Compr Physiol 10:1207-1240, 2020.

Comparison of underwater gait training and overground gait training for improving the walking and balancing ability of patients with severe hemiplegic stroke: A randomized controlled pilot trial

BACKGROUND

Walking training is an essential intervention to improve the function in stroke patients. However, only a limited number of gait training strategies are available for stroke patients with relatively severe disabilities.

RESEARCH QUESTION

Is underwater gait training or overground gait training more effective in severe stroke patients?

METHODS

A total of 21 patients with severe hemiplegic stroke were randomly assigned to the experimental and control groups. All participants (n = 21) received 60-minute sessions of general physical therapy, 5 times a week for a period of 12 weeks. Additionally, the experimental and control groups underwent underwater and overground walking training, respectively, for 30 min twice times a week for 12 weeks. Postural assessment for stroke score, center of pressure path length and velocity, step time and step length difference, and walking velocity were measured before and after the 12-week training.

RESULTS

Both groups showed a significant decrease in the center of pressure path length and velocity after the intervention compared to the values before the intervention (p < .05). However, there was no significant difference in the center of pressure path length and velocity changes after training between the two groups (p > .05). In the walking variables, the step length difference changes after training between the two groups showed a significant difference (p < .05). In the experimental group, the step length difference increased after the intervention compared to that before the intervention (+4.55 cm), whereas that of the control group decreased (-1.25 cm).

SIGNIFICANCE

In severe stroke patients, underwater gait training can be effective for improving balancing ability, but it may be less effective on the improvement of gait function than overground walking.

CLINICAL TRIAL REGISTRATION NUMBER

KCT0002587 (https://cris.nih.go.kr).

Muscle Activation and Distribution during Four Test/Functional Tasks: A Comparison between Dry-Land and Aquatic Environments for Healthy Older and Young Adults

BACKGROUND

The use of rehabilitation protocols carried out in water has been progressively increasing due to the favorable physical properties of the water. Electromyography allows one to register muscle activity even under water.

AIM

To compare muscle activity between two groups (healthy young adults (HYA) and healthy older adults (HOA)) in two different environments (dry land and aquatic) using surface electromyography during the execution of four different test/functional movements.

METHODS

Analytical cross-sectional study. HYA and HOA carried out four functional tasks (Step Up and Down, Sit To Stand test, Gait Initiation and Turns During Gait) in two different environments (dry land and aquatic). Absolute and relative muscle activation was compared between each group and between each environment. In addition, the stability of the measured was calculated through a test-retest (ICC 2:1).

RESULTS

Within the same environment there were significant differences between young and older adults in three of the four functional tasks. In contrast, in the gait initiation, hardly any significant differences were found between the two groups analysed, except for the soleus and the anterior tibial. Measurement stability ranged from good to excellent.

CONCLUSIONS

Level of the musculature involvement presents an entirely different distribution when the test/functional task is performed on dry land or in water. There are differences both in the relative activation of the musculature and in the distribution of the partition of the muscles comparing older and young adults within the same environment.

Kinetic parameters during land and water walking performed by individuals with Down Syndrome

BACKGROUND

Down Syndrome (DS) is a genetic condition presenting delay in acquisition of main motor milestones, such as walking. Although studies have been investigating the biomechanical parameters during land walking performed by individual with DS, the literature is scarce regarding kinetic parameters analysis in this population, specially during water walking.

RESEARCH QUESTION

This study sought to assess the vertical ground reaction force (Fz) of walking performed in water and on land at different speeds by individuals with DS.

METHODS

Fourteen adults with DS (age: 27.9 ± 7.9 years; body mass: 58.4 ± 12.9 kg; height: 1.4 ± 0.1 m, body mass index: 29.2 ± 5.4 kg.m^-2) completed two sessions of data collection, one on land and another in aquatic environment. The protocol consisted of walking performed at three self-selected speeds (slow, comfortable and fast) in randomized order. The Fz was assessed with a waterproof force plate in each condition. Two-way repeated-measures ANOVA (environment and speed), with Bonferroni's post hoc tests, were used for analysis. A significance level was set as α = 0.05.

RESULTS

Significant differences were observed between environments (p < 0.001), with reduced first peak of Fz (68-73%), second peak of Fz (66-70%), loading rate (75-78%) and impulse (40-41%) in the water walking for all speeds analyzed. In the aquatic environment, no significant difference was observed for the first and second Fz peaks with the increasing speed of walking. Moreover, the loading rate significantly increased (p = 0.019) as the impulse significantly reduced (p < 0.001) in the higher speeds.

SIGNIFICANCE

Individuals with DS present reduced Fz outcomes during water walking in comparison to land. Therefore, water walking may be performed by individuals with DS with safe vertical loads on lower limbs regardless the self-selected speed for rehabilitation, correction of gait and training purposes.

The benefits of combining water and land-based therapy

As the general population ages and lives longer with chronic disease and related disability, an increasing number of individuals may be pre-cluded from participating and excelling in traditional land-based therapy or exercise alone, despite its known benefits. This article discusses the benefits of water as an exercise and therapeutic medium, as well as the value of combining both water and land modalities, which enhance the benefits of exercise synergistically. This combined water and land approach has the potential to help clients achieve greater therapeutic benefits and clinical outcomes. As an example, described in this article are the rationale and basic framework for one treatment paradigm supported by research literature, the Burdenko Method, which has utilized combined exercise in water and on land for over four decades. These perspectives will hopefully foster increased understanding and application of exercise principles and programs outside of traditional land-based approaches.

Vertical Ground Reaction Force During a Water-Based Exercise Performed by Elderly Women: Equipment Use Effects

Purpose: The present study aimed to compare the vertical ground reaction force responses during the performance of the stationary running water-based exercise with and without equipment at different cadences by elderly women. Method: Nineteen elderly women (age: 68.6 ± 5.0 years; body mass: 69.0 ± 9.5 kg; height: 154.9 ± 5.6 cm) completed one session consisting of the performance of the water-based stationary running with elbow flexion and extension immersed to the xiphoid process depth. The exercise was performed in three conditions, without equipment, with water-floating and with water-resistance equipment, at three cadences (80 b·min^-1, 100 b·min^-1 and maximal) in a randomized order. Peak and impulse of vertical ground reaction force were collected during the exercise using an underwater force plate. Repeated measures two-way ANOVA was used (α = 0.05). Results: Peak vertical ground reaction force (p < .001) and impulse (p ≤ 0.002) resulted in lower values for the water-floating use (0.42-0.48 BW and 0.07-0.13 N.s/BW) in comparison to the water-resistance equipment use (0.46-0.60 BW and 0.09-0.16 N.s/BW) and to the non-use of equipment (0.45-0.60 BW and 0.07-0.17 N.s/BW), except for the impulse at the maximal cadence. In addition, peak vertical ground reaction force at 80 b·min^-1 (p = .002) and impulse at the maximal cadence (p < .001) showed lower values compared to the other cadences. Conclusion: The use of water-floating equipment minimizes the vertical ground reaction force during the stationary running water-based exercise performed by elderly women regardless of the cadence.

Kinematic Comparison of Aquatic- and Land-Based Stationary Exercises in Overweight and Normal Weight Children

PURPOSE

This study examined lower extremity kinematics in healthy weight (HW) and overweight (OW) children during water- and land-based stationary exercises (stationary running, frontal kick, and butt kick) at light submaximal intensity.

METHODS

Participants included OW (N = 10; body fat percentage: 34.97 [8.60]) and HW (N = 15; body fat percentage: 18.33 [4.87]) children, aged 10 to 13 years. Spatiotemporal data, lower extremity joint kinematics, and rating of perceived exertion (RPE) were collected during water- and land-based stationary exercises. Repeated measures analysis of variance compared kinematic variables and RPE between groups and environments. A polygon area function compared coordination patterns between environments.

RESULTS

RPE responses were significantly greater in OW than HW children on land (13.6 [0.7] vs 11.6 [0.7]; P < .001), whereas the RPE responses were similar between groups in water (11.2 [0.7] vs 11.1 [0.8]; P > .05). OW children were significantly more upright than HW children during land-based exercise, whereas there were no differences observed between groups during aquatic-based exercise. The duration of stance and swing phases, angular velocity, and cadence were significantly lower in water than on land.

CONCLUSION

Compared with HW children, OW children performed stationary exercises in a more upright posture on land, with higher RPE. However, these differences diminished in water. Aquatic-based exercise may be effective in minimizing the effects of excess mass on OW children's ability to complete physical activity.

Water-based exercises in pregnancy: Apparent weight in immersion and ground reaction force at third trimester

BACKGROUND

The morphological alterations during pregnancy may affect the biomechanical loads during exercise practice. Aquatic exercises may suit pregnant women, who are recommended to exercise with low vertical ground reaction force loads. Therefore, the study aimed to determine the apparent weight reduction during immersion and the vertical ground reaction force of three specific water-based exercises in pregnant women at the third trimester.

METHODS

Eleven pregnant women volunteered to take part in the study [32.0 (SD 1.3) weeks, 28.1 (SD 5.7) years, 72.5 (SD 10.1) kg]. The protocol started with the participants immersed to the xiphoid process depth for the apparent weight assessment. Then, three water-based exercises (stationary running, frontal kick and butt kick) were randomly performed at a pre-selected cadence, with 5-min interval. The vertical ground reaction force was measured in each exercise and peak, impulse, contact time and swing time were determined. Repeated measures ANOVA was used (α = 0.05).

FINDINGS

The apparent weight reduction resulted a mean of 82.9 (SD 6.5)% of body weight. Peak, impulse, contact time and swing time revealed no significant difference between exercises (P > 0.05). Values of peak of vertical ground reaction force ranged from 0.67 to 0.72 units of body weight.

INTERPRETATION

Pregnant women at the third trimester can benefit from the apparent weight reduction during immersion for exercising. The three water-based exercises presented similar vertical ground reaction force values, which are considered as low odds for musculoskeletal injuries. Therefore, these findings highlight the safety of the water-based exercise program during pregnancy.

Aquatic therapy for children with Duchenne muscular dystrophy: a pilot feasibility randomised controlled trial and mixed-methods process evaluation

BACKGROUND

Duchenne muscular dystrophy (DMD) is a rare disease that causes the progressive loss of motor abilities such as walking. Standard treatment includes physiotherapy. No trial has evaluated whether or not adding aquatic therapy (AT) to land-based therapy (LBT) exercises helps to keep muscles strong and children independent.

OBJECTIVES

To assess the feasibility of recruiting boys with DMD to a randomised trial evaluating AT (primary objective) and to collect data from them; to assess how, and how well, the intervention and trial procedures work.

DESIGN

Parallel-group, single-blind, randomised pilot trial with nested qualitative research.

SETTING

Six paediatric neuromuscular units.

PARTICIPANTS

Children with DMD aged 7-16 years, established on corticosteroids, with a North Star Ambulatory Assessment (NSAA) score of 8-34 and able to complete a 10-m walk without aids/assistance. Exclusions: > 20% variation between baseline screens 4 weeks apart and contraindications.

INTERVENTIONS

Participants were allocated on a 1 : 1 ratio to (1) optimised, manualised LBT (prescribed by specialist neuromuscular physiotherapists) or (2) the same plus manualised AT (30 minutes, twice weekly for 6 months: active assisted and/or passive stretching regime; simulated or real functional activities; submaximal exercise). Semistructured interviews with participants, parents (n = 8) and professionals (n = 8) were analysed using Framework analysis. An independent rater reviewed patient records to determine the extent to which treatment was optimised. A cost-impact analysis was performed. Quantitative and qualitative data were mixed using a triangulation exercise.

MAIN OUTCOME MEASURES

Feasibility of recruiting 40 participants in 6 months, participant and therapist views on the acceptability of the intervention and research protocols, clinical outcomes including NSAA, independent assessment of treatment optimisation and intervention costs.

RESULTS

Over 6 months, 348 children were screened - most lived too far from centres or were enrolled in other trials. Twelve (30% of target) were randomised to AT (n = 8) or control (n = 4). People in the AT (n = 8) and control (n = 2: attrition because of parental report) arms contributed outcome data. The mean change in NSAA score at 6 months was -5.5 [standard deviation (SD) 7.8] for LBT and -2.8 (SD 4.1) in the AT arm. One boy suffered pain and fatigue after AT, which resolved the same day. Physiotherapists and parents valued AT and believed that it should be delivered in community settings. The independent rater considered AT optimised for three out of eight children, with other children given programmes that were too extensive and insufficiently focused. The estimated NHS costs of 6-month service were between £1970 and £2734 per patient.

LIMITATIONS

The focus on delivery in hospitals limits generalisability.

CONCLUSIONS

Neither a full-scale frequentist randomised controlled trial (RCT) recruiting in the UK alone nor a twice-weekly open-ended AT course delivered at tertiary centres is feasible. Further intervention development research is needed to identify how community-based pools can be accessed, and how families can link with each other and community physiotherapists to access tailored AT programmes guided by highly specialised physiotherapists. Bayesian RCTs may be feasible; otherwise, time series designs are recommended.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41002956.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 27. See the NIHR Journals Library website for further project information.

Effectiveness of aquatic exercises compared to patient-education on health status in individuals with knee osteoarthritis: a randomized controlled trial

OBJECTIVE

To compare the effectiveness of aquatic exercises with patient-education in individuals with knee osteoarthritis.

DESIGN

Randomized controlled trial with blinded assessor and intention-to-treat analysis.

SETTING

Aquatic Physiotherapy Centre and Primary Health Care Unit.

SUBJECTS

A total of 60 patients, aged 68.3 (SD = 4.8) with clinical symptoms and radiographic grading (Kellgren-Lawrence 1-4) of knee osteoarthritis were included.

INTERVENTIONS

An eight-week treatment protocol of aquatic exercise ( n = 31) (16 individual sessions, twice a week) and an educational program (group sessions, once a week) ( n = 29).

MAIN MEASURES

Before, after eight-week intervention, and a three-month follow-up with results for the following outcome measures: pain, function, quality of life, functional mobility, and depression.

RESULTS

At the end of treatment, the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) functional capacity values reduced in favour of the aquatic exercise group for both the total score MD (mean difference) = -14.2; 95% CI (confidence interval) (-18; -10.5), P = 0.04 and the pain domain MD = -3.8 points; 95% CI (-8.71; -1), P = 0.021. The total score also reduced in the follow-up: MD = -12.3 points; 95% CI (-24.7; -6.1), P = 0.017. No differences were found for the outcomes functional mobility or depression.

CONCLUSION

Aquatic exercise improved pain and function after eight weeks, and function at the three-month follow-up compared to the patient-education program.

Limb symmetry during double-leg squats and single-leg squats on land and in water in adults with long-standing unilateral anterior knee pain; a cross sectional study

Background

The presence of pain during movement typically results in changes in technique. However, the physical properties of water, such as flotation, means that water-based exercise may not only reduce compensatory movement patterns but also allow pain sufferers to complete exercises that they are unable to perform on land. The purpose of this study was to assess bilateral kinematics during double-leg squats and single-leg squats on land and in water in individuals with unilateral anterior knee pain. A secondary aim was to quantify bilateral asymmetry in both environments in affected and unaffected individuals using a symmetry index.

Methods

Twenty individuals with unilateral knee pain and twenty healthy, matched controls performed body weight double- and single-leg squats in both environments while inertial sensors (100 Hz) recorded trunk and lower body kinematics. Repeated-measures statistics tested for environmental effects on movement depths and peak angles within the anterior knee pain group. Differences in their inter-limb symmetry in each environments was compared to the control group using analysis of variance tests.

Results

Water immersion allowed for greater movement depths during both exercises (double-leg squat: +7 cm, p = 0.032, single-leg squat: +9 cm, p = 0.002) for the knee pain group. The double-leg squat was symmetrical on land but water immersion revealed asymmetries in the lower body frontal plane movements. The single-leg squat revealed decreased hip flexion and frontal plane shank motions on the affected limb in both environments. Water immersion also affected the degree of lower limb asymmetry in both groups, with differences also showing between groups.

Conclusions

Individuals with anterior knee pain achieved increased squat depth during both exercises whilst in water. Kinematic differences between the affected and unaffected limbs were often increased in water. Individuals with unilateral anterior knee pain appear to utilise different kinematics in the affected and unaffected limb in both environments.

Functional reach and lateral reach tests adapted for aquatic physical therapy

Abstract Introduction: Functional reach (FR) and lateral reach (LR) tests are widely used in scientific research and clinical practice. Assessment tools are useful in assessing subjects with greater accuracy and are usually adapted according to the limitations of each condition. Objective: To adapt FR and LR tests for use in an aquatic environment and assess the performance of healthy young adults. Methods: We collected anthropometric data and information on whether the participant exercised regularly or not. The FR and LR tests were adapted for use in an aquatic environment and administered to 47 healthy subjects aged 20-30 years. Each test was repeated three times. Results: Forty-one females and six males were assessed. The mean FR test score for men was 24.06 cm, whereas the mean value for right lateral reach (RLR) was 10.94 cm and for left lateral reach (LLR) was 9.78 cm. For females, the mean FR score was 17.57 cm, while the mean values for RLR was 8.84cm and for LLR was 7.76 cm. Men performed better in the FR (p < 0.001) and RLR tests than women (p = 0.037). Individuals who exercised regularly showed no differences in performance level when compared with their counterparts. Conclusion: The FR and LR tests were adapted for use in an aquatic environment. Males performed better on the FR and RLR tests, when compared to females. There was no correlation between the FR and LR tests and weight, height, Body Mass Index (BMI), foot length or length of the dominant upper limb.

Cardiorespiratory performance of coronary artery disease patients on land versus underwater treadmill tests: a comparative study

OBJECTIVE

To compare responses to a cardiopulmonary exercise test on land versus on an underwater treadmill, to assess the cardiorespiratory performance of coronary artery disease patients while immersed in warm water and to compare with the performance of healthy individuals.

METHODS

The sample population consisted of 40 subjects, which included 20 coronary artery disease patients aged 63.7±8.89 years old, functional class I and II, according to the New York Hearth Association, and 20 healthy subjects aged 64.7±7.09 years old. The statistical significances were calculated through an ANOVA test with a (1 - β) power of 0.861. ClinicalTrials.gov: NCT00989248 (22).

RESULTS

Significant differences were uncovered in coronary artery disease group regarding the variables heart beats (HB), (p>0.01), oxygen consumption (VO2), (p>0.01) and carbon dioxide production (VCO2) (p<0.01). Also, for the same group, in relation to the environment, water versus on land for HB, VO2, VCO2 and oxygen for each heart beat (VO2/HB) all of than (p<0.01). The stages for data collected featured the subject's performance throughout the experiment, and within the given context, variables rating of perceived exertion (RPE), HB, VO2, VCO2 and VO2/HB (p<0.01) showed significant interactions between test stages and environment. Additionally, there was a significant interaction between the etiology and the test stages for the variables HB, VO2 and VCO2 (p<0.01). Electrocardiographic changes compatible with myocardial ischemia or arrhythmia were not observed. The subjects exhibited lower scores on Borg's perceived exertion scale in the water than at every one of the test stages on land (p<0.01).

CONCLUSION

This study show that a cardiopulmonary exercise test can be safely conducted in subjects in immersion and that the procedures, resources and equipment used yielded replicable and reliable data. Significant differences observed in water versus on land allow us to conclude that coronary artery disease patients are able to do physical exercise in water and that the physiological effects of immersion do not present any risk for such patients, as exercise was well tolerated by all subjects.

ACL Rehabilitation Progression: Where Are We Now?

PURPOSE OF REVIEW

With the increase of publications available to the rehabilitation specialist, there is a need to identify a progression to safely progress the patient through their post-operative ACL reconstruction rehabilitation program. Rehabilitation after ACL reconstruction should follow an evidence-based functional progression with graded increase in difficulty in activities.

RECENT FINDINGS

Clinicians should be discouraged not to use strict time frames and protocols when treating patients following ACL reconstruction. Rather, guidelines should be followed that allow the rehabilitation specialists to progress the patient as improvements in strength, edema, proprioception, pain, and range of motion are demonstrated. Prior to returning to sport, specific objective quantitative and qualitative criteria should be met. The time from surgery should not be the only consideration. The rehabilitation specialist needs to take into account tissue healing, any concomitant procedures, patellofemoral joint forces, and the goals of the patient in crafting a structured rehabilitation program. Achieving symmetrical full knee extension, decreasing knee joint effusion, and quadriceps activation early in the rehabilitation process set the stage for a safe progression. Weight bearing is begun immediately following surgery to promote knee extension and hinder quadriceps inhibition. As the patient progresses through their rehabilitative course, the rehabilitation specialist should continually challenge the patient as is appropriate based upon their goals, their levels of strength, amount of healing, and the performance of the given task.

Quantifying kinematic differences between land and water during squats, split squats, and single-leg squats in a healthy population

Aquatic exercises can be used in clinical and sporting disciplines for both rehabilitation and sports training. However, there is limited knowledge on the influence of water immersion on the kinematics of exercises commonly used in rehabilitation and fitness programs. The aim of this study was to use inertial sensors to quantify differences in kinematics and movement variability of bodyweight squats, split squats, and single-leg squats performed on dry land and whilst immersed to the level of the greater trochanter. During two separate testing sessions, 25 active healthy university students (22.3±2.9 yr.) performed ten repetitions of each exercise, whilst tri-axial inertial sensors (100 Hz) recorded their trunk and lower body kinematics. Repeated-measures statistics tested for differences in segment orientation and speed, movement variability, and waveform patterns between environments, while coefficient of variance was used to assess differences in movement variability. Between-environment differences in segment orientation and speed were portrayed by plotting the mean difference ±95% confidence intervals (CI) throughout the tasks. The results showed that the depth of the squat and split squat were unaffected by the changed environment while water immersion allowed for a deeper single leg squat. The different environments had significant effects on the sagittal plane orientations and speeds for all segments. Water immersion increased the degree of movement variability of the segments in all exercises, except for the shank in the frontal plane, which showed more variability on land. Without compromising movement depth, the aquatic environment induces more upright trunk and shank postures during squats and split squats. The aquatic environment allows for increased squat depth during the single-leg squat, and increased shank motions in the frontal plane. Our observations therefore support the use of water-based squat tasks for rehabilitation as they appear to improve the technique without compromising movement depth.

Effects of high intensity resistance aquatic training on body composition and walking speed in women with mild knee osteoarthritis: a 4-month RCT with 12-month follow-up

OBJECTIVE

To investigate the effects of 4-months intensive aquatic resistance training on body composition and walking speed in post-menopausal women with mild knee osteoarthritis (OA), immediately after intervention and after 12-months follow-up. Additionally, influence of leisure time physical activity (LTPA) will be investigated.

DESIGN

This randomised clinical trial assigned eighty-seven volunteer postmenopausal women into two study arms. The intervention group (n = 43) participated in 48 supervised intensive aquatic resistance training sessions over 4-months while the control group (n = 44) maintained normal physical activity. Eighty four participants continued into the 12-months' follow-up period. Body composition was measured with dual-energy X-ray absorptiometry (DXA). Walking speed over 2 km and the knee injury and osteoarthritis outcome score (KOOS) were measured. LTPA was recorded with self-reported diaries.

RESULTS

After the 4-month intervention there was a significant decrease (P = 0.002) in fat mass (mean change: -1.17 kg; 95% CI: -2.00 to -0.43) and increase (P = 0.002) in walking speed (0.052 m/s; 95% CI: 0.018 to 0.086) in favour of the intervention group. Body composition returned to baseline after 12-months. In contrast, increased walking speed was maintained (0.046 m/s; 95% CI 0.006 to 0.086, P = 0.032). No change was seen in lean mass or KOOS. Daily LTPA over the 16-months had a significant effect (P = 0.007) on fat mass loss (f² = 0.05) but no effect on walking speed.

CONCLUSIONS

Our findings show that high intensity aquatic resistance training decreases fat mass and improves walking speed in post-menopausal women with mild knee OA. Only improvements in walking speed were maintained at 12-months follow-up. Higher levels of LTPA were associated with fat mass loss.

TRIAL REGISTRATION NUMBER

ISRCTN65346593.

Water depth effects on impact loading, kinematic and physiological variables during water treadmill running

PURPOSE

The purpose of this study was to compare impact loading, kinematic and physiological responses to three different immersion depths (mid-shin, mid-thigh, and xiphoid process) while running at the same speed on a water based treadmill.

METHODS

Participants (N=8) ran on a water treadmill at three depths for 3min. Tri-axial accelerometers were used to identify running dynamics plus measures associated with impact loading rates, while heart rate data were logged to indicate physiological demand.

RESULTS

Participants had greater peak impact accelerations (p<0.01), greater impact loading rates (p<0.0001), greater stride frequency (p<0.05), shorter stride length (p<0.01), and greater rate of acceleration development at toe-off (p<0.0001) for the mid-shin and mid-thigh compared to running immersed to the xiphoid process. Physiological effort determined by heart rate was also significantly less (p<0.0001) when running immersed to the xiphoid process.

CONCLUSION

Water immersed treadmill running above the waistline alters kinematics of gait, reduces variables associated with impact, while decreasing physiological demand compared to depths below the waistline.

Horizontal ground reaction forces to stationary running performed in the water and on dry land at different physiological intensities

The aim of the present study was to compare the peak anterior-posterior (Fy) and medio-lateral (Fx) ground reaction forces (GRFs) of women performing stationary running at different intensities in aquatic and dry land environments. Fourteen young women performed the stationary running exercise at three cadences (first ventilatory threshold, second ventilatory threshold and maximum effort, as determined during exercise in water) in aquatic and dry land environments. Two-way repeated measures ANOVA was used to analyse the data (α = .05). As a result, significantly lower peak Fy anterior, Fy posterior, Fx medial and Fx lateral values were observed for the aquatic environment, except for the Fy posterior at the first ventilatory threshold. Significant differences were observed between cadences in the peak Fy anterior, Fy posterior, Fx medial and Fx lateral values, with higher values for the cadence corresponding to maximum effort compared to the first ventilatory threshold, except for the Fy posterior and Fx medial in the aquatic environment. The results indicate that the horizontal GRFs are reduced in the aquatic environment and depend on the intensity of stationary running exercise performance.

Reliability of ground reaction forces in the aquatic environment

The aim of this study was to verify the reliability of the kinetic parameters of gait using an underwater force platform. A total of 49 healthy participants with a median age of 21years were included. The kinetic gait data were collected using a 0.6×0.6×0.1m aquatic force plate (Bertec®), set in a pool (15×13×1.30m) with a water depth of 1.20m and water temperature of 32.5°C. Participants walked 10m before reaching the platform, which was fixed to the ground. Participants were instructed to step onto the platform with their preferred limb and data from three valid attempts were used to calculate the average values. A 48-h interval between tests was used for the test-retest reliability. Data were analyzed using interclass correlation coefficients (ICC) and results demonstrated that reliability ranged from poor to excellent, with ICC scores of between 0.24 and 0.87 and mean differences between (d¯)=-0.01 and 0.002. The highest reliability values were found for the vertical (Fz) and the lowest for the mediolateral components (Fy). In conclusion, the force platform is reliable for assessing the vertical and anteroposterior components of power production rates in water, however, caution should be applied when using this instrument to evaluate the mediolateral component in this environment.

Principles and Application of Hydrotherapy for Equine Athletes

Hydrotherapy has become a key element within equine rehabilitation protocols and is used to address range of motion, proprioception, strength, neuromotor control, pain, and inflammation. Various forms of hydrotherapy can be tailored to the individual's injury and the expected return to athletic performance. This article describes the mechanisms of action of hydrotherapies and potential use in the clinical management of equine musculoskeletal injuries.

Target intensity and interval walking training in water to enhance physical fitness in middle-aged and older women: a randomised controlled study

PURPOSE

To determine the target intensity for fast walking during interval walking training (IWT) in water for middle-aged and older people to enhance physical fitness.

METHODS

Thirty-one women [59 ± 5 (SD) years old] were randomly divided into two groups: IWT on land (LG, N = 15) and in water (WG, N = 16). All subjects were instructed to perform ≥ 6 sets of fast and slow walking for 3 min each in a day, ≥ 4 days week(-1), for 8 weeks, at an intensity 35% higher than the oxygen consumption rate at the gas exchange threshold (VO2GET), with a subjective feeling of 16-18 points of the Borg scale during fast walking in each condition. Before and after IWT, we measured VO2GET, peak aerobic capacity (VO2peak) by graded walking and cycling tests on land and isometric knee extension (F EXT) and flexion (F FLX) forces.

RESULTS

Before IWT, the VO2GET for walking in water was 14% higher and the heart rate (HR) at a given VO2 was ~10 beats min(-1) lower (P=0.001) than on land. During IWT, subjects in both groups performed IWT for ~4 days week(-1)(P > 0.9) with a 14% higher fast walking intensity in WG than in LG (P < 0.05). After IWT, the VO2peak and VO2GET for cycling, F EXT and F FLX increased more in WG than in LG (all, P < 0.05).

CONCLUSION

Walking in water elevated VO2GET and decreased HR at a given exercise intensity in middle-aged and older women, which enabled them to perform exercise at a higher metabolic rate than on land due to improved subjective feelings, which, for these subjects, resulted in greater gains in physical fitness.

Effects of underwater treadmill training on leg strength, balance, and walking performance in adults with incomplete spinal cord injury

OBJECTIVE

To document the effects of underwater treadmill training (UTT) on leg strength, balance, and walking performance in adults with incomplete spinal cord injury (iSCI).

DESIGN

Pre-test and post-test design.

SETTING

Exercise physiology laboratory.

PARTICIPANTS

Adult volunteers with iSCI (n = 11).

INTERVENTION

Participants completed 8 weeks (3 × /week) of UTT. Each training session consisted of three walks performed at a personalized speed, with adequate rest between walks. Body weight support remained constant for each participant and ranged from 29 to 47% of land body weight. Increases in walking speed and duration were staggered and imposed in a gradual and systematic fashion.

OUTCOME MEASURES

Lower-extremity strength (LS), balance (BL), preferred and rapid walking speeds (PWS and RWS), 6-minute walk distance (6MWD), and daily step activity (DSA).

RESULTS

Significant (P < 0.05) increases were observed in LS (13.1 ± 3.1 to 20.6 ± 5.1 N·kg(-1)), BL (23 ± 11 to 32 ± 13), PWS (0.41 ± 0.27 to 0.55 ± 0.28 m·s(-1)), RWS (0.44 ± 0.31 to 0.71 ± 0.40 m·s(-1)), 6MWD (97 ± 80 to 177 ± 122 m), and DSA (593 ± 782 to 1310 ± 1258 steps) following UTT.

CONCLUSION

Physical function and walking ability were improved in adults with iSCI following a structured program of UTT featuring individualized levels of body weight support and carefully staged increases in speed and duration. From a clinical perspective, these findings highlight the potential of UTT in persons with physical disabilities and diseases that would benefit from weight-supported exercise.

Knee osteoarthritis: Clinical connections to articular cartilage structure and function

Articular cartilage is a unique biphasic material that supports a lifetime of compressive and shear forces across joints. When articular cartilage deteriorates, whether due to injury, wear and tear or normal aging, osteoarthritis and resultant pain can ensue. Understanding the basic science of the structure and biomechanics of articular cartilage can help clinicians guide their patients to appropriate activity and loading choices. The purpose of this article is to examine how articular cartilage structure and mechanics, may interact with risk factors to contribute to OA and how this interaction provides guidelines for intervention choices This paper will review the microstructure of articular cartilage, its mechanical properties and link this information to clinical decision making.

Effect of therapeutic aquatic exercise on symptoms and function associated with lower limb osteoarthritis: systematic review with meta-analysis

BACKGROUND

Current management of osteoarthritis (OA) focuses on pain control and maintaining physical function through pharmacological, nonpharmacological, and surgical treatments. Exercise, including therapeutic aquatic exercise (TAE), is considered one of the most important management options. Nevertheless, there is no up-to-date systematic review describing the effect of TAE on symptoms and function associated with lower limb OA.

PURPOSE

The purpose of this study was to conduct a systematic review with meta-analysis to determine the effect of TAE on symptoms and function associated with lower limb OA.

DATA SOURCES

The data sources used in this study were: MEDLINE, PubMed, EMBASE, CINAHL, PEDro, and SPORTDiscus.

STUDY SELECTION

All studies selected for review were randomized controlled trials with an aquatic exercise group and a nontreatment control group. In total, 11 studies fulfilled the inclusion criteria and were included in the synthesis and meta-analysis.

DATA EXTRACTION

Data were extracted and checked for accuracy by 3 independent reviewers.

DATA SYNTHESIS

Standardized mean difference (SMD) with 95% confidence interval (95% CI) was calculated for all outcomes. The meta-analysis showed a significant TAE effect on pain (SMD=0.26 [95% CI=0.11, 0.41]), self-reported function (SMD=0.30 [95% CI=0.18, 0.43]), and physical functioning (SMD=0.22 [95% CI=0.07, 0.38]). Additionally, a significant effect was seen on stiffness (SMD=0.20 [95% CI=0.03, 0.36]) and quality of life (SMD=0.24 [95% CI=0.04, 0.45]).

LIMITATIONS

Heterogeneity of outcome measures and small sample sizes for many of the included trials imply that conclusions based on these results should be made with caution.

CONCLUSIONS

The results indicate that TAE is effective in managing symptoms associated with lower limb OA.

Variation in percentage weight bearing with changes in standing posture during water immersion: implication for clinical practice

BACKGROUND

The degree of weightlessness during water immersion is usually estimated through percentage weight bearing (PWB). However, variations in PWB in different standing postures have not been documented. The study was designed to investigate the PWB of apparently healthy individuals in four standing postures at the anterior superior iliac spine level of immersion.

METHODS

One hundred and ninety-three consenting undergraduates were purposively enlisted in this study. Participants' body weight (BW) was measured on land as well as in Erect Standing (ES), Grasp-Inclined-Prone-Standing (GIPS), Half-Grasp-Inclined-Towards-Side Standing (HGITSS) and Inclined-Standing with Head Support (ISHS) postures in hydro pool, using a specially designed water-proof weighing scale. PWB was calculated by dividing BW in water by BW on land and multiplying by 100. Data were analyzed using mean, standard deviation and ANOVA at α = 0.05.

RESULTS

The mean age and BW (on land) of the participants were 22.4 years and 60.7 kg respectively. Participants' PWB were significantly different (p < 0.05) across the four standing postures. PWB was highest in ES and lowest in ISHS; PWB in ES (52.3 ± 5.8) being significantly higher (p < 0.001) than that observed in the derived standing postures. Further, PWB in GIPS (43.3 ± 5.6) and ISHS (43.2 ± 7.3) were significantly lower than in HGITSS (47.4 ± 5.2) posture while PWB in GIPS and ISHS postures were not significantly different (p > 0.05).

CONCLUSION

Changes in standing posture have significant effect on PWB in hydro pool. The finding has implication for partial weight bearing exercises in hydro pool.

Physiological and biomechanical responses to walking underwater on a non-motorised treadmill: effects of different exercise intensities and depths in middle-aged healthy women

Non-motorised underwater treadmills are commonly used in fitness activities. However, no studies have examined physiological and biomechanical responses of walking on non-motorised treadmills at different intensities and depths. Fifteen middle-aged healthy women underwent two underwater walking tests at two different depths, immersed either up to the xiphoid process (deep water) or the iliac crest (shallow water), at 100, 110, 120, 130 step-per-minute (spm). Oxygen consumption (VO2), heart rate (HR), blood lactate concentration, perceived exertion and step length were determined. Compared to deep water, walking in shallow water exhibited, at all intensities, significantly higher VO2 (+13.5%, on average) and HR (+8.1%, on average) responses. Water depth did not influence lactate concentration, whereas perceived exertion was higher in shallow compared to deep water, solely at 120 (+40%) and 130 (+39.4%) spm. Average step length was reduced as the intensity increased (from 100 to 130 spm), irrespective of water depth. Expressed as a percentage of maximum, average VO2 and HR were: 64-76% of peak VO2 and 71-90% of maximum HR, respectively at both water depths. Accordingly, this form of exercise can be included in the "vigorous" range of exercise intensity, at any of the step frequencies used in this study.

Respostas bioquímicas e físicas ao treinamento realizado dentro e fora da água em atletas de futsal

O objetivo deste estudo foi analisar os efeitos do treinamento físico em quadra e do treinamento físico em piscina (hidroginástica) sobre os índices bioquímicos relativos ao dano muscular e a aptidão física de atletas de futsal. Doze jogadores de futsal foram divididos em dois grupos: 1) grupo de treinamento em quadra (GTQ, n = 6) e 2) grupo de treinamento em piscina (GTP, n =6). Foram verificados os índices de capacidades aeróbicas e aneróbicas pelos testes de RAST e Yo-yo intermitent, o dano muscular pela creatina quinase (CK) e lactato desidrogenase (LDH) e os níveis de stress oxidativo pelos níveis de ácido tiobarbitúrico (TBARS) e atividade da catalase (CAT) antes e após 10 sessões de trainamento (p<0,05). Os resultados mostraram que ambos os grupos melhoraram a condição aeróbica após as 10 sessões de treinamento. Mas o GTP apresentou maior atividade da CAT em repouso e menores níveis de CK ao ser comparado com o GTQ na 10ª sessão de treino. Concluiu-se que o treino com hidroginástica parece ser uma alternativa interessante para a melhoria das capacidades físicas e para a proteção muscular durante a preparação física inicial de atletas de futsal.

Effects of a progressive aquatic resistance exercise program on the biochemical composition and morphology of cartilage in women with mild knee osteoarthritis: protocol for a randomised controlled trial

BACKGROUND

Symptoms associated with osteoarthritis of the knee result in decreased function, loss of working capacity and extensive social and medical costs. There is a need to investigate and develop effective interventions to minimise the impact of and even prevent the progression of osteoarthritis. Aquatic exercise has been shown to be effective at reducing the impact of osteoarthritis. The purpose of this article is to describe the rationale, design and intervention of a study investigating the effect of an aquatic resistance exercise intervention on cartilage in postmenopausal women with mild knee osteoarthritis.

METHODS

A minimum of 80 volunteers who meet the inclusion criteria will be recruited from the local population through newspaper advertisements. Following initial assessment volunteers will be randomised into two groups. The intervention group will participate in a progressive aquatic resistance exercise program of 1-hour duration 3 times a week for four months. The control group will be asked to maintain normal care during this period. Primary outcome measure for this study is the biochemical composition of knee cartilage measured using quantitative magnetic resonance imaging; T2 relaxation time and delayed gadolinium-enhanced magnetic resonance imaging techniques. In addition, knee cartilage morphology as regional cartilage thickness will be studied. Secondary outcomes include measures of body composition and bone traits using dual energy x-ray absorptiometry and peripheral quantitative computed tomography, pain, function using questionnaires and physical performance tests and quality of life. Measurements will be performed at baseline, after the 4-month intervention period and at one year follow up.

DISCUSSION

This randomised controlled trial will investigate the effect a progressive aquatic resistance exercise program has on the biochemical composition of cartilage in post-menopausal women with mild knee osteoarthritis. This is the first study to investigate what impact aquatic exercise has on human articular cartilage. In addition it will investigate the effect aquatic exercise has on physical function, pain, bone and body composition and quality of life. The results of this study will help optimise the prescription of aquatic exercise to persons with mild knee osteoarthritis.

TRIAL REGISTRATION

ISRCTN65346593.

All-epiphyseal, all-inside anterior cruciate ligament reconstruction technique for skeletally immature patients

Anterior cruciate ligament (ACL) injuries are an increasingly recognized problem in the juvenile population. Unfortunately, outcomes with conservative treatment are extremely poor. Adult reconstruction techniques are inappropriate to treat skeletally immature patients because of the risk of physeal complications, including limb-length discrepancy and angular deformities. "Physeal-sparing" reconstruction techniques exist, but their ability to restore knee stability is not well understood. We describe an all-epiphyseal ACL reconstruction for use in skeletally immature patients. This is an all-inside technique with the femoral tunnel drilled retrograde and the tibial tunnel drilled retrograde; both tunnels are entirely within the epiphysis. Fixation of the hamstring autograft is achieved with soft-tissue buttons on both the femur and tibia. We present case examples for 2 patients who underwent the all-inside, all-epiphyseal reconstruction and our postoperative rehabilitation protocol. We present a novel surgical technique for an all-inside, all-epiphyseal ACL reconstruction in skeletally immature patients.

Return to sport following hip injury

Returning to both recreational and competitive sport requires the patient demonstrate the ability to perform their activity without pain, without compensation and without apprehension. The primary focus of this article will be to provide progressive weight bearing phased treatment solutions and both objective and empirical return to play testing suggestions. In addition to satisfactorily completing the test battery with maximum effort, the patient must demonstrate the ability to meet the demands for competing within their respective sport specific environment. Returning to competition will most likely include early phase movement screening and clinical clearance followed by late phase athletic and field testing. Hip structure will and must influence training program design. It is therefore important to recognize that indications for return to play must not focus on a single rehabilitation or exercise variable, but rather a combination of clinical, functional and sport specific demands.

Impact forces of plyometric exercises performed on land and in water

Background:

Aquatic plyometric programs are becoming increasingly popular because they provide a less stressful alternative to land-based programs. Buoyancy reduces the impact forces experienced in water.

Purpose:

To quantify the landing kinetics during a range of typical lower limb plyometric exercises performed on land and in water.

Study Design:

Crossover design.

Methods:

Eighteen male participants performed ankle hops, tuck jumps, a countermovement jump, a single-leg vertical jump, and a drop jump from 30 cm in a biomechanics laboratory and in a swimming pool. Land and underwater force plates (Kistler) were used to obtain peak impact force, impulse, rate of force development, and time to reach peak force for the landing phase of each jump.

Results:

Significant reductions were observed in peak impact forces (33%-54%), impulse (19%-54%), and rate of force development (33%-62%) in water compared with land for the majority of exercises in this study (P < 0.05).

Conclusions:

The level of force reduction varies with landing technique, water depth, and participant height and body composition.

Clinical Relevance:

This information can be used to reintroduce athletes to the demands of plyometric exercises after injury.

Early aquatic physical therapy improves function and does not increase risk of wound-related adverse events for adults after orthopedic surgery: a systematic review and meta-analysis

OBJECTIVES

To investigate whether early postoperative aquatic physical therapy is a low-risk and effective form of physical therapy to improve functional outcomes after orthopedic surgery.

DATA SOURCES

Databases MEDLINE, CINAHL, AMED, Embase, and PEDro were searched from the earliest date available until October 2011. Additional trials were identified by searching reference lists and citation tracking.

STUDY SELECTION

Controlled trials evaluating the effects of aquatic physical therapy on adverse events for adults <3 months after orthopedic surgery. Two reviewers independently applied inclusion and exclusion criteria, and any disagreements were discussed until consensus could be reached. Searching identified 5069 potentially relevant articles, of which 8 controlled trials with 287 participants met inclusion criteria.

DATA EXTRACTION

A predefined data extraction form was completed in detail for each included study by 1 reviewer and checked for accuracy by another. Methodologic quality of included trials was assessed independently by 2 reviewers using the PEDro scale.

DATA SYNTHESIS

Pooled analyses were performed using random effects model with inverse variance methods to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs) (continuous outcomes) and risk difference and 95% CIs (dichotomous outcomes). When compared with land-based physical therapy, early aquatic physical therapy does not increase the risk of wound-related adverse events (risk difference=.01, 95% CI -.05 to .07) and results in improved performance of activities of daily living (SMD=.33, 95% CI=.07-.58, I(2)=0%). There were no significant differences in edema (SMD=-.27, 95% CI=-.81 to .27, I(2)=58%) or pain (SMD=-.06, 95% CI=-.50 to .38, I(2)=32%).

CONCLUSIONS

After orthopedic surgery aquatic physical therapy improves function and does not increase the risk of wound-related adverse events and is as effective as land-based therapy in terms of pain, edema, strength, and range of motion in the early postoperative period.

Effect of gender, cadence, and water immersion on ground reaction forces during stationary running

STUDY DESIGN

Controlled laboratory study.

OBJECTIVES

To analyze the vertical and anteroposterior components of the ground reaction force during stationary running performed in water and on dry land, focusing on the effect of gender, level of immersion, and cadence.

BACKGROUND

Stationary running, as a fundamental component of aquatic rehabilitation and training protocols, is little explored in the literature with regard to biomechanical variables, which makes it difficult to determine and control the mechanical load acting on the individuals.

METHODS

Twenty-two subjects performed 1 minute of stationary running on land, immersed to the hip, and immersed to the chest at 3 different cadences: 90 steps per minute, 110 steps per minute, and 130 steps per minute. Force data were acquired with a force plate, and the variables were vertical peak (Fy), loading rate (LR), anterior peak (Fx anterior), and posterior peak (Fx posterior). Data were normalized to subjects' body weight (BW) and analyzed using repeated-measures analysis of variance.

RESULTS

Fy ranged from 0.98 to 2.11 BW, LR ranged from 5.38 to 11.52 BW/s, Fx anterior ranged from 0.07 to 0.14 BW, and Fx posterior ranged from 0.06 to 0.09 BW. The gender factor had no effect on the variables analyzed. A significant interaction between level of immersion and cadence was observed for Fy, Fx anterior, and Fx posterior. On dry land, Fy increased with increasing cadence, whereas in water this effect was seen only between 90 steps per minute and the 2 higher cadences. The higher the level of immersion, the lower the magnitude of Fy. LR was reduced under both water conditions and increased with increasing cadence, regardless of the level of immersion.

CONCLUSION

Ground reaction forces during stationary running are similar between genders. Fy and LR are lower in water, though the values are increased at higher cadences.