Aquatic Therapy in life-style diseases

Life-style diseases

Aquatic therapy (AT) plays a crucial role in managing and preventing lifestyle diseases, offering a unique and effective approach to improving health and well-being. Lifestyle diseases, such as cardiovascular diseases, immuno-metabolic diseases, and musculoskeletal disorders, are often linked to sedentary lifestyles, poor dietary habits, stress, chronic (nociplastic) pain, sleeplessness. AT provides a variable-impact, versatile, and enjoyable means of addressing these health issues.
One of the primary benefits of aquatic exercise is its ability to promote cardiovascular fitness. Water resistance provides a natural form of resistance, requiring the body to work harder during movements. This enhances cardiovascular endurance, lowers blood pressure, and improves circulation, reducing the risk of heart-related conditions. Additionally, aquatic exercise is suitable for individuals with joint problems or arthritis, as the buoyancy of water reduces impact on joints, facilitating pain-free movement and promoting joint flexibility. For individuals with diabetes, aquatic exercise contributes to better blood sugar control. Regular sessions in the water help enhance insulin sensitivity, making it an effective component of a comprehensive diabetes management plan. The buoyancy of water also reduces the impact on the feet and lowers the risk of injuries, particularly important for those with diabetes-related neuropathy; with mechanical low impact one can achieve a physiological high impact. One could say: the more co-morbidities, the better AT.
Variable-impact means that exercise intensity can be chosen from passive to high intensity impact training, depending on the goal: Aqua-T-Relax, Clinical Ai Chi, Aqua-T-Fit, motor-cognitive exergaming and BRRM are interventions that will be used in this variable-impact approach.
Underlying mechanisms to be addressed are low grade systemic inflammation, the heart-brain axis, the gut-brain axis, cerebral health (blood flow and large scale neuronal networks) and the proprioceptive system to decrease central sensitization

Clinical Ai Chi
Original Ai Chi has been developed by Jun Konno, the late owner of an aquatic fitness institute in Yokohama, Japan. Around 2000 Ai Chi quickly became popular because of it’s simplicity and effects. Ai Chi is mindful and active, including 20 continuous slow and broad movements (kata’s), accomplished without force. Ai Chi focuses on breathing, upper limb movement, trunk (mobile) stability, lower limb movement, balance and coordinated total body movements. The basis of support is gradually narrowing and challenge the centre of gravity progressively. Different protocols exist, consisting of a choice of the 20 kata’s and/or a different amount of repetitions, see e.g. at www.clinicalaichi.org
Clinical Ai Chi is adapted to the possibilities of a person with a musculoskeletal and/or neurological problem. The elements of Clinical Ai Chi should fit in a custom-made treatment programme and be the result of a clinical reasoning process. Ai Chi is a postural activity in which transfers of the centre of gravity, reaching with arms, supporting activity of legs and continuous concentric –eccentric contractions are characteristic. Most of these characteristics are related to static – and dynamic balance control and might influence motor control to prevent falling
Clinical questions could be: “can Ai Chi be adapted to facilitate hip-strategies in patients with chronic low back pain”, or “can Ai Chi be adapted to Parkinson patients in order to train medio-lateral stability”.

Aquatic motor-cognitive therapy
This is a very recent development, based on the emerging notion that movement is important for brain functioning: brain vasculature health and brain plasticity. Both moderate aerobic exercise and high intensity interval training (HIIT) increase blood flow, also in the brain. At comparable physiological intensities, brain blood flow is higher in water than on land. Higher flow velocities increase immuno-metabolic activity of endothelial cells: supporting plasticity processes, e.g. related to executive functions. Executive functions are cognitive control processes, governing goal-directed motor control, especially during complex, novel or ambiguous situations. These situations can often be translated as playing/exergaming with therapeutic intentions, which also happens in enriched environments. In one sentence: the added immuno-metabolic effects of (intensive) exercise in water opens a door to include cognitive elements – especially executive functions - during motor control in complex situations. These situations often have an equilibrium component and might be difficult to achieve on land when working with patients with increased fall risk. A clinical question could be: “are you able to walk in 4 different ways, always 3 steps, and try to mix these 4 ways in as many ways as you can”? Memory and problem solving are the cognitive functions that are involved in this assignment of gait variability.
It has become clear that important effects on neuroinflammation can be achieved, which might be of utmost importance in various life-style diseases.

Passive manual handling
It is easy to handle another person in - warm – water. This has led to a huge amount of passive handling concepts. The most known concept internationally is Watsu, or water Shiatsu, a wellness concept based on influencing meridians. Clients are handled with choreographic elements, which can lead to deep relaxation and happiness. Many variations exist: with or without music, under water or at the surface, without or with flotation aids.
Massage techniques are often included in a session, depending on massage skills of the “giver”.
Passive manual handling can be used to make persons mindwander or daydream: activating one of the important large scale brain networks: the default mode network. Another option is to ask persons to concentrate on the movements and feel them: proprioceptive perception is used which is import in decreasing nociceptive stimuli. The clinical question then could be: “close your eyes and feel which movements your low back is making and try to interpret these as harmless”.
Manual skills can be used also without a choreography: the patients just float with flotation aids and the therapist applies manipulations from manual therapy techniques like e.g.
Kaltenborn, Mulligan, osteopathy, chiropraxy. Scientific evidence of all passive manual handling is scarce

Cardiovascular training
Evidence is overwhelming: cardiovascular (endurance) training in water can have the same short-term and long-term physiological adaptations as cardiovascular training on land. The aquafitness industry created a massive amount of workout variations. The principles are simple though: at least 20% of skeletal muscles have to be used for some time and in some intensity in order to create an oxygen debt: the stimulus for an increase in cardiac work.
Maintaining a certain level of functional endurance doesn’t need much work, according to various norm values, e.g. those of the American College of Sports Medicine. Increasing cardiovascular fitness with classical endurance training needs at least some 20 minutes at minimum 50% of the maximal oxygen uptake (VO2max). A time-efficient way is High Intensity Interval Training (HIIT). The original program exists of 8 bouts of 20 seconds 90% VO2max with 10 seconds of rest in between the bouts: this takes 4 minutes. Cardiovascular training becomes increasingly more important in the treatment of a wide variety of diseases: not only for those that have a sedentary life-style (pain, muscle weakness, spasticity etc), but also for those that have a disease which is linked with neuroinflammation, like Alzheimer or multiple sclerosis. A pool offers the possibility to train for those that are restricted on land.
A clinical question could be: “can you find a level of exertion in which you are a little out of breath during the next jumping exercises?”.