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[Physio Explained] Making waves: aquatic physiotherapy for musculoskeletal conditions with Dr Sophie Heywood

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In this episode with Dr Sophie Heywood, we discuss the role of aquatic physiotherapy for musculoskeletal conditions. We explore: 

  • What does the evidence say about aquatic based physiotherapy? 
  • What does aquatic physiotherapy involve?
  • Populations which do well in the pool compared to on land
  • Role of aquatic physiotherapy in chronic pain
  • Importance of progressive overload
  • Role of “drag” in the pool 

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Dr Sophie Heywood is a Titled sports and exercise physiotherapist who has completed a PhD in clinical reasoning, biomechanics and functional aquatic exercise for people with knee osteoarthritis. She currently works at St Vincent’s Hospital, the Melbourne Sports Medicine Centre and Hydro Functional Fitness, and oversees the foundational and advanced training in aquatic physiotherapy at the Australian Physiotherapy Association.

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Our host is @sarah.yule from Physio Network

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SPEAKER_01:

One of the great opportunities for us in aquatic physio is to help people to understand pain and help them to understand why exercise might be important for them to manage their chronic condition in particular. And I think there's an opportunity for us to spend more time talking to people about their experience with exercise when they start.

SPEAKER_02:

What is the evidence for aquatic physio in musk conditions? And what do we need to know? Today we'll explore these questions and unpack what's unique about exercise in the water. We'll discuss how understanding the properties of water can transform our clinical decision making. Sophie Haywood is a titled sports and exercise physio who has completed a PhD in clinical reasoning, biomechanics, and functional aquatic exercise for people with knee osteoarthritis. She works at St. Vincent's Hospital in Melbourne, the Melbourne Sports Medicine Centre, and Hydrofunctional Fitness, and she oversees the foundational and advanced training in aquatic physiotherapy at the Australian Physiotherapy Association. Sophie has worked for more than 25 years across a range of roles, including in aquatic rehab and recovery in professional Australian rules football, as well as in public hospitals and in private practice. You're going to love today's episode. I'm Sarah Yule, and this is Physio Explained. Welcome to the podcast, Sophie. Thank you so much for joining us today.

SPEAKER_01:

Pleasure, Sarah, good to be here.

SPEAKER_02:

We've already mentioned how many times I'll try to avoid, say, some sort of aquatic-related pun, but in for a penny, in for a pound, so we'll dive straight into it. What is the evidence for aquatic physio for musculoskeletal conditions?

SPEAKER_01:

This is a good place for us to start. I think there's randomized controlled trial and systematic review level evidence for most musculoskeletal conditions to show that two to three times a week of aquatic exercise over at least six weeks we'll see change in most of the things that we're all interested in changing. So improvements in quality of life, improvements in function, improvements in pain. In most circumstances, for musk conditions, the outcomes are the same for land-based exercise as they are for aquatic-based exercise. So aquatic exercise isn't better or worse, it's the same. And that's a good thing. It shows that it's effective. Most of the research has been done in hippineo A. There's lots of studies. We probably don't need many more studies in hippineo A. We know it's effective in improving many outcomes. There's also research in joint replacement, hip and knee joint replacements in particular, as well as other post-surgical populations, as well as evidence in lower back pain and fibromyalgia, those kind of things. So I think the evidence is strong.

SPEAKER_02:

Just to clarify, two to three times a week with significant change over a six-week period is fantastic evidence. In the context of those studies, what does aquatic physio actually look like? Presumably it's the application of our land-based strength and conditioning principles to actually attain this change.

SPEAKER_01:

If we look at the evidence across the years, most of the studies in aquatic exercise, and whether we're defining it or whether in the manuscript or the journal, it's called hydrotherapy or it's called aquatic physical therapy or it's called aquatic exercise. It can be called lots of different things. Most of the studies are usually designed by or implemented by physios. Not all of them, of course, but most of them are. In terms of what it looks like, that's a really great question because I think although the evidence shows meaningful changes in important domains like quality of life and pain and function, what we see in the studies is quite generic or lower level exercise. If I looked at the all of the programs, I think that they're underloaded. In terms of your comment related to land-based strengths or conditioning principles, I think there's a bit of a disconnect related to understanding how they're implemented in the pool. And I think this is a problem not just in the literature. It's definitely a problem for physios to have a think more clearly about what those principles look like in the pool. So the programs themselves, I think, are lacking a little bit of specificity and certainly lacking progression and loading across those six weeks, which in my mind means that we should be able to do better in the clinical practice in our own with our own patients. We should be able to see better outcomes if we're really thinking about those things.

SPEAKER_02:

So it's sounding like that the studies are potentially underloading, but still obviously making change. How do you think that impacts our selection of who goes into the pool versus who stays on land?

SPEAKER_01:

The literature doesn't give us a good information about that, unfortunately. The populations in must conditions, they're big groups of people. We don't have clarity about the subgroups of people that might do better. I think clinically we all know from our own experience that the types of people that do well in the pool have often been unsuccessful for exercise on land, and that may be related to lots of different things. For example, I can think about people who have had a negative experience with being flared up with land-based exercise, probably because it's been overloaded or there hasn't been enough education around persistent pain or response to exercise. Those people do well in the pool because they're not interested in land-based exercise or they've they feel like it's not for them. I think people who have got multimorbidity and most of our or many of our older patients will have diabetes, hypertension, obesity, lots of other conditions that they're juggling managing. And the pool, I think, gives people an opportunity to do some cardiovascular conditioning and have more successful exercise than they might on land. I think it's a real gap in the literature for us to understand who does better. But I think clinically we understand who does better. It's people who have got significant pain that's not well managed. It's people who aren't mobilising very much and the pool gives them an opportunity to be more successful or to do bigger chunks of exercise or higher intensity of exercise. So weakness, pain, or have maybe had a negative experience. I think they're the people that generally do well in the pool.

SPEAKER_02:

And I suppose, presumably, by the sounds, when we look at the mechanism of function improvement, we might be looking at factors that are just beyond pure strength changes.

SPEAKER_01:

Totally. One of the great opportunities for us in aquatic physio is to help people to understand pain and help them to understand why exercise might be important for them to manage their chronic condition in particular. And I think there's an opportunity for us to spend more time talking to people about their experience with exercise when they start. It's actually a really interesting question to ask someone and one that maybe we skip over, but people have often had negative experiences with exercise. I guess I'm thinking in particular for people with knee osteoarthritis or other chronic conditions where they've been not as well supported as would be ideal, or that just there hasn't been the time that would have allowed them to understand what was going on. And I think in the water, we can spend more time with someone building their skills in terms of coping with a flare, understanding that pain doesn't mean damage, some of those beliefs that people might have with osteoarthritis or with persistent pain that are not that helpful for them in managing their condition. And I think the water is a place where they feel more positive about what they're able to achieve, and that's a great door that we can open to help. People feel more empowered for people not to feel so worried or fear-avoidant or concerned or overwhelmed about exercise. So yeah, it's not just about the technical aspect of delivering a certain type of exercise. It's also about supporting someone to feel like they're empowered to exercise. So absolutely.

SPEAKER_00:

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SPEAKER_02:

Moving more towards understanding that exercise in the water, what do you think we as clinicians need to know about exercise in water to improve our practice and our effectiveness?

SPEAKER_01:

There's lots of things. I think if we understand the physiology of immersion, we can be safe and we can screen people well and we can start gently and slowly, and people can gain confidence with being in water, but we can also maximise the opportunities we've got with cardiovascular conditioning, knowing that someone's stroke volume and cardiac output is higher. So I think the first thing is making sure we're clear about physiological change and the opportunities that presents us with in terms of improving someone's functional fitness or cardiovascular capacity. The next thing is being clear about the forces in water. Obviously, in musculoskeletal conditions, we're prescribing different types of exercise to understand the amount of load that we're giving with any one exercise. We need to be clear that buoyancy is an up thrust force, it's relative to the volume of water we're displacing. And so the direction of movement changes how much load buoyancy is giving us or not giving us. And I think across the board, physios understand buoyancy clearly, patients understand buoyancy. Most of us understand that at a particular depth we're offloaded relative to where the water comes up to us. At our waist, we're loading at 50%, at our chest, we're loading at 30%. I think drag is not well understood and underutilised by physios and generally in aquatic exercise, and drag relates to how fast we move in the water and our surface area. And I think when you watch an aquatic physio session, it looks like everything's in slow motion and drag slows us down. Our self-selected speed of walking in the pool is two to three times slower. Our faster speed of walking in the pool is two to three times slower. So drag prevents us from walking faster and moving faster. But I think we need to use drag and we need to speed up the loading to get higher levels of resistance with exercise so we're progressively loading someone over the time we might have with them. Or so that they understand that they can change the speed of their movement to manage a flare or to make things harder. Drag is incredibly exciting and unique in that people can control it themselves, so they can control their own speed. And this is useful if someone's got fear avoidance or they're worried about movement. So educating someone to understand about speed and drag, I think is useful. But understanding ourselves with each exercise, is it buoyancy or drag that's the dominant force? And how do we make each of those forces, how do we manipulate them to make the exercise easier or harder, depending on whether someone comes back and they've how they've tolerated that last session? I think being clear about that, which I guess links to the last thing that I think is important for us to understand. Often in musculoskeletal aquatic physio, we're managing more than one patient at the same time or more than one client. So I think it would be typical for most physios to be managing four to six clients. And some of them might be complicated in some way, whether it's their presentation or something else. And I think the constraints of that mean that sometimes our clinical reasoning's a bit washed out. There's our second pun for the session to think about. I think our clinical reasoning can be a little bit messy. We don't progress people. We're not thinking clearly about what this person wants out of these sessions, what's been their experience in the water, how am I being clear about what they can do well on land that I don't need to do in the pool? How can I be clearer about what's a unique opportunity in the water and maximising that for this person and talking to them about what they want? And also thinking about what that means for discharge planning. Most of the musculoskeletal patients we have in the pool will have chronic conditions. And I think for us to be more effective, we have to start thinking about what that longer term management looks like for that person. So I think the physiology of immersion, understanding the forces in water and understanding what someone wants and being clear about our clinical reasoning and our collaboration is the best way for us to treat everyone as an individual and get the best for them out of their program, rather than everything being looking at a little bit the same. Because most patients will do well in the pool. They like the opportunity to move around and movement and exercise is generally easier, and in itself, that is a win. But I think there's things that we can do that are more specific and more targeted and more collaborative, which will give all of our patients better outcomes.

SPEAKER_02:

That's a great summary. So we're looking at hydrostatic pressure, buoyancy, and then how the water assists and resists effectively, and then funneling that into our clinical application, which I think is a really great point. It's something that we that's the lens that it always comes back to.

SPEAKER_01:

Yeah, I think we often want to make sure that we're maximizing carryover to land-based exercise too. And I think for me that fits into understanding the forces in water. If we understand buoyancy and drag and loading and we're progressively loading someone, then we're more likely to get them to a point where they are going to see improvements in their land-based function. And I think that's really, really important. Absolutely.

SPEAKER_02:

Looking forward and looking ahead, what do you think are the most interesting opportunities in water for physios to consider?

SPEAKER_01:

We've touched on some of them. There's things that people can do in the pool that they can't do on land. Single leg exercise is really valuable in the water and pushing someone onto a single leg if they've got limitations in terms of balance or weakness. The pool's really great place to do endurance exercise. It's a really great place to do power-based exercise, and there's emerging evidence for lots of different populations that power-based exercise is the way forward to improve function. I'm thinking particularly about, for example, changing someone's community-based gait speed. So power-based exercise, I think we probably underutilise. Cardiovascular conditioning for musculoskeletal populations, I think, is also probably underutilised. And the pool is a great option for people to do higher intensity exercise that they can't do on land, often related to pain. We touched on talking about education and building empowerment and coping strategies for people. I think that's another unique opportunity. And participation, having a think about linking someone in, whether it's socially or whether it relates to exercise in general, or thinking about where is this person going to be in six months? What can they do by themselves? How can I build their self-efficacy and their confidence to exercise by themselves? I think that's really important for us to consider.

SPEAKER_02:

Just to go back to a point you made earlier, knowing that perhaps we underload, knowing that you've mentioned using hydrostatic pressure, using the principles of buoyancy, drag, at how we apply that, is there anything you think would be low-hanging fruit for clinicians listening that we can use to load our patients a bit more effectively in the water tomorrow that we haven't already covered?

SPEAKER_01:

We'd probably talked a lot about programs being underloaded, flagging that when someone starts in the pool for their first session, that in terms of physiological change and being safe and imagining that people have got other cardiovascular or respiratory comorbidities, that first session is gentle and that we're spending some time understanding what people's past experience is with exercise and what their past experience is with being in the water, whether they're happy to be, what their links socially are to water, what they might want to do in the future. I think spending a little bit more time talking to someone and understanding what they want and what their experience is a really great thing to do. And that first conversation can really help the direction about where someone might go with you. And then I'm thinking about the other thing that would be good for us all to think about is further down the track when someone's not being revved up too much pain-wise after a session, and you've spent some time helping them to understand that pain doesn't mean damage in chronic conditions, and they're building a bit of confidence that we can think about exploring their fear avoidance and things like squats, things that they might not do on land, and encouraging them and giving them the confidence to know that they can do that in the water. And then building more speed into our programs with all exercises, particularly functional exercises, whether it's gait or squats or calf raises, and maybe pushing a little bit more towards power-based exercise, I think would be a really good thing for people to experiment with in low reps to start off with, not at maximal speed, sub-maximal power-based exercise, I think is a good way to start to understand how someone responds. And I'm obviously talking about people's conditions that are not irritable. So I think starting gently and trying to understand what the person's experience has been with exercise and water might help discharge planning. And then further down the track, when people are doing well, pushing speed into particularly closed chain exercise and gait would be really great for both power, muscular performance and power, but also cardiovascular conditioning.

SPEAKER_02:

Well, a very big thank you to you, Sophie, for sharing your expertise and your passion. I think your insights have very much added depth to this discussion. There we go, another one. I think we're on a count of four or five now. But to our listeners, hopefully this episode has given you something to think about, whether you're already using the pool or dipping your toes in. Thanks, Sarah. Thanks, Sophie.