CompletePT's Aquatic Therapy Program for Hips
Since 1999, CompletePT Pool & Land Physical Therapy has been treating up to five hundred patients a week in our 92-degree heated indoor pool and in our spacious gym and treatment areas. We also treat up to one hundred patients a week in our spectacular pool inside the Jodie Foster Aquatic Pavilion on the Motion Picture & Television Fund campus in Woodland Hills, CA. Nearly a quarter of those patients are hip patients - patients with osteoarthritis, hip dysplasia, posttraumatic osteoarthritis, avascular necrosis, or bursitis. Most of them come to us after having read Heal Your Hips: How to Prevent Hip Surgery - and What to Do If You Need It, written by orthopedic surgeon Robert Klapper, M.D. and Lynda Huey (John Wiley & Sons, 1999). Their desire to return to pain-free daily life is always at the top of their priorities. Many of them achieve that goal without surgery, while others eventually decide that they must indeed have hip surgery. A small portion of these surgical patients are candidates for hip arthroscopy while the larger majority will have hip implant surgery. Following surgery, they return to our pool to regain their strength, flexibility, mobility, and function. As they progress, we transition them into our land therapy program where they must once again face gravity as they do in their activities of daily living (ADLs).
When the hip becomes disabled, people can't move well on land; but in water they are able to move with greater ease. They can walk, bend, kick, and even run when those movements would be unthinkable on land.
All of our hip patients begin with gait training in waist-deep water. If they experience pain, they move to chest-deep water, and if they still aren't pain-free, we add a flotation belt around the waist. By offloading the body's weight, hip patients can walk relatively pain-free. Those with longstanding hip pain often have developed serious compensatory movements while walking. Spending time each session on gait training helps these patient relearn or refine the correct biomechanics of walking. We make corrections as we watch patients walk from the front, the back, and the side, assisting patients by holding their pelvis in place. In that way, patients learn to make the hip do the walking, not other parts of the body that have taken over the job. Our gait training sequence consists of walking forward, backward, and sideways, marching, and a long-leg walk (See pages 87- 92 of Heal Your Hips for complete instructions). Patients spend five to ten minutes on gait training at the beginning of their sessions.
Click here to see the books, DVD, and water equipment available, or call Huey's Athletic Network at 800-909-0300 or 310-829-5622.
Deep-Water Intervals (DWIs)
We choose the appropriate flotation belt for each patient depending on his or her waist size, muscle density, and physical complaints. For instance, the Hydro-Tone belt offers the most buoyancy for muscular athletes while the Wet Sweat Belt provides the most comfort for short patients. Next, we attach a Waterpower Workout tether around the belt and attach the other end to the bar on the side of our pool as in photo 1. (In pools without bars, attach tethers to ladders, lane dividers, or even athletic bags on the side of the pool.)
Once outfitted, patients spend fifteen to twenty minutes doing the four skills of deep-water intervals:
2) Power walk,
3) Speed walk, and
(See pages 76-84 in Heal Your Hips for complete instructions.)
Precautions: Patients who have had hip implant surgery must follow the hip precautions given to them by their surgeons for the length of time their doctors suggest. Once they no longer have hip precautions, they may begin some of the variations suggested in "Flies" and "Deep Back Kicks." Patients with hip implants or femoral head resurfacing should not use ankle weights on any of these exercises as shown in photos 2-5.
Run. Run in an upright position using the exact motion of good running form on land (photo 2). Watch for knees pointing outward due to hip pain or crossing the mid-line of the body due to muscle weakness and bad biomechanics. Hip implant patients must follow their precautions, meaning they must not lift their knees so high as to create greater than 90 degrees of hip flexion.
Power walk. Begin an exaggerated walking motion in which the knees never bend. Swing the arms and legs forward and backward in a smooth, flowing motion using opposition - right arm and left leg forward, then left arm and right leg (photo 3). Turn the hands so the palms face backward and they're wide like paddles. Flex the foot on the leg that swings forward and point the foot on the leg that swings backward. One foot is flexing and one is pointing on each step. Hip patients should emphasize full range of motion while performing this exercise, especially reaching for full extension.
Speed walk. (See page 79 in Heal Your Hips for a photo.) Turn the hands with the thumbs forward so they "slice" through the water. Keep the elbows and knees straight throughout this exercise. Lift the toes to help keep the knees straight. Tighten the abdominals and buttocks muscles, then quicken and shorten the steps and make fast, toy soldier-like movements. Hip implant patients should wait several weeks before trying this, then proceed per patient's pain tolerance.
Flies. Open the arms and legs to a wide position, then pull the arms and legs back to center. Lean back at first until balance in an upright position can be achieved. Keep the hands flat and just below the surface of the water. (If the patient is wearing ankle weights as explained in the next paragraph, he or she may need to hold the side of the pool for greater stability.) Next, all hip patients except postsurgical implant patients can add external and internal hip rotation by pointing the toes out during abduction (photo 4) and in during adduction (photo 5). Stay within the patient's pain-free range. Over the weeks, that range will increase.
If the patient continues to have hip pain even without weightbearing in deep water, we try to make them pain-free by adding ankle weights. This hip distraction often helps patients move more easily and with less pain when we induce such a traction force to the hip joint. (Note: Postsurgical hip implant patients would never add ankle weights!) The primary patients with whom we use hip distraction are those with osteoarthritis (OA). We start by adding 2.5 pounds per lower extremity. Surprisingly, just this small amount of weight on each ankle can create a significant increase in active range of motion both during the session and afterward. (The weights have the added bonus of providing additional strength training.) If hip distraction proves positive for a patient, we may increase the tractioning pull to 3.5 pounds around each ankle as their treatment progresses. Some of our larger patients have required as many as 5 pounds to achieve the desired effect. As the weight increases, we most likely will also need to add a second flotation belt. The combination we like best is a Hydro-Tone belt closest to the waist with a large Wave belt on top. If more buoyancy or stability is needed, the patient can also hold onto a noodle.
It is essential to assess each patient's overall medical condition prior to adding weights, because such weights are inappropriate for cardiac patients and for people with replaced joints, knee problems, and certain back conditions.
The DWIs can be very challenging with the weights added, so patients must be closely monitored. At first, the intensity and duration must be decreased as patients move slowly with the new weight and resistance.
Remove any ankle weights before moving into the stretching exercises. Our pool has unique, double therapy bars - one is placed nine inches below the other on the wall, which gives us a built-in, three-tiered stretching program. Beginners place their feet below the bottom bar. Intermediates place their feet between the two bars, and our most advanced patients increase all their stretches by placing the balls of their feet on the bottom bar. The following exercises appear with complete instructions on pages 114-117 of The Complete Waterpower Workout Book or pages 93-96 in Heal Your Hips. Emphasize the importance of stretching with all hip patients - allow enough time in their programs and ask them to hold every stretch at least thirty seconds.
Curl and stretch. With the feet at the appropriate height on the wall of the pool, bend both knees and hips and curl up as tightly as possible, chin to chest, tailbone pressed toward the heels. Breathe slowly and relax. Then straighten both legs as much as possible and relax again. Hip implant patients must place their feet low on the wall so as not to violate the precaution limiting them to less than 90 degrees of hip flexion.
Hamstring stretch. Keep the foot of the affected hip on the side of the pool; the other foot dangles below. Straighten the leg as much as possible and press the heel toward the side of the pool as in photo 6. Then relax and breathe deeply. After thirty seconds, switch legs. The foot with the affected hip may not lift as high on the wall as the other. Note any differences between sides and spend more time stretching where needed.
Body Swing. Return both feet to the wall and open the feet slightly wider than the shoulders. Bend the knee on the side of the affected hip and swing the body that way (photo 7). Then straighten that knee and bend the other. As the patient swings away from the affected hip, he may experience pain since this moving stretch forces the hip into abduction. Stay within the patient's pain-free range. That range will increase over the weeks.
Lateral split. Open the legs as wide apart as possible making sure the pelvis is square with the pool wall. Breathe and relax for thirty seconds, then lean forward to increase the stretch.
Quad and hip flexor stretch. Move to shallow water to stand on the pool bottom. Hold the side of the pool and grasp the ankle on the unaffected side. Pull the heel toward the buttocks stretching the quads. Hold for thirty second, then let the knee drift straight back and look up toward the ceiling, moving the stretch higher into the hip flexors. To increase the stretch, push the foot into the hand. (See photo 8.) Many hip patients need assistance with this stretch. Pool therapists can help stabilize the pelvis while pulling the leg backward in order to prevent compensatory movements such as lumbar extension.
Start doing each of these kicks for thirty seconds, building up to one minute for most patients, up to two minutes for elite athletes. As patients become accomplished at this, ask them to increase kick intensity the last thirty seconds. (See pages 85-87 in Heal Your Hips for photos.)
Deep Back Kicks. Hold the side of the pool with both hands, or at our pool, we place one hand on the top bar and one hand on the bottom bar for better control and balance. Let the buttocks float up, but keep the eyes focused down on the water. Swing one leg forward almost to touch the side of the pool and the other leg swings backward - not anywhere near high enough to break the surface of the water. Switch leg positions so one is swinging forward and one is swinging backward at the same time. As each leg swings back, add a powerful isometric contraction in that side of the buttocks muscle. All hip patients except postsurgical implant patients can next try performing this exercise with legs internally rotated, then externally rotated; that is, with feet turned in, then feet turned out. Different muscles will be strengthened with these variations.
Flutter kick, front and back. Hold the side of the pool and perform a flutter kick first face down, then on the back. Avoid face-down flutter kicking with patients who have a history of lower back pain.
Bicycling. Braced in a corner of the pool, on a side or on the side of the pool, bend the knees to perform a bicycling movement. As patients advance, ask them to lift the knee and then the entire leg and foot out of the water so they can gain speed as well as add gravity to their work.
Scissors. Still braced, open the legs as wide as possible, then cross one over the other as far as possible to improve range of motion. Hip implant patients don't cross one leg over the other while they are under hip precautions.. They simply open their legs wide, then pull them back together.
Lower Extremity Exercises
Remove all flotation devices so patients can perform these exercises with increased stability. However, if a patient finds that weightbearing causes pain, replace the belt and move to deeper water for off-loading the weight. Perform the exercises first with the unaffected hip so patients can remember how a healthy hip is supposed to work. Then repeat with the affected hip, staying within a pain-free range. Begin with ten repetitions of each exercise, gradually building to thirty reps. Once that is achieved, try adding a buoyancy cuff to help increase range of motion of the hip. After three to five sessions of work with buoyancy, it's time for strengthening within that wider range. Start with a 4-Fin for minimal to moderate resistance, then a few weeks later, try a Hydro-Tone boot for maximal strengthening. Click here for photos and to order equipment.
Lateral leg raises. Stand with the affected side closest to the pool, holding the side of the pool. Maintain erect posture and lift the leg to the side, then pull it back to the starting position. Keep the toes pointing forward; don't let them turn toward the ceiling. Don't let patients lean to the side to lift the leg higher. Ask patients to place their hands on the iliac crest so they begin to understand which movement comes from the hip, and how much hip range of motion may have been coming from the back.
Leg swings. Swing a straight leg forward toward the surface of the water, then down and backward. Reach backward only within a pain-free range, especially if the patient has lower back pain. Watch for sideways movements that may have developed from long-term hip pain and help patients learn straight forward and backward movements. Also avoid forward and backward movements with the trunk - keep a stable, erect posture isolating the movement to the hip where the work is targeted.
Leg circles. Postsurgical hip implant patients and patients with lower back pain can start with very small circles, but all hip patients should do at least some version of this most-important of hip exercises, for nowhere on land can you find smooth resistance such as this through the entire range of the hip's motion. Lift the leg straight forward, then sweep it through a smooth circular motion out to the side, then behind the body. Complete the circle by brushing the leg past the standing leg and beginning the next circle. After completing the reps, reverse the direction of the circle, going from clockwise to counterclockwise or the opposite.
As patients near the completion of their rehabilitation, their strength and resiliency need to be challenged. Try introducing these few impact exercises with patients wearing a flotation belt at first. After a few visits, if patients had no increase in hip pain, remove the belt. As patients progress further, they can jump higher and higher. For a complete program of impact exercises, see pages 36-52 in The Complete Waterpower Workout Book or "Lynda Huey's Waterpower Workout" DVD. Start with ten repetitions of each exercise, gradually working up to thirty.
Lunges. Assume a lunge position, right leg and left arm forward, left leg and right arm back. Jump up and switch arm and leg positions so left leg and right arm are forward.
Jacks. Jump to a side-stride position with the legs slightly more than shoulder-width apart, the arms extended out to the sides at water level. Jump back so legs are together, knees bent and arms by the sides.
Squat jumps. Jump up and down, bending and straightening the knees. Volleyball and basketball players can add an overhead reach as in photo 9.
Power frog jumps. Jump off both feet and lift both knees toward the chest. At the same time sweep both arms forward to meet in front of the knees.
Stair Climbing with Speedo Step. Place the step where it can be as level as possible on the pool bottom, not slanted. Ask patients to stand on the step putting all their weight on the affected leg. Then, lower down to the pool bottom, keeping the body erect. Push back up to the starting position as in photo 10. Next try partial step-downs, performing ten repetitions, lowering and pushing up without ever touching the pool bottom. Start with ten reps and work up to thirty. Emphasize this exercise to strengthen the hip throughout this movement, because going down steps, weightbearing on the affected side, is one of the hardest things for hip patients to do on land.
This hip program is successful on many levels - even if hip surgery cannot be prevented, patients will have achieved a new level of fitness which speeds their recovery after surgery. Because they have fun in the pool with us, they often buy their own equipment, find a pool near their home, and make these exercises part of their life-long maintenance program.
This pool program is based on the elimination of gravity for increased pain-free range of motion. But we don't live in water; we live on land. All of our pool exercises are designed to prepare patients for a return to functional land-based exercises. Therefore, patients must transition to our land therapy program, starting with once a week in the gym (photo 11) and twice a week in the pool. As they gain strength against gravity, we move them to twice a week in the gym and once a week in the pool. Just before they are discharged, they are working at a high level, three times a week on land.
While we have them in the pool, however, we make sure all hip patients do every one of the components in our program, for each one is essential to the full recovery of range of motion, strength, endurance, and function. Attention to all of these components is critical in order to Heal Your Hips.