The water way to mobility and pain-free living.

BackHab is a very basic aquatic-therapy and rehabilitation technique that has been an effective treatment for many orthopedic and chronic conditions.

When physicians referred their back-pain patients to the pool, we needed to find the best rehabilitation option for them. These patients had already finished their traditional therapy. We researched back pain and found that muscle imbalances greatly led to back problems. We decided to have back-pain patients stand at the pool edge and do exercises to stretch their iliopsoas, hamstrings, and low back, and also to strengthen their abdominal and hip extensors. It didn’t work. Patients leaned, hung, or rested on the pool edge—their alignment was terrible.

Rehabilitation therapists must remember that while we are rehabilitating using controlled exercises, we are programming nervous systems with movement patterns. If technique and posture are poor during rehabilitation and exercise, the same will be true at work and in activities of daily living (ADLs). Instead of improving musculoskeletal function, poor techniques and posture only accelerate musculoskeletal dysfunction.

We gave alignment cues while patients stood at the pool edge and did their exercises. They looked better while they were participating in the program. However, when they got out of the pool, they exhibited no postural carryover to walking/moving on land. We decided to have patients walk using various strides while participating in the program so they would learn to move with upright alignment while we strengthened and stretched the muscles. We chose each stride to work or stretch specific muscles. This worked really well, but we found that balance was an issue when using varied strides. We then decided to add challenges for balance and coordination, and trunk stabilization—the results were excellent.

The Final Evolution

BackHab II, in its final evolution, is a highly integrated program. It is concerned first with alignment and the ability to move with that proper alignment. Once that is accomplished, the various strides are used to improve balance and coordination, strength and endurance, flexibility, and trunk stability.

To get the most benefit from rehabilitation, we need to progress to an integrated approach. Since the body works as a kinetic chain, what happens in one joint affects the other joints. This tells us that single-issue (knee, hip, back) rehabilitation is only one (usually the first) component in helping to restore integrated function throughout the whole kinetic chain. In BackHab II’s integrated approach, exercises are used to work the problem area and the surrounding musculature. They also keep the patient in a more proprioceptively challenging position for carryover to ADLs. Progressing the patient from an isolated single-issue rehabilitation programs through an integrated continuum allows for better function in life.

Prerequisites

Patients must be mobile and have basic cognition to participate in and benefit from the program. They also must wear slip-resistant water shoes for safety. Slipping on a tile lane marker (on the pool bottom) could create new or more pronounced pain. Additionally, most accidents in the pool are slips and falls on the deck. The shoes protect patients in the locker room, on the deck, and in the pool.

Equipment

No equipment is used in the traditional program. However, if patients have a flaccid limb or are too buoyant, ankle weights can be used. If patients need support due to balance issues, we put a large inner tube around them to help hold them up. We find these better than the belts because of the compression the belts create, in terms of both breath and joint compression.

Getting Started

We begin with alignment walking. Here’s a sample of how we get people moving:

“Begin walking forward and backward, and think about your alignment. From a side view, the ear should be directly over the shoulder and the shoulder should be directly over the hip. The rib cage should be lifted, and the scapula—the shoulder blades—should be lightly pressed down. The chin should be back a bit from where it usually is—not up or down, just back.

“Continue walking, and use diaphragmatic (belly) breathing. If you feel that you have the alignment perfected, you can progress by stopping with both feet down and then beginning again without any change in that perfect alignment. Give yourself enough walking time to get some momentum going so it’ll be more difficult to stop and restart. Each time you stop, think ‘alignment’; and make sure that each time you start moving again, you don’t lean forward. Keep that perfect posture.”

Two Sample Strides

Exercise: Rolling Heel to Toe, Toe to Heel

Goal: Balance and coordination, stride awareness, pronation/supination awareness, and stretching and strengthening the tibialis anterior and gastrocnemius.

Considerations: Eliminate rocking the body side to side, forward or backward; compare feet.

Here’s how to guide patients:

“We’re moving on to Rolling Heel to Toe.

If you’re moving forward, accentuate rolling your foot from the base of the heel to the tip of the toe. If you’re backing up, you’ll be rolling from the tip of the toe to the base of the heel. Roll right down the center of the foot. Keep your torso tall as you do this. It feels like a massage for the entire bottom of the foot, doesn’t it? Notice if your foot slaps instead of rolls, and notice if you roll to one side of the foot. Slow down enough to practice a complete roll without skipping the rolling motion on any portion of the foot bottom. Then, slow down even more to practice rolling down the center of the foot.”

Exercise: High Knee

Goal: Gluteal and hamstring endurance, flexibility.

Considerations: Lift both knees equally, and press the foot back when moving backward.

Here’s how to guide patients:

“First, return to a normal stride. Then, lift your knee before each step. Keep your alignment upright, and notice how high each knee comes. Lift the knee as high as possible, even when you’re backing up. You’ll get a lot of gluteal and hamstring work as you swing your leg back to back up. When you’re backing up, keep your knee flexed during the hip extension. After the hip extension is finished, extend the knee and step backward.”

A Few Sample Progressions

A basic, easy progression is to turn the head to the left or right and continue moving in a straight line forward and backward. This will challenge balance and coordination, and will help break the patient out of compartmental movement patterns. The energy cost will increase a bit because of the additional recruitment of synergists and stabilizers.

Another possible progression is to close the eyes—as long as it is safe to do so in terms of collisions with walls, steps, lane markers, or other patients. This will increase the difficulty for balance and coordination, and will increase proprioceptive awareness. Patients should maintain perfect technique, alignment, symmetrical movement, equal stride length and width, and should move in a straight line.

If you want to increase balance skills, the pause-or-stop progression is great. After patients raise their knee as high as it can go, have them pause their movement momentarily before lowering the knee to step forward or backward. This pause is excellent for balance and also increases the energy cost by requiring the re-recruitment of muscle fibers. To make it more difficult and add trunk stabilization to the benefits, have patients stop their entire body (not just the knee). This means that the arms do not flail during the stop, and that all the balance effort goes to the trunk.

Another progression you may want to use is slow motion. Ask patients to move at half-speed, and then have them slow down even more. It’s difficult to maintain alignment, symmetrical movement, and balanced movement when slowing down. This progression is excellent for proprioception, balance, coordination, trunk stabilization, and complete neuromuscular retraining.

Asking patients to imagine that the foot is almost too heavy to lift increases energy cost (with increased muscular recruitment), helps overall balance and coordination, and increases repatterning in terms of moving proximal to distal.

Finally, there are the old progression standbys of adding turbulence or moving patients a bit deeper while moving through the BackHab II exercises.

Guidelines for BackHab II and Progressions

• Begin slowly to evaluate how easily patients can work through the continuous drag and resistance.

• The water offers controlled low-impact opportunities. Stick with walking strides, not jogging, to maintain a biomechanical stress level that can be tolerated.

• Move all the strides forward and backward, or right and left.

• Repeat all strides for 2 to 4 minutes, or as tolerated.

• As soon as perfect technique is lost, patients should rest or switch to a different stride or progression.

• Begin with a conservative stride length, and eventually  increase it.

• Start with 10–15 minutes of walking. Increase at least 5 minutes each week up to 30 minutes total.

• The ideal frequency for excellent outcomes is 3 times per week.

The BackHab II progressions listed here can be used singly or together depending on patients’ technique and tolerance.

BackHab II is an excellent program that is applicable to almost all skill levels. The anecdotal benefits patients have experienced include increased coordination and balance, increased strength and endurance, improved core stability, decreased pain, and increased range of motion and reaction time. It can be used in groups or as a one-on-one technique. It is basic enough that it can be used for not only the back, but also for the hips, knees, and shoulders. It can also help treat arthritis, fibromyalgia, multiple sclerosis, Parkinson’s disease, and other orthopedic and chronic disorders.

“I currently use BackHab in a number of ways, as both a warm-up activity and as a component of my treatment,” says Jennifer Beasley, MPT. “I work with patients who are being treated for low-back injuries and knee injuries, and BackHab is an integral part of my rehab approach, specifically for the balance components it incorporates. I have seen patients challenged in many different ways by using different BackHab techniques, and the benefits have carried over into the land-based results.”

Drop it into your toolbox and try it!

Ruth Sova, MS, ATRIC, is president of the Aquatic Therapy & Rehab Institute Inc, Port Washington, Wis. She can be reached at ruthsova@ruthsova.com.