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Sport-Specific Aquatic Rehabilitation

Wicker, Anton MD, PhD, MS, MSc

Current Sports Medicine Reports: March-April 2011 - Volume 10 - Issue 2 - p 62-63
doi: 10.1249/JSR.0b013e31820f233a
Invited Commentary

Department of Physical Medicine and Rehabilitation, Paracelsus University Salzburg, Salzburg, Austria

Address for correspondence: Anton Wicker, MD, PhD, MS, MSc, Department of Physical Medicine and Rehabilitation, Paracelsus University Salzburg, MuellnerHauptstrasse 48, A-5020 Salzburg, Austria (E-mail:

In sport-rehabilitation processes, especially treating high-level athletes, it is a fact that the athlete's foremost desire is to return to competition or training as soon as possible. In spite of the injury, the athlete should be able to train sport-specifically as soon as and as intensively as possible.

The following three aspects should be in optimum harmony with each other:

  1. The injured structure of the body should be given specific treatment.
  2. Attention should be given to the position of the injured anatomic structure in the chain of motion, pertaining to the specific type of sport. Moreover, regulation of motion and the sensomotor system should be given attention.
  3. It should be ensured that the athlete's stamina is not impaired, especially in terms of strength, speed, and endurance. A training program specifically designed to maintain the athlete's stamina should be pursued, as far as possible, even while the athlete is affected by the injury.

In modern rehabilitation centers, an important aspect of treatment is the personality of the injured athlete. The treatment should include conscious visualization of the motion pertaining to the specific type of sport. For example, ski-specific technical motions can be recalled in the present time and made available to the patient at the therapeutic swimming pool (with the help of videotaping techniques). This is one of several aspects of so-called "mental training." A rehabilitation program for athletes should be based on the principles of training and motion. The program should include exercises, training instructions, and corrective measures specially adapted to the sport and the specific injury.

Water is an excellent therapeutic medium for this purpose, because underwater therapy takes the reduced stress-bearing capacity of the injured structure (e.g., the knee joint) into account, and yet it permits the patient to drill motion patterns that are characteristic for various sports.

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Specificity of Water in Therapy

The concept of underwater therapy offers hitherto unknown possibilities of rehabilitation. Several metabolic and kinetic factors can be influenced by using various effective elements of water, such as buoyancy, temperature, resistance, hydrostatic pressure, and electrolyte content. It is the reduced weight of the human body in water that makes it possible to mimic sport motions, even though the injured structure (e.g., the knee joint) cannot be subjected to normal stress. The various kinetic factors affected by the injury and by surgical trauma undergo a phase of repair during which certain reactions are set in motion. These reactions have major effects on the mobility, the loading capacity, and the strength of the joint. An additional cumulative effect of the above-mentioned factors is that the central regulation of motion is altered. The patient loses confidence and starts to feel afraid. Fear essentially influences the course of motion, in particular the timing of motion. The consequences of fear can be observed immediately at a clinical level. The dynamic-motor stereotype of motion, including that of automatized patterns of motion such as ordinary walking, undergoes marked changes. Reducing stress on the body helps to reduce fear. Fear disturbs the rhythm of motion, and rhythm is the primary criterion for the evaluation of motion. Additional criteria are flow, precision, stability, force, speed, and extent of motion. A summation of these factors causes what is known as the harmony of motion.

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Reducing Fear and Training Coordination of Motion

Owing to mechanical and nociceptive stimulation of sensory nerve endings (Pacini's, Ruffini's, and Golgi's organs, free nerve endings, and muscle spindles) from the injury, as well as from surgical trauma, the activity of motor neurons and the strength of the involved muscles are downregulated such that these factors adjust to and protect the weakened tissue. When stress is reduced, the muscles, as well as the psyche, relax. What is more, the patient experiences less pain. Consequently, normal gait without significant limping is achieved early in water, a fact that counteracts the development of stereotyped patterns of motion. If the patient who has sustained an injury of the lower limb or of the trunk consistently trains to walk in water during the first 4 wk after surgery, the following results will be achieved:

  • Training of symmetry and a less pronounced tendency to develop stereotyped patterns of motion.
  • Better coordination of the trunk, arms, and legs, and it is possible to drill the entire chain of motion.
  • Safe enhancement of kinesthetic perception because of the buoyancy of the human body in water and the resistance of water.
  • Early commencement of proprioceptive training (position, extension, direction, speed, acceleration, and position of body parts in space) and favorable influence on the sense of equilibrium.
  • Rhythm training and a favorable effect on the timing of motion.
  • Improved elasticity and sensitivity of the entire musculature of the leg and the trunk.
  • Enhanced flexibility of the lower extremity from massage and hydrostatic.
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Inner Training

Water is an entirely new world of experience for the patient. Underwater therapy may be regarded as a step toward so-called "inner training." The method of inner training is based on a practical philosophy whose aim is to arouse and enhance spiritual and creative abilities by meditation and perfecting the execution of physical exercises. Inner training is a valuable adjunct to conventional training and treatment because it takes not only external aspects, but also the athlete's subjective world of experience, into account. Inner training enhances the ability to relax and regenerate and reduces the subjective stress associated with training and treatment.

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Sport-Specific Imitative Training

It is known that the brain is aware of motion patterns. Hence the major goal of rehabilitation should be purposeful application of water in a manner that enables the athlete to execute motion patterns pertaining to his or her daily life, as well as specific motions associated with his or her sport. The buoyancy of the human body in water makes it possible to perform natural motions that are executed in three-dimensional fashion, in a spiral pattern and via several joints, in spite of the fact, that the injured joint (e.g., the knee) is too weak to sustain ordinary stress levels. Thus performing specific technical sports movements in water permits early commencement of a training program designed on the basis of motion techniques that are specifically adapted to the injury. Moreover, the program is designed such that it favorably influences neuromuscular patterns of motion.

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Possibilities of Video Training in Water

Sport-motor video training is defined as video-based learning (in rehabilitation, it is a relearning process) of motor skills. The information obtained by video documentation has two aspects in the rehabilitation process: The sport-specific technique from before the injury is presented and is intended to communicate exactly what should be done in the water (video instruction), and the presentation informs the athlete about what he or she actually has done (video feedback). Mentally, the rehabilitation training program should be performed as if the techniques were being performed during regular training before the injury.

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Training (Mimicking) Sport-Specific Motions in Water

It is possible to imitate sport-specific motions, like skiing or other sport motions, in the pool. For example, an injured alpine skier can run the downhill slope mentally such that his or her motor memory is trained and the information is stored. However, the neuromuscular aspects of motion can be practiced several times, and the rhythm of sport-specific imitative exercises can be preserved without the normal loading stress (buoyancy).

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Training of Stamina

In addition to being suitable for training flexibility and coordination of motion, water eminently is useful for training stamina. While carrying out basic stamina training in water, we use various aids. One such aid is a life jacket fitted with rubber bands. These bands are fixed to the edge of the pool such that the athlete is forced to swim against insurmountable resistance. The patient floats on his or her back and performs backstrokes, primarily using his or her arms. By training in extensive or intensive mode in this medium, the athlete will be able to minimize loss of stamina during rehabilitation.

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Our experience has shown that applying various possibilities of underwater therapy and combining these techniques with a rehabilitation concept specifically designed to suit the type of injury and the injured athlete improves the quality of rehabilitation and helps the athlete return early to competitive training after an injury or disease. The athlete knows that he or she is injured but has the feeling that he or she still is in a training process.

© 2011 American College of Sports Medicine