Aquatic Cardiac Rehabilitation

Aquatic exercises are popular because of the buoyancy afforded by water which lowers joint stress and resistance created by moving one's limb through water.

Recently water based activity is also becoming popular in cardiac rehabilitation. But it’s still controversial because of the safety concerns put forth by many doctors.

SAFETY CONCERNS:

Physiological changes after immersion could jeopardize diseased myocardium.

Possible problems	Physiological changes	Possible clinical outcomes
Increase in central blood volume	Increase stroke volume and cardiac output and left ventricular   volume. Decrease in heart rate	Increase in left ventricular wall stress, angina, ST depression.
Cold Water exposure	Increase in PaCO2 and decrease in heart rate	Increase in ventricular irregularity Increase in arrhythmia

PRACTICAL CONCERNS:

Heart Rate:  As its difficult to monitor it, there might be a problem in deciding intensity for exercise prescription

Monitoring: ECG and Blood pressure monitoring also becomes difficult.

PATIENT SELECTION:

Exercise is most beneficial for LOW-MODERATE RISK cardiac patients who either like swimming or have orthopedic or arthritis problems which may increase by land based exercise.

Water based exercises are particularly beneficial for individuals with peripheral vascular diseases. Particularly if temperature is 30-33 degree Celsius.Warmer water facilitates vasodilation and added buoyancy afforded by water decreases lower limb stress, allowing longer exercise duration.

EXERCISE PRESCRIPTION CONSIDERATIONS:

Water temperature: 26- 33degrees

Temperature at lower end is better for heat dissipation while upper end temperature is comfortable for most of the patients. If patient has orthopedic or PVD better is upper end temperature. Temperature should never be less than 15 degrees.

INTENSITY:

40-85% of the functional capacity. Start with a 40-50% of the functional capacity.

FREQUENCY AND DURATION:

Perform exercise at least 3 days per week

Aerobic portion: 20-30min. If you are performing Swimming: 1000 yards (500-2000) and Walking: 400-700 yards/workout

Warm up and cool down is very important. Warm up can be done for 3-5 min of stretches and light calisthenics on pool deck And Cool down in water3-5 min free standing and wall stretches.

MONITORING:

Frequent monitoring of Blood pressure and heart rate.

ECG should be done during early stages

EMERGENCY PROCEDURES: The staff should be well trained for CPR and defibrillator should also be present.

AQUATIC ACTIVITIES /EXERCISES:

1) WATER WALKING

It’s one of the safest and easiest activity. Energy cost is determined by depth, speed, and degree of arm involvement.The depth of the water should be between thighs and chest so as to have a greater energy cost. Going deeper may decreased the cost as buoyant forces affordable by water offsets the increased resistance that comes from having water coverage over greater body surface area. Energy cost increases with increase in speed. To increase intensity involve arms. Arms can be used in simulated swimming motion either above (front crawl)or below breast stroke.

2) GAIT TRAINING

Gait training and submerged interval training help you gain benefits of jogging or running without added impact on joints.

Similarly stretching and extensions help in flexibility with help of underwater leg movements such as kicks, bicycling maneuver and lateral rises.

THE PLOW

It’s a type of gait exercises .Once you are comfortable walking and jogging in water try using a wide hand held exercise tool called plow to increase resistance of your gait.

According to study in Journal of Athletic training: plow exercise mimics physical demands of aerobic sports like football and should be completed in shallow water sprints of 6 to 10 sec interval.

3) BUOYANCY RESISTED STERTCHES

Basic stretches: recovering joint .more intense variety can be used to create aerobic effect

Begin with underwater kicks.

Added effect: stretch your leg as much possible during end of each kick and gradually increase power and speed. If it’s difficult perform lunge/lateral raise in shallow water.

3) SWIMMING

Variants of strokes. For modified backstrokes, side strokes and breast strokes intensity can be controlled by most of the patients.

Front crawl not recommended by many people.

4) SWIMNASTICS/ WATER AEROBICS

These are Upright group water exercises, essentially aerobic dance conducted in water

5-10 min warm up in water then a 15-20 min of aerobic arm and leg exercise and 5 min cool down, resistive movements can also be done with help of  water dumbbells, floats/paddles.

Aqua stepping: step aerobics using weighted steps can also be done.

5) WATER VOLLEYBALL

Fun alternative: Played in shallow end. Water level: waist to nipple level. It should not be replaced to aerobics.

RECENT EVIDENCE:

Training induced increase in NO metabolites in CHF and CAD : an extra benefit of water based exercise. (European Journal of cardiovascular prevention rehabilitation Aug 2009)

CONCLUSION OF THE STUDY:

The cardio respiratory capacity of patients was significantly improved after rehabilitation.Water based exercise seemed to effectively increase the basal level of plasma nitrates. Such changes may not be related to an enhancement of endothelial function and may be important for health of patient.

DISCLAIMER: Please consult your doctor before attempting any of the above exercises.