Aquatic Therapy & Rehab

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1 Aquatic Therapy & Rehab i n s t i t u t e ATRI Newsletter Summer 2014 Volume 7 Issue 2 In This Issue ARTICLES Featured Course: Extension for Function 3-4 Deciphering Codes! 5-6 LE Resistance Blades 7-8 Featured Colleague: Mary Essert 12 Featured Course: Balance Training for Healthy Aging The FREE ATRI elist My Favorite Pool Exercise 17 EDUCATIONAL DATES & LOCATIONS About Sanibal Harbor Resort 2 ATRI Certification Exam National Conferences 9-10 Ways to Save Money in Chicago MIscellaneous Promotional Opportunities International Aquatic Therapy Symposium June 28-July 2 Sanibel, FL Come join us ATRI

2 Now s the time to register! International Aquatic Therapy Symposium Resort Headquarters Sanibel Harbour Marriott Resort & Spa, Sanibel/Fort Myers, FL The Sanibel Harbour Marriott Resort & Spa is a luxurious tropical escape where 85 acres of coastal scenery welcome you. Overlooking Sanibel and Captiva Islands on Florida s Southwest Gulf Coast, Sanibel Harbour Marriott Resort & Spa was named among the Top 100 Spa Resorts in the US by Conde Nast Traveler. Swimming, kayaking, tennis, and a world-class fitness center are all part of the resort experience. Explore acclaimed angling from the resort s own fishing pier or catch a glimpse of dolphins from a memorable cruise with Holiday Adventure Tours & Boat Rental. Family programs include Dive-In Movies, Sun Sport Rentals, Catamaran & Yacht Tours, plus other special events. AND it s our 20th Anniversary! Here are just SOME of the courses from the first day and a half only there s so much more! Go to for more courses. Intro. to Aquatic Therapy and Rehab Rehab for Injured Warriors and Athletes Orthopedic Progressions Stop Seated Stress with Integrated Core Training Parkinson s Disease: Improving Functional Mobility Watsu Experiential Chair and Seated Exercise Adaptations The Burdenko Method: Rehab of Common Orthopedic and Sports Injuries Sensory Integrated Imagery Feldenkrais for Neck and Shoulders Documentation for Aquatic Therapy UE Strengthening Techniques Therapeutic Interventions for Ataxia and Related Disorders Amputee Options and Outcomes Calming Fearful Patients Therapeutic Noodle Progressions AquaFlow for Mothers-to-Be Chronic Conditions Muscle and Mind Mixes Nekdoodle Progressions with Flotation 1Russian Pediatric Programs Self-Aqua Therapy YU-GA Tai Chi Arthritis Feldenkrais Basics Weight Management A New Approach to Abdominal Exercises Functional Cervical Maneuvers European Pediatric Interventions Ai Chi World AquaStretch Basics Balance and Core Strength Trunk-Centered Movement Stroke Rehabilitation Gender Differences in Back Pain Developing a Treatment Plan for Complex Conditions Aging Alive: Training for the Baby Boomer Innovative Exercises for the Hip Aging Well Pediatrics: An Integrated Approach ATRI Newsletter SUMMER Volume 7 Issue 2

3 Featured Course: Extension for Function Ruth Sova Extension can offer improved outcomes that carry over to daily life. Just because we re born in a fetal position doesn t mean we have to return to it. Extension is vital for maintaining a healthy posture and yet so many of our exercises are focused on flexion. We focus on flexion for hips, backs, knees, elbows, shoulders, necks, etc. when we might provide clients with better function if we offered some focus on extension. Here s an example: Begin walking backwards as you inhale for a few counts and exhale for a few. Each time you inhale, lift the crown of your head (your chin should push back and up, you ll feel a stretch on the back of your neck). Relax your head/neck when you exhale. Continue lifting on the inhalation and relaxing on the exhalation. Next, press your shoulder blades down during the inhalation and head lift. Relax everything during the exhalation. Continue for at least 6 reps. During the Extension and Function course we continue to add more extension to our movements and we leave the pool taller than when we arrived. Why do this? Thoracic kyphosis and forward spinal flexion are extremely common musculoskeletal imbalances brought on by prolonged time in some postural positions learned through exercise and/or activity choices, environmental factors, myofascial dysfunction, pain, and psychological stress. Health issues (minor to major) from forward flexion include: musculoskeletal aches and pains breathing problems limited function impaired athletic performance gastrointestinal upsets increased mental stress vision issue decreased organ function joint instability falls inability to move away from midline Standing Extension Standing extension is vital to bladder and bowel function. Bladder and bowel issues are integrally connected to standing balance and walking in children as well as adults. A child learns to accomplish upright standing and walking before gaining bladder and bowel control. A woman experiencing a high-risk pregnancy and placed on bed rest will lose bladder and bowel control within four weeks. An elderly continent individual placed in longterm care for dementia related problems will most often be incontinent within three to four weeks if walking is not encouraged. ATRI Newsletter SUMMER Volume 7 Issue 2

4 Extension for Function PNF Stretching Besides using extension exercises, for all the above reasons, we will use PNF stretching first. This is to assist in full range of motion before attempting muscle repatterning. Proprioceptive neuromuscular facilitation (PNF) stretching techniques are commonly used in the athletic and clinical environments to enhance both active and passive range of motion (ROM) with a view to optimizing motor performance and rehabilitation. The literature sites PNF as the most effective stretching technique when the aim is to increase ROM, particularly in respect to shortterm changes in ROM. A summary of the research findings suggests that an active PNF stretching technique achieves the greatest gains in ROM, e.g. utilizing a shortening contraction of the opposing muscle to place the target muscle on stretch, followed by a static contraction of the target muscle. The inclusion of a shortening contraction of the opposing muscle appears to have the greatest impact on enhancing ROM. When including a static contraction of the target muscle, this needs to be held for approximately 3 seconds at no more than 20% of a maximum voluntary contraction. The greatest changes in ROM generally occur after the first repetition and in order to achieve more lasting changes in ROM, PNF stretching needs to be performed once or twice per week. The superior changes in ROM that PNF stretching often produces compared with other stretching techniques has traditionally been attributed to autogenic and/or reciprocal inhibition (although the literature does not always support this hypothesis). Instead, and in the absence of a biomechanical explanation, the contemporary view proposes that PNF stretching influences the point at which stretch is perceived or tolerated. The mechanism(s) underpinning the change in stretch perception or tolerance are not known, although pain modulation has been suggested. Treatment Plan We must first find the lack of flexibility, then apply PNF stretch to increase ROM. When ROM is compromised, extension to neutral cannot occur long term. After ROM improvements re made we use the breath, coordinated with simple exercises, to train the patient and his musculoskeletal system. Progressions are used to continually move the patient in the right direction. Not all progressions actually progress each patient so a mix of progressions will be used International Aquatic Therapy Symposium June 28-July 2 Sanibel, FL DON T MISS IT! ATRI Newsletter SUMMER Volume 7 Issue 2

5 Deciphering Codes! Beth Scalone, PT, DPT, OCS There is Morse code, zip codes, area codes, computer science codes, genic code, and secret codes. What do all codes have in common? They convert a piece of information into another usually a shortened form or representation. In the rehab world, billing codes and diagnosis codes are how we communicate with insurance companies regarding what the patient is being treated for and specifically the types of skilled service is provided to care for that diagnosis. Understanding the basic components to rehabilitation codes can help aquatic therapists be more efficient and compliant in their documentation resulting in faster and improved claims processing. Let s start with diagnosis codes. For years now we have been using ICD-9 codes to indicate primary and secondary medical diagnoses for which a patient was referred or being treated. According to the Center of Medicare Services the new codes in town, ICD-10 codes, will replace ICD-9 codes on October 1, 2014 ( gov/medicare/coding/icd10 ). ICD-10 codes are already used in UK, France, Australia, Germany and Canada beginning in The basic structure of the ICD-10 code is the following: Characters 1-3 (the category of disease); 4 (etiology of disease); 5 (body part affected), 6 (severity of illness) and 7 (placeholder for extension of the code to increase specificity). This allows for greater specificity of diagnosis. Box 1 below shows the example the ICD-10 code choices for knee osteoarthritis. M17 Osteoarthritis of knee M17.0 Bilateral primary osteoarthritis of knee M17.1 Unilateral primary osteoarthritis of knee M17.10 Unilateral primary osteoarthritis, unspecified knee M17.11 Unilateral primary osteoarthritis, right knee M17.12 Unilateral primary osteoarthritis, left knee M17.2 Bilateral post-traumatic osteoarthritis of knee M17.3 Unilateral post-traumatic osteoarthritis of knee M17.30 Unilateral post-traumatic osteoarthritis, unspecified knee M17.31 Unilateral post-traumatic osteoarthritis, right knee M17.32 Unilateral post-traumatic osteoarthritis, left knee M17.4 Other bilateral secondary osteoarthritis of knee M17.5 Other unilateral secondary osteoarthritis of knee M17.9 Osteoarthritis of knee, unspecified Box 1 Billing codes, also known as CPT-4 codes essentially convey to the payer what type of skilled care was provided. There are over 150 codes utilized by physical therapists. For example aquatic therapy as a skilled intervention has a CPT code of Regardless of whether you perform gait training, therapeutic exercise or manual therapy you would bill if those services were performed in the water. Hydrotherapy a passive modality (whirlpool) has a CPT code of Billing codes have a weighted value with codes considered to require more skill or greater expense to perform are reimbursed at a higher rate. Because billing codes do not always provide enough information about a service provided there are several modifiers which can be added to clarify a patient s circumstance. For example, the KX modifier is added to charges if a patient with Medicare reaches their annual therapy allowance (cap) of $1920 and the necessary criteria for the excep- ATRI Newsletter SUMMER Volume 7 Issue 2

6 Deciphering Codes! tions is documented in the patient chart. Without the KX modifier, Medicare will deny payment. This KX modifier should not be universally applied to all Medicare patients regardless of how much therapy they have received for the calendar year. This excessive use sends a red flag which could elicit an audit. The 59 modifier is utilized to indicate to the payer that two billed codes happened as two separate services and should not be bundled. The bundling leads to reduced payment. For example if you perform therapeutic exercise (97110) on land for half the treatment and aquatic therapy (97113) for half the treatment, if you do not apply the 59 modifier some payers bundle those codes and view them as occurring simultaneously and will only pay for one. In many instances your billing company or department will add this modifier. The 59 modifier also comes into play when billing the group code (97150) and aquatic therapy code (97113). Without the modifier Medicare perceives that it was group water exercise and not one on one skilled aquatic therapy for part of the session and group for the remaining time. A side note about the group code is to always be sure to check with the insurance company, as some companies do not allow group and one-on-one therapy to be billed on the same date. In addition to billing codes associated with payment, Medicare requires codes that provide information about the patient s level of function. These mandatory G codes must be reported at the initial evaluation, on or before the tenth therapy visit and upon discharge in order to receive payment for the other services provided on that date of service. The G code indicates the primary area of function you will be addressing in therapy and each G code must be assigned a modifier to indicate level of impairment. A final set of codes utilized by Medicare are referred to as PQRS (physician quality reporting system). This set of codes indicate various aspects of therapy assessment and plan. For example fall risk screening, BMI calculation, medication review, pain assessment and functional assessment. Each code has specific definitions and rules about when and on whom to report. These codes, although not mandatory, result in a payment penalty if not reported successfully. To learn more about these complex set of codes see Patient-Assessment-Instruments/PQRS/index.html?redirect=/PQRS/. These codes are reported by outpatient clinics only, hospital based departments are not required to report PQRS related codes. Now bringing the diagnosis and billing codes together are LCDs (local coverage determinants). The fiscal intermediaries (the companies who process and pay out Medicare claims) link diagnosis codes to allowed billing codes. Meaning if the diagnosis code does not include as an accepted treatment codes then denial of payment for aquatic therapy occurs. It is important to obtain the list of codes from your regional fiscal intermediary from which your clinic receives payment. This article only scratches the surface. Billing codes are essentially forms of communication. Billing is complex process and it is recommended that clinic seek professional medical billers to assist in generating clean (without error) claims with codes presented in the correct order to maximize reimbursement. Medicare rules change frequently so it is important to stay on top of the changes to be able to train staff on current best coding practices. A TRI has a wide range of promotional opportunities to suit your budget. Whether you are a company, clinic, hospital or have a product you want to promote, we have an option for you. We are currently upgrading our Website and have included the opportunity for you to link to our site with several of the options. For more information contact Monica at ATRI Newsletter SUMMER Volume 7 Issue 2

7 MY FAVORITE PIECE OF EQUIPMENT: LE Resistance Blades Max Resistance Blades 2 ankle cuffs for 69$ High Speed Blades 2 ankle cuffs for 69$ The LE resistance blades Velcro to the ankle in 2 different sizes; max resistance and high speed blades. The blades have applications with a variety of exercises which can be performed in deep water with the assistance of a floatation device and standing in shallow water. You should buy the blades because they allow for greater unrestricted Omni directional ROM compared to other more bulky LE resistance tools. The blades can easily be used for simultaneous LE strength and core control exercises. Exercises such as running, walking, hip circles, straight leg kick throughs, abduction, or any of the standard standing hip and knee exercises. Typically best suited for patients who can tolerate reps of any specific exercise bilaterally without significant soreness, and no loss of form. The only significant downside to the blades that I have found is that they don t provide vertical resistance, however, with slight modifications to water position most exercises can be performed without sacrificing form. Aquatic providers should be aware that typically the blades are best suited for advanced patients who need additional strength gains from more resistance than water resistance and speed alone can provide. Patients who have poor core control or kinesthetic awareness need to be observed closely for appropriate form and biomechanics as most patients initially over compensate by side bending or going into lordosis for increased power production, using the big dumb back and side muscles rather than utilizing finesse muscles. The bottom line; when compared to the bulky hydro-boots which can range from $ and are size dependent, or the single directional use of hydro-fins the resistance blades are an effective and economic tool that every clinic should utilize. Broken down information sections; Pros: You should buy the blades because they allow for greater unrestricted omni directional ROM compared to other more bulky LE resistance tools. The blades can easily be used for simultaneous LE strength and core control exercises. Cons: The only significant downside to the blades that I have found is that they don t provide resistance vertically, however, with slight modifications to water position most exercises can be performed without sacrificing form. Exercises; essentially any of the standard standing hip and knee exercises but here are some of my favorites; Hip Circles: Straight leg gentle or active hip circles clockwise and counter clockwise through available active hip ROM avoiding accessory motions through lordotic motion or side-bending. Single Leg Bicycle: Exaggerated bicycle motion in standing forwards and backwards. Straight leg kick through and extension (Rhonde de Jombe): straight leg fluid transition between hip flexion and hip extension. ATRI Newsletter SUMMER Volume 7 Issue 2

8 MY FAVORITE PIECE OF EQUIPMENT: LE Resistance Blade Abduction: Kicking leg out to the side keeping the foot pointed straight forwards through available active hip ROM (avoid turning up to engage hip muscles.) Perform bilaterally in deep water or single leg standing in shallow. Patients: Typically best suited for patients who can tolerate reps of any specific exercise bilaterally without significant soreness, and no loss of form. Contraindications/Precautions: Typically the blades are best suited for advanced patients who need additional strength gains using more resistance than water pressure alone can provide. Patients who have poor core control or kinesthetic awareness need to be observed closely as most patients initially over compensate for increased resistance using the big dumb back and side muscles rather than utilizing finesse muscles. Conclusion: The bottom line; when compared to the bulky hydro-boots which can range from $ and are size dependent, or the single directional use of hydro-fins the resistance blades are an effective economic tool that every clinic should utilize. Dylan Palmer PTA Physical Therapy Associates, Spokane Washington ATRI Certification Exam Onsite Exam Dates at ATRI Events: Sunday, May 4, Chicago, IL (Rosemont, IL) Wednesday, July 2, Sanibel, FL (Fort Myers, FL) Friday, August 29, Las Vegas, NV (Henderson, NV) Sunday, September 21, Washington, DC (Tysons Corner, VA) Sunday, November 16, Chicago, IL (Rosemont, IL) Certification Q&A Can I use my teaching hours for renewal? The aquatic therapy courses you teach count for continuing education in the following way: Send us a description, objectives, outline, and bibliography of the course and how many hours the course is worth. You can receive continuing education units for teaching it once. For example: If you teach an 8-hour course, you will get 8 continuing education units total - one time only, no matter how often you teach the course. The certification exam is also available online and can be taken any time for your convenience. For more information go to our website and click on Certification Information. ATRI Newsletter SUMMER Volume 7 Issue 2

9 2014 National Aquatic Therapy Conferences May 1-4 Chicago, IL August Las Vegas, NV September Washington, DC November Chicago, IL See for detailed information. ATRI Certification Exam offered in at all National Conferences. Offered Online Anytime! Featured Specialty Certificate Programs at each site, plus PLENTY of General Education! COURSES Chicago, IL May 1-4, 2014, Westin O Hare (Rosemont, IL) For full information go to Please direct questions to or call Specialty Certificate Courses Thursday-Friday, May Day Track 15 hours Adult Balance Training and Post-CVA Specialty Certificate Program Pool Workshop / Beth Scalone, PT, DPT, OCS, ATRIC / Ruth Sova, MS, ATRIC Friday-Sunday, May Day Track 15 hours Upper Quadrant Specialty Certificate Program Pool Workshop / Beth Scalone, PT, DPT, OCS, ATRIC / Terri Mitchell, BA, PTA, ATRIC General Ed Courses Thursday, May 1 Full-Day Courses 8 hours Intro. to Aquatic Therapy and Rehab Pool Workshop / Ruth Sova, MS, ATRIC AquaStretch TM Basics Pool Workshop / Donna Adler, BA, ATRIC / Terri Mitchell, BA, PTA, ATRIC Friday, May 2 Half-Day Morning Courses 3 hours Low Back Pain Dysfunction Land Workshop / Mitchell Intermediate AquaStretch TM for Pediatrics and Neurological Issues Pool Workshop / Adler ATRI Newsletter SUMMER Volume 7 Issue 2

10 Courses - Chicago Friday, May 2 Half-Day Afternoon Courses 3 hours Inflammation & Aquatics Land Workshop / Adler Post-Rehab Core-Centered Stability Progressions Pool Workshop / Lori Templeman, BA Saturday, May 3 Half-Day Morning Courses hours Chronic Conditions Land Workshop / Adler & Mitchell Treatment of Lumber Conditions Pool Workshop / Marty Biondi, PT, CSCS, ATRIC Saturday, May 3 Half-Day Afternoon Courses 3 hours Balance Improvement Interventions Pool Workshop / Biondi Intermediate AquaStretch TM for Lower Extremity Land Workshop / Mitchell & Adler Sunday, May 4 One-Hour Morning Course ATRI Certification QuickPrep Lecture / Sova Sunday, May 4 Half-Day Morning Courses 3 hours Business Side of Aquatic Therapy Lecture / Scalone Gait Training Options Pool Workshop / Biondi 3 Ways to Get Money (or get money back) for the Chicago Conference 1. Sign up to take the schedule below save $450. We expect these courses to have a light registration but they are excellent in content. Three of you can enjoy this deal. Usual tuition: $855 for members, and $925 for non-members. Your tuition for these courses: $405 for members, and $475 for non-members. See below for more information. 2. Get a $300 grant for the 15-hour Upper Quadrant Specialty Certificate. We have four Upper Quadrant grants for $300 each. Usual tuition: $595 for members, and $655 for non-members. Tuition if you win one of the grants: $295 for members, and $355 for nonmembers. See below for more information. 3. Get a $250 grant to take any Complete Conference class schedule you want. We have four $250 grants that weren t used at Professional Development Days. t ATRI Newsletter SUMMER Volume 7 Issue 2

11 3 Ways to Get Money (or get money back) for the Chicago Conference Register for the schedule listed here and save $450. Usual tuition: $855 for members, and 1 $925 for non-members. Your tuition for these courses: $405 for members, and $475 for non-members. Open to three new registrants. No other courses can be traded. Do NOT register online. You won t get the discount and we can t get you a refund. Contact: or call for more information or to register. Thursday May 1 st Intro to Aquatic Therapy (full-day course) Friday May 2 nd Low Back Pain Dysfunction (half-day course) Inflammation and Aquatics (half-day course) Saturday May 3 rd Chronic Conditions (half-day course) AquaStretch for Lower Extremity (half-day course) Sunday May 4 th The Business Side of Aquatic Therapy (half-day course) Grants for the 15-hour Upper Quadrant 2 Specialty Certificate. Usual tuition: $595 for members, and $655 for non-members. Tuition if you win one of the grants: $295 for members, and $355 for non-members. Available to four new registrants. Do NOT register online. Contact to be put in the lottery. Mention the Chicago Upper Quadrant lottery in your . Get a $250 grant to take any class 3 schedule. Usual tuition varies according to number of days registered for. See for tuition and courses. Available to four new or already registered. Do NOT register online. Contact to be put in the lottery. Mention Chicago Any Class Schedule in your . General Information The ATRI website has a copy of the registration form if you don t have one. Go to org/chicago%20may%2014.htm to find it. Please do not register online. You will not receive the specials above if you register online. We are unable to refund registration fees if you register online. Are you already Registered? You re eligible to be in the third special be sure to send Ruth your name If your name is not drawn you will automatically go into an onsite drawing. These special deals cannot be combined together or combined with other promotions. ATRI Newsletter SUMMER Volume 7 Issue 2

12 Featured Colleague Mary Essert, B.A., ATRIC Mary Essert, B.A., ATRIC, has been actively involved in teaching aquatics and exercise since she began by teaching Red Cross swim lessons in She began by expanding into work with individuals with disabilities when she developed some of the first programs at the YMCA in Dutchess County New York. Mary s 60 year history with the American Red Cross is evidence of her commitment to teaching swimming, water safety and water fitness to a diverse population. Her work with Grace Reynolds and the national YMCA led to development of program and certifications for special populations and older adults. Her YMCA career from 1975 to 1994 in New York and Illinois provided a strong base to return to emphasis on seniors with her Move it or Lose It program in aquatic and land exercise. In her time in Illinois, she continued to consult with and work with the YMCA. She also assisted the Illinois Regional Area Agencies on Aging (AAA) in development of wellness classes. Her company also served a dozen nursing homes, retirement centers, the cancer wellness center, and other institutions with staff who taught regular classes. Upon a family move to El Cerrito, California in 1994, she went to work with two physical therapy groups and the Albany school district. This therapy tech experience and study, certification and practice of warm water bodywork techniques, Watsu and Jahara led her to more active teaching with the Aquatic Therapy and Rehabilitation Institute (ATRI). Ms. Essert is current in Aquatic Exercise Association (AEA), ATRI certification, and Instructor for the Arthritis Foundation. She provides CEC s and continuing education products for both AEA and ATRI. In addition, she frequently consults upon request and provides articles for aquatic publications. Her present employment at Conway Regional Health Systems (Conway, AR) allows time for writing, staff training, and teaching regular classes for individuals with arthritis, fibromyalgia, and other conditions several days a week. This profession has allowed me to continue to work effectively with the support of my supervisors and peers. I am very grateful. Because of the aquatic environment, I do not plan to wear a prosthesis. Mary Essert is recognized as a specialist and program expert with supporting products with a particular interest in breast cancer and fibromyalgia. She has developed programs for post polio syndrome. These have led to many workshops and currently updated DVDs which have sold internationally. Mary s list of current and former certifications is long. Honors and awards recognize Ms. Essert s professional contributions to aquatics. These include the International Swimming Hall of Fame John K. Williams award in Adapted Aquatics and the Paragon Award, the Illinois and Arkansas Governor s Council on Fitness Leadership, and the Lifetime Achievement awards from AEA, ATRI, and USWFA. Colleagues credit her mentorship and strong networking skills as major contributions to the industry. Ms. Essert has spent a lifetime encouraging physical activity. Water has been the principle medium for Ms. Essert s own regular exercise. She said, I have worked in the water almost daily through two bouts of chemotherapy totaling 16 months in 1980 (breast cancer) and 2007 (lung cancer and sarcoma), 35 sessions of radiation in 2007, and in 2013, a complete right arm amputation (sarcoma). For me, water is a panacea, a place where body, mind, and spirit thrive. Every day I try to share this good news with others. You can meet Mary and see her teach by joining us in Sanibel for Symposium. ATRI Newsletter SUMMER Volume 7 Issue 2

13 Featured Course: Balance Training for Healthy Aging By: Laurie Denomme, B. Kinesiology, FAFS & Helen Tilden, RN Balance is not something we think about in our younger years as we dodge and dart to avoid being caught in a game of tag, walk heel-toe on a narrow curb or race up and down a flight of stairs. Our balance is always there for us to prevent or minimize falls. However, as we age, balance tends to become something we think about. Multiple systems have an effect on our balance. Impairment in one or more of these systems increases the risk of falling. Examples of deficits that impact balance include: Damaged or impaired sensory processes (visual, vestibular, proprioceptors), Musculoskeletal changes (reduced flexibility and ROM, loss of strength), Reduced ability to anticipate/adapt to posture and balance needs (cognition), Inadequate neuromuscular response (slowed or no motor response). Therefore, although most falls are associated with older adults in the literature, aging is not the only factor to consider. Trauma or disease processes, may occur at any age and contribute to balance deficits. Consequently, the addition of balance training into any exercise program is an essential healthy aging. Balance Strategies When the center of gravity (CoG) is not in alignment with the base of support (BoS), body movements occur to return the body back to the start position or transfer to another direction. There are several strategies to maintain balance but the body most often makes reaction corrections from the ankle, hip, or with a step. Ankle strategy Small changes are made through the ankle to reposition the CoG over the BoS. This occurs often when on uneven or unfamiliar surfaces. Example: sand, gravel, uneven pavement. The ankle works with the arch of the foot to provide flexibility and stability. Hip strategy Larger changes are made through a multi-joint strategy from the hips and usually occur when the head and hips move asynchronously. This strategy is often employed when standing on small support surfaces, such as a curb or small step. Step strategy When unable to reposition the CoG with the ankle or hip strategy, the body will reposition the BoS under the CoG by taking a step. Often the hands and arms are used to help balance the body in a reach out (usually forward), to prevent or break the fall. Aquatic Exercise Progressions Exercises can be designed to resemble the movement patterns of the ankle, hip and step strategy to enhance ability to control body movement. Let s take a look at an example: Single Leg Balance Reach Stand on one leg and reach with the opposite foot: 1. Front (anterior) and back (posterior), from 12 to 6 o clock. 2. Side to side (right and left lateral), from 3 to 9 o clock. 3. Along the anterior and posterior lateral angles, from 2 to 8 o clock and 10 to 4 o clock. To change the purpose of the exercise, try these simple modifications: 1. To target ankle mobility, reach the moving foot at ankle height. To engage more motion at the hip, increase the height of the reach to knee or hip level. ATRI Newsletter SUMMER Volume 7 Issue 2

14 Balance Training for Healthy Aging 2. First, allow clients to self-select distance, then evaluate their ability to increase the length of the reach. 3. Try holding on to a pool wall and see how the body moves differently when it senses this additional source of stability progressing to free standing with no props for support. 4. Improve strength by adding speed to the moving leg to work against the resistance of the water. Smaller range of motion, quick movements front to back, side to side, or a mix of the combinations around the clock will build ankle, knee and hip strength. 5. Add turbulence to any of the progressions to enhance balance whether stationary or moving. 2 o clock 8 o clock Supporting Research & Resources Gray Institute Functional Video Digest DVD. Balance: The Time of Transformation available at www. grayinstitute.com Mansfield, A., Peter, A, L., Liu, A., Maki, B.E. (2007) A perturbation-balance training program for older adults: study protocol for a randomized controlled trial. BMC Geriatrics 7:12. Article retrieved from biomedcentral.com/ /7/12 Melzer, I., Elbar, O., Tsedek, I., Oddsson, L. (2008) A water-based training program that included perturbation exercises to improve stepping responses in older adults: study protocol for randomized controlled cross-over trial. BMC Geriatrics 8:19 retrieved from Orr, R. et al., Efficacy of progressive resistance training on balance performance in older adults: a systematic review of randomized controlled trials, Sports Med, 2008; 38(4): Abstract retrieved from ncbi.nlm.nih.gov/pubmed/ Join co-author Laurie Denomme in the Power Balance for Healthy Aging workshop presented in Chicago, Illinois at the ATRI National Aquatic Therapy Convention November Laurie holds a Bachelor of Kinesiology and is a Fellow of Applied Functional Science through the Gray Institute. Creator of several best-selling aquatic exercise education products, she has presented internationally at AEA, ATRI, IDEA and other conferences, voted Top 10 presenter at AEA s International Conference in both 2011 and 2012, and is the recipient of the AEA 2013 Global Fitness Professional Award. Visit or ATRI Newsletter SUMMER Volume 7 Issue 2

15 The FREE ATRI elist Want to stay up to date with current practice ideas AND pool information? Join the ATRI elist it s FREE! Go to and click on ATRI elist in the tabs in the left column and follow the directions. You can unsubscribe the same way anytime you want. Here s a sample thread on SHOULDERS: Anyone have any numbers or information on shoulder injuries caused to people who are too weak to stabilize their shoulders while doing exercises to strengthen their shoulders. I m having a hard time convincing instructors that they shouldn t be using floating devices, as opposed to nothing or small non-buoyant equipment. One of our kinesiologists says there is no issue because there s no risk of impingement because they don t have the musculature to cause a problem. What other kinds of shoulder injuries could be caused by working shoulders when participants aren t strong enough to maintain stability in the joint? Marni Hill Response 1: Your kinesiologist has a very poor understanding of how the shoulder works. If the rotator cuff is too weak to stabilize the head of the humerus, then elevation of the arm (flexion, scaption or abduction of the shoulder) will cause the deltoids to jam the humeral head into the acromion, which will cause impingement. I always look at basic motion without resistance first. If this can be done without altering shoulder mechanics (look for hiking up or shrugging the shoulder), then resistance may be added. If not, then do not add resistance either on land or in the water. When teaching a class, it might be good to go through the exercise or motion without resistance first to warm up. Then you can instruct your clients to add resistance if if feels too easy and they can stabilize the shoulder properly. Another thing to consider is that about 1/3 of the population has what is described as a hooked acromion, anatomy, in which the tip of the acromion process has a hook shape, encroaching into the subacromial space. This population is more prone to impingement. You cannot tell by looking or touching who has a hooked acromion, so it is good to assume that a portion of your clients will have this anatomy and should avoid repetitive overhead elevation or abduction in the internally rotated position. If there is pain with shoulder motions, you may instruct your clients to try the exercise in the externally rotated position, which increases subacromial space. Personal trainers and kinesiologists who push their clients beyond what their anatomy can handle are good for my business as a physical therapist, but I wish I didn t have any patients who came to me with problems that came from overzealous exercise personnel. It would be wonderful if we could get the word out to look at the basic motion first, then add resistance only when appropriate. Corrine Dutto, MPT, OCS Response 2: Hi Marni, I would disagree with your kinesiologist. A person without enough rotator cuff strength to hold the humeral head down in the glenoid against the upward force of buoyancy is still at risk for impingement even if the arm never goes over 90 degrees. The buoyancy device with push the humerus upward jamming the humeral head under the acromion, impinging the supraspinatus tendon, the bursa and long head of the biceps. Buoyancy equipment devices such as short bars/ dumbbells or pushing down noodles without appropriate scapular stabilization and humeral head stability will lead to injury because of faulty mechanics that ensue. With deep water exercise there is an added risk especially if the person does not have adequate floatation, they will over use UE to keep their head above water. ATRI Newsletter SUMMER Volume 7 Issue 2

16 The FREE ATRI elist I don t have aquatic based research to prove this but as a DPT, orthopedic certified specialist who has done aquatic therapy for over 20 years that is my expert opinion. When we perform exercise correct alignment and movement patterns should always be observed whether we are in the water or on land. Beth Scalone, PT, DPT, OCS, ATRIC Okay and here is the shameless plug: Terri Mitchell PTA and I are teaching and upper quadrant specialty certificate course for ATRI May 2-4 in Chicago (go to for details) which will cover various techniques and exercise progressions for a variety of upper extremity and quadrant diagnoses. Response 3: You most definitely can injure the shoulder with miss use of buoyant dumbells. If the scapular depressors are weak then control is missing to push the dumbell under and over use of the UT occurs, the same thing happens with control the upward motion of the dumbell, Chronic impingement can tear the tendon, I have seen many patients in physical therapy with shoulder injuries from buoyant dumbell equipment. You are correct, small less buoyant resistive equipment is the better choice. Susan Finigan Grants for the 15-hour Chicago Upper Quadrant Specialty Certificate! Usual tuition: $595 for members, and $655 for non-members. Tuition if you win one of the grants: $295 for members, and $355 for non-members. Available to four new registrants. Do NOT register online. Contact to be put in the lottery. Mention the Chicago Upper Quadrant lottery in your . ATRI Newsletter SUMMER Volume 7 Issue 2

17 My Favorite Pool Exercises As a practicing physical therapist in Los Angeles, I have found that the pool is my favorite practice setting and can be a healing mediums for a variety of different impairments. I quickly learned that there is no appropriate one size fits all exercise. Exercise prescription is based off of in depth observation and identification of the patient s movement dysfunction. However, I have noticed my patients with low back pain and radiating symptoms into the lower extremities have success with a spinal stabilization program in the pool. There has been many research studies confirming that people with low back pain have delayed or no activation of their spinal stabilizers (transverse abdominus, rectus abdominus, obliques, multifidus and the pelvic floor) during functional movement. However before determining the direction of the spinal stabilization program, I must determine which muscles are short/tight and which muscles are elongated and weak through movement observation, postural analysis, and palpation. Exercise 1: supine Pilates scissors with kick boards. The patient is lying on the back at the surface of the water with flotation support by a kick board under each hand and forearm region. The patient needs to flex their abdominal muscles to stay stable and perform lower limb movements such as flies or scissors. Look at the belly button area to correct any spinal rotation and palpate to correct rib flaring. This exercise is appropriate for those who tend to carry themselves in lumbar spine extension and anterior pelvic tilt. They also tend to have overactive (hypertonic) lower paraspinals in this lordotic area. This exercise trains them to shorten their abdominal muscles and engage them during movements and decrease unnecessary spinal rotation during gait. Exercise 2: Noodle forward lean planks: the patient is standing in water a little above the umbilical area in neutral spine. The patient will hold a noodle in front of them with both hands and slowly fall forward with control until they are up on their toes and there is no hinging at the lumbar spine or hips. The patient is leaning forward but straight in alignment. The patient will hold this plank position stable while slowly and in a small range of motion do alternating marching by bending each knee back. Stepping away from the center and back towards the center can be performed as well. The abdominals will be eccentically working to avoid a dip in the spine and the paraspinals of the lumbar spine will have to be activated to avoid rotation. This exercise is appropriate for those who tend to have a flat lumbar spine, in a posterior pelvic tilt, and short hamstrings. Alice Murphy, DPT Questions: ATRI Newsletter SUMMER Volume 7 Issue 2

18 Just imagine. You ve spent the day in classes - you ve learned something new, picked up a number of great tips to make your sessions even better... And you ran into that nice person you met once before... the one whose address you lost... It s the end of the day, and you have a wonderful feeling of accomplishment! Take a look at that view... and breathe deeply... does life get any better than this? Register NOW!! June 28-July 2 Sanibel, FL Our next issue will deal with Hips Functional Core Balance Documentation Contributions are welcome... Send your thoughts and comments to Ruth Sova at ATRI Newsletter SUMMER Volume 7 Issue 2

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