Loading of the Lower Limb when Walking Partially Immersed: Implications for Clinical Practice

doi:10.1016/S0031-9406(10)61377-6

Physiotherapy

Volume 78, Issue 3, 10 March 1992, Pages 164-166

https://doi.org/10.1016/S0031-9406(10)61377-6 Get rights and content

Summary

The hydrotherapy pool is commonly used by physiotherapists, both in the early stages and in the later progression of partial weight-bearing walking re-education. Progression is made by decreasing the depth of the water and by increasing the speed of ambulation. Because no work has been done on this aspect of hydrotherapy, there are no data available to work out the degree of partial weight-bearing during the pool treatment of specific patients.

A force-measuring platform was constructed which would measure the loading when a subject walked across it. This platform could be used on dry land but could also be placed in the bottom of the pool. Nine subjects were asked to walk over the platform on dry land and also in the pool at different speeds and in various depths of water while readings of the loadings were recorded.

The results obtained will enable physiotherapists to plan a progressive weight-bearing exercise programme of known loadings for the lower limb of any patient. It will also provide a method of measurement of loading which could be used in the evaluation of different weight-bearing treatment regimes.

References (3)

B Davis et al.
Hydrotherapy in Practice
(1988)

There are more references available in the full text version of this article.

Cited by (120)

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This study aimed to investigate the effects of water-based exercise (WBE) on body composition.
Trials published up to October 28, 2022 were searched using the PubMed, EMBASE, Web of Science, Cochrane, Scopus, and Ovid databases. Randomized controlled trials of healthy adults published in English, comparing WBE and control groups, were included. Other studies with different research designs and participants with medical diagnoses were excluded. The main outcome measures were body weight (BW), body fat mass (BFM), body fat percentage (BFP), lean mass (LM), and skeletal muscle mass (SMM).
Overall, 17,458 potential studies were identified. After a closer inspection, 79 full-length articles were considered for further screening. Finally, 20 studies, involving 565 participants, were included in the meta-analysis. The WBE was beneficial in reducing BW, BFM, and BFP and increasing LM and SMM. Subgroup analyses were conducted based on different exercise intensities and times per week. Moderate- or moderate-vigorous-intensity exercise helped improve body composition, while lower-intensity WBE or aquatic high-intensity interval training (HIIT) seemed less helpful. Training for <120 min/week was insufficient to improve body composition. Training for >120 min/week was associated with improvements in body composition.
Moderate- or moderate-vigorous-intensity WBE helps improve body composition. Adults are encouraged to exercise for >120 min/week.
The effect of aquatic High Intensity Interval Training on cardiometabolic and physical health markers in women: A systematic review and meta-analysis
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We performed a meta-analysis of randomized controlled trials (RCTs) assessing the effect of Aquatic High Intensity Interval Training (AHIIT) on cardiometabolic and physical health markers in women.
Systematic search used 7 databases (MEDLINE, PubMed, SPORTDiscus, Cochrane, Embase, CINAL complete, PsycINFO). The Physiotherapy Evidence Database (PEDro) score was used to evaluate the methodological quality of the studies. Clinical trials compared AHIIT with a control group that receive no exercise training. We integrated randomized controlled trials published in English, and participants were women aged ≥18 years. The outcome of interest was the change in cardiometabolic and physical health markers.
Among 242 articles screened, 18 articles (13 trials) were included in this meta-analysis comparing AHIIT (n = 261) with a control group (n = 215). The median PEDro score was 5.5 out of 10 (range, 4–8). AHIIT significantly improved peak oxygen uptake (Hedges' g 0.610; 95% CI 0.277–0.943; P < 0.001), reduced resting heart rate (Hedges' g −0.495; 95% CI -0.866 to −0.124; P < 0.05), as well as chair to stand test. (Hedges’ g 0.548; 95% CI 0.019 to 1.077; P < 0.05).
AHIIT has a moderate effect in improving cardiometabolic and physical health markers in women.
A review on muscle activation behaviour during gait in shallow water and deep-water running and surface electromyography procedures
2020, Journal of Bodywork and Movement Therapies
Citation Excerpt :
Drag forces depends of the drag coefficient, the projection of the frontal area of the body, the water density, and the square of the velocity. For this reason, the greater the velocity of displacement, the greater the drag force, and consequently the greater the weight loads incurred (Gitter and Stovlov, 1995; Harrison et al., 1992; Orselli and Duarte, 2011). Therefore, when walking in water there is a small variation in partial weight bearing, especially at faster speeds.
Surface electromyography (sEMG) can provide information on muscle activation patterns during gait.
To characterize electromyographic activity during gait in shallow water and during deep-water running compare to on land and to review and analyse underwater surface-electromyographic (sEMG) procedures.
Eight databases (MEDLINE, EMBASE, WEB OF SCIENCE, SPORT Discus, CINAHL, SCOPUS, SCIELO, and LILACS) were searched from their inception to the December of 2019.
The selected studies had to be related to electromyographic analysis of gait in an aquatic environment.
The studies that met the inclusion criteria were reviewed by two independent reviewers and divided into four groups.
Ten studies met the inclusion criteria. Lower muscle activation was found with treadmill water walking compared to treadmill land walking. With deep-water running, the leg muscles (tibialis anterior and gastrocnemius lateralis) have lower muscle activation when compared to on land running, but the trunk and thigh muscles have higher activation.
If gait is performed on an aquatic treadmill, the muscles assessed had lower muscle activation when compared to land. During deep-water running activities, lower activation of the distal leg muscles and a higher activation thigh muscles were found when compared to on land. Studies did not follow standard processes in sEMG procedures.
Comparison of underwater gait training and overground gait training for improving the walking and balancing ability of patients with severe hemiplegic stroke: A randomized controlled pilot trial
2020, Gait and Posture
Walking training is an essential intervention to improve the function in stroke patients. However, only a limited number of gait training strategies are available for stroke patients with relatively severe disabilities.
Is underwater gait training or overground gait training more effective in severe stroke patients?
A total of 21 patients with severe hemiplegic stroke were randomly assigned to the experimental and control groups. All participants (n = 21) received 60-minute sessions of general physical therapy, 5 times a week for a period of 12 weeks. Additionally, the experimental and control groups underwent underwater and overground walking training, respectively, for 30 min twice times a week for 12 weeks. Postural assessment for stroke score, center of pressure path length and velocity, step time and step length difference, and walking velocity were measured before and after the 12-week training.
Both groups showed a significant decrease in the center of pressure path length and velocity after the intervention compared to the values before the intervention (p < .05). However, there was no significant difference in the center of pressure path length and velocity changes after training between the two groups (p > .05). In the walking variables, the step length difference changes after training between the two groups showed a significant difference (p < .05). In the experimental group, the step length difference increased after the intervention compared to that before the intervention (+4.55 cm), whereas that of the control group decreased (-1.25 cm).
In severe stroke patients, underwater gait training can be effective for improving balancing ability, but it may be less effective on the improvement of gait function than overground walking.
Clinical trial registration number: KCT0002587 (https://cris.nih.go.kr)
Kinetic parameters during land and water walking performed by individuals with Down Syndrome
2020, Gait and Posture
Citation Excerpt :
The lower Fz pattern observed in the aquatic environment may be attributed to the physical characteristics of water, such as buoyancy effect and water drag force during movement. In the present study, a reduced apparent weight of 73% (xiphoid process depth) was verified, which is in accordance to the literature analyzing individuals without DS [22–23]. This reduction implies a much lower vertical load when the participant is in contact with the platform.
Down Syndrome (DS) is a genetic condition presenting delay in acquisition of main motor milestones, such as walking. Although studies have been investigating the biomechanical parameters during land walking performed by individual with DS, the literature is scarce regarding kinetic parameters analysis in this population, specially during water walking.
This study sought to assess the vertical ground reaction force (Fz) of walking performed in water and on land at different speeds by individuals with DS.
Fourteen adults with DS (age: 27.9 ± 7.9 years; body mass: 58.4 ± 12.9 kg; height: 1.4 ± 0.1 m, body mass index: 29.2 ± 5.4 kg.m^-2) completed two sessions of data collection, one on land and another in aquatic environment. The protocol consisted of walking performed at three self-selected speeds (slow, comfortable and fast) in randomized order. The Fz was assessed with a waterproof force plate in each condition. Two-way repeated-measures ANOVA (environment and speed), with Bonferroni’s post hoc tests, were used for analysis. A significance level was set as α = 0.05.
Significant differences were observed between environments (p < 0.001), with reduced first peak of Fz (68-73%), second peak of Fz (66-70%), loading rate (75-78%) and impulse (40-41%) in the water walking for all speeds analyzed. In the aquatic environment, no significant difference was observed for the first and second Fz peaks with the increasing speed of walking. Moreover, the loading rate significantly increased (p = 0.019) as the impulse significantly reduced (p < 0.001) in the higher speeds.
Individuals with DS present reduced Fz outcomes during water walking in comparison to land. Therefore, water walking may be performed by individuals with DS with safe vertical loads on lower limbs regardless the self-selected speed for rehabilitation, correction of gait and training purposes.
Water-based exercises in pregnancy: Apparent weight in immersion and ground reaction force at third trimester
2019, Clinical Biomechanics
Citation Excerpt :
Therefore, aquatic exercises may be performed with a high neuromuscular load (Alberton et al., 2014b) combined with a low osteoarticular load due to the buoyancy, which promotes a reduction in the apparent weight (AW) of the immersed individuals (Harrison et al., 1992) and can help pregnant women to remain active until the end of pregnancy decreasing the chances of injury. In this regard, literature reports AW reduction around 70% for young individuals immersed at xiphoid process depth (Alberton et al., 2013; Harrison et al., 1992). Only one study was found in literature (Finkelstein et al., 2004) investigating this outcome in pregnant women (ranging from 16 to 36 gestational week).
The morphological alterations during pregnancy may affect the biomechanical loads during exercise practice. Aquatic exercises may suit pregnant women, who are recommended to exercise with low vertical ground reaction force loads. Therefore, the study aimed to determine the apparent weight reduction during immersion and the vertical ground reaction force of three specific water-based exercises in pregnant women at the third trimester.
Eleven pregnant women volunteered to take part in the study [32.0 (SD 1.3) weeks, 28.1 (SD 5.7) years, 72.5 (SD 10.1) kg]. The protocol started with the participants immersed to the xiphoid process depth for the apparent weight assessment. Then, three water-based exercises (stationary running, frontal kick and butt kick) were randomly performed at a pre-selected cadence, with 5-min interval. The vertical ground reaction force was measured in each exercise and peak, impulse, contact time and swing time were determined. Repeated measures ANOVA was used (α = 0.05).
The apparent weight reduction resulted a mean of 82.9 (SD 6.5)% of body weight. Peak, impulse, contact time and swing time revealed no significant difference between exercises (P > 0.05). Values of peak of vertical ground reaction force ranged from 0.67 to 0.72 units of body weight.
Pregnant women at the third trimester can benefit from the apparent weight reduction during immersion for exercising. The three water-based exercises presented similar vertical ground reaction force values, which are considered as low odds for musculoskeletal injuries. Therefore, these findings highlight the safety of the water-based exercise program during pregnancy.

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Research ReportLoading of the Lower Limb when Walking Partially Immersed: Implications for Clinical Practice

Summary

Hydrotherapy in Practice

Research Report
Loading of the Lower Limb when Walking Partially Immersed: Implications for Clinical Practice