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Pool-based rehab: a complete guide | Sports Injury Bulletin

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Pool-based rehab: a complete guide

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"Pools are excellent environments in which to train water provides buoyancy and
resistance properties that allow the individual to undertake exercise with minimum
impact on the body."
Angela Calder (performance consultant for Australian Institute of Sport)
If the pool is such a great training env ironment, why does it not feature far more prominently in our
athletic clients rehabilitation and recov ery sessions? Although the ex tent to which pool training is used
will v ary from country to country , the unav oidable reality is that most sports support professionals fail
to use water workouts as a rehab tool for one simple reason: ignorance.
That was certainly true in my case 1 0 y ears ago, when I started working at the Sports Injury and
Rehabilitation Centre in Lilleshall, central England. Up until then Id only ev er gone to the pool to swim,
play on inflatables and do some top bombing from the div ing boards. At Lilleshall I had my first
ex posure to pool-based training as part of the rehabilitation programme for footballers receiv ing
treatment at the centre. Ev en then, it didnt occur to me that y ou could also use the pool as a training
tool when y ou werent injured. It wasnt until I started working with the England netball team that I was
ex posed to the use of the pool in this way .
With the help of the team coach and Marques Church, a clev er strength and conditioning coach from
New Zealand, who shared all his knowledge with me, I soon started to include a wide range of poolbased training in my athletes programmes. Ten y ears on, I hav e learned a great deal about how water
workouts can improv e body alignment, aerobic and anaerobic fitness, flex ibility , strength and ov erall
balance and coordination, and I still use the pool with my athletes for training, recov ery and
rehabilitation. Below I set out some of the applications and drills I hav e found inv aluable ov er the
y ears.
To be able to use the pool effectiv ely , y ou must first understand a little about the properties of water,
the effect of water immersion on phy siology and how both of these things affect our mov ement and
function.
Key properties of water
Buoy ancy : The term used to describe a fluid force that alway s acts v ertically upwards. It was, of course,
the Greek mathematician Archimedes who first worked out the magnitude of a buoy ant force in his
famous principle: the buoy ant force acting on a body is equal to the weight of the fluid displaced by the
body (1 ,2,3). Buoy ancy is helpful in training because it enables the water to support the body , which is
particularly useful during rehabilitation from injury . Y ou can also increase an athletes buoy ancy with
the aid of floatation dev ices such as belts and v ests.
Hy drostatic pressure: In a fluid, this increases with depth, and is applied ov er the surface of any
object immersed in the fluid(1 ,2). This turns out to be another v aluable property in rehabilitation: the
increased pressure on the body can be used to reduce swelling and allow the athlete to ex ercise an
injured limb without the risk of aggrav ating swelling.
Fluid dy nam ics (flow): When an object such as a human hand mov es slowly through water, there is
little apparent disturbance around the hand. As the speed of mov ement increases, wav es and eddies are
created(1 ,2). Two different ty pes of flow ex ist: l laminar, characterised by smooth lay ers of fluid
molecules flowing parallel to one another l turbulent, characterised by a mix ing of the lay ers of fluid
molecules.
In pool training, we can alter the fluid dy namics to change the intensity of the training session. If the
athlete maintains a streamlined shape, they will produce minimal disruption to flow. But when they
adopt an unstreamlined shape or use an unstreamlined object such as a float, they will disturb flow and
increase drag, which ups the intensity of the mov ement.
Depth: T here is an inv erse relationship between water depth and the am ount of body
weight supported by the m usculoskeletal sy stem . When y ou stand on the bottom of the
pool im m ersed up to y our neck, y our body is bearing about 8% of its weight. Drop the
water lev el to around m id chest and the body bears 28% to 35% of its weight, increasing to

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Pool-based rehab: a complete guide | Sports Injury Bulletin

47 % to 54% at waist height (see T able 1, below)(4). So by changing the lev el of the body in
the water y ou can increase or decrease loading on the m usculoskeletal sy stem , which is
v ery useful for rehab and injury prev ention. Bear in m ind, though, that the v alues in
T able 1 reflect static weight bearing: if y our athlete is bouncing up and down, lifting arm s
abov e their head etc, the loading v alues will increase proportionate to the am ount of the
body out of the water.
How the body behav es in water A body in water produces a different phy siological response to
how it behav es on dry land, so it is essential that the therapist or coach understands the key differences.
Cardiov ascular sy stem Respiratory function decreases, because of increased pressure on the thoracic
cav ity . We lose up to 9% of our v ital capacity (total v olume of air forcefully ex pired after max imal
inspiration)(5). The rate at which we breathe increases, but sub-max imal and max imal heart rates tend
to be 8% to 1 0% lower (1 0-20bpm) than on dry land(6). Max imal ox y gen uptake v alues (V O2max ) can
decrease by around 1 7 % (5,7 ,8) although this does not affect y our ability to use water-based training
to improv e y our athletes V O2max (see below). Note, howev er, the importance of the correct water
temperature: warm water can increase cardiov ascular demand ov er and abov e the demands of
ex ercise. One study (9) found that cardiac output increased significantly at 40C compared to 25C or
34C. The study also noted that at 36C the centralisation of peripheral blood flow was ov ercome by the
thermal stimulus to increase heart rate. The message here is that y ou do not want to put an athlete into
a pool for an intense training session if the temperature is greater than 28C because of the increased risk
of thermal stress. The changes to cardiov ascular response require the coach to do some maths and
recalibrate the appropriate v alues for their athletes to achiev e when they work in water. I learned from
ex perience that it is not a good idea to try to get an athletes heart rate up to lev els comparable with
those y ou would ex pect them to achiev e during an aerobic workout on dry land. Its not that they are
just being lazy ! There are equations that can supposedly predict max imum heart rates for water-based
drills, but I prefer to get the athlete to use a heart rate monitor and gauge their HR response against the
usual tests (observ ation, RPE etc) or against v alues recorded in a water-based max imal training session
that y ou hav e prev iously conducted. Either method should allow the coach to set training zones
equiv alent to those used on dry land. Although I hav e found no research on anaerobic work in the pool,
I do use it for anaerobic conditioning sessions. I apply the same training principles as on dry land
(adapted as appropriate for water work), namely :

- high-intensity efforts with recovery efforts in between ; - 20 to 30min session

duration
I fav our the flex ed running position (see below) because it allows the athlete to switch into a higher
cadence and thereby kick into the high-intensity work phase in the least amount of time.
Muscular sy stem The muscle actions that we so carefully deconstruct and use as the basis of our
strength and conditioning programmes with athletes on dry land change dramatically in water, as this is
a v irtually grav ity -free env ironment. The key conceptual difference is that the normal prime-mov er
deceleration action (eccentric contraction or lengthening against resistance) does not alway s apply in
the water. Depending on the mov ement and the training equipment being used, some muscle actions
below the water surface are concentric only . This in turn means that the antagonist muscle takes on the
prime mov er role for the eccentric or return phase of an action, but mov ing concentrically . Using a
bicep curl as an ex ample, on land with weights (dumbbells), grav ity acts on the weight and the biceps
work eccentrically (lowering phase) and concentrically (lifting phase) during the curl. If y ou perform
the same ex ercise in the water just wearing webbed glov es, force is generated against the direction of
y our motion, so the biceps contract concentrically in one direction (up or flex ing) and the triceps
contract concentrically in the other (down or ex tending). If y ou now perform the same ex ercise
without the webbed glov es but using dumbbells made from foam to prov ide buoy ancy , y ou hav e to
work against the effects of buoy ancy and the triceps will be working eccentrically and concentrically
during the bicep curl. This all gets v ery complicated, particularly if y ou are undertaking strength work
in shallow water (where there is some grav itational effect on the body ). There is v ery scant research
work on this area to help us, either. The best we can say here is that, as the ex ample of the bicep curl
shows, therapists should not assume that a specific muscle strengthening ex ercise on dry land can be
reproduced in the water in order to achiev e the same rehab goal.
Nerv ous sy stem Research shows we hav e a higher pain threshold when immersed in water, and
patients with lower-limb arthritis show significant improv ements in proprioception and balance with
water-based training(1 0). It is reasonable to suggest that athletes recov ering from joint injuries such as
ACL rupture might enjoy similar improv ements in proprioception in the water.
Is swim m ing a good workout? Swimming is undoubtedly a great way of training the cardiov ascular
and musculoskeletal sy stems, but I will alway s prefer aqua training ov er a swim session for my clients,
for two main reasons. First, most land-based athletes are not trained swimmers. If y ou are a strong
swimmer with great technique, then swimming may be a good cross-training modality , but I hav e found
that I can train my athletes quickly and effectiv ely in the aqua running techniques described below to a
lev el that produces a really v aluable training effect. I know that it would take far longer to get them to a
good enough standard of swimming to obtain similar results, and time is a precious commodity in
sports rehab and conditioning. Second, most of my clients are inv olv ed in running-based activ ities, so
swimming offers less transferable benefits than drills that replicate the mov ement patterns of their landbased activ ities.
How to plan effectiv e workouts - Cardiov ascular training
Deep water running is a good alternativ e to pounding the streets day after day (5,6). In a joint study ,
researchers from England and Tasmania compared the effectiv eness of deep water running and road
running in improv ing max imum ox y gen uptake in a group of 20 untrained y oung women. Both training
programmes produced similar and substantial improv ements in V O2max , and the researchers

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concluded that deep water running, in common with other aerobic activ ities, offers significant
cardiov ascular benefits when performed at an appropriate frequency (three to fiv e day s a week),
intensity (60% to 7 5% of max imum heart rate) and duration (20 to 60 minutes)(1 1 ).
Aqua jogging/running The two terms tend to be used interchangeably . Although I believ e the two
adapted techniques outlined below giv e more bangs for y our buck, standard aqua jogging is a good
training technique, so here are the basic rules on form: l Maintain almost upright body position, with
just a slight forward lean from the pelv is (5 to 1 0 degrees) l Keep trunk tight l Bring the knees to
approx imately 90 degrees and simply push the foot straight down behind y ou (av oid a bicy cling
mov ement) l Pull the arms forward and back with no lateral mov ement, keeping the hands relax ed and
relax ed thumbs pointing up (see Figure 1 , ov er).
I frequently hear coaches and athletes argue that standard aqua jogging is too easy to prov ide an
adequate workout. It is true that this kind of running in deep water doesnt really create a lot of
disruption to the flow. So I adapt it, using techniques shown to me by Marques Church, to increase the
lev el of challenge for the athletes I work with, and they happily accept that these sessions are as tough
as any thing they undertake on dry land. It is well worthwhile try ing these out y ourself to get a sense of
the effort required. Y ou can progress or alter the intensity of these drills by employ ing any of the
following techniques: l using fins on feet l using a 2:1 ratio of feet to hands (two leg driv es to each arm
driv e) or v ice v ersa l attaching floats to arms or legs (watch for ex cessiv e build up of lactate) l using
bungees attached to the side of the pool to add v ariety or as a tool for interv al work (go to full ex tension
and hold/go to full ex tension then drift and repeat/go to ex tension, drift back to edge of pool and go out
again).
Drill 1: Flex ed position running A whole-body ex ercise similar to running. Unlike standard aqua
jogging, when performing this drill the body will be almost horizontal. This technique is particularly
useful for games play ers (hockey , rugby etc) who adopt a flex ed position. Y ou will get increased
activ ation around the gluteals, hip flex ors and hamstrings.
T echnique l Work in deep water where y our feet cannot touch the ground l Once in the water, lower
y our hips so y ou maintain a forward lean from the pelv is of about 45 degrees l Keep trunk tight l Reach
straight forwards to full ex tension with one arm, then pull y our arm back with palm leading. Bend y our
arm as y ou pull back, until approx 90 degrees at elbow, then continue pulling through to y our hip l
Bring opposite knee forward towards y our chest (keep toes pulled up so foot is flex ed) while pushing the
other leg straight back until fully ex tended. Keep toes/foot flex ed until the bottom of the leg driv e,
when the foot may plantar-flex l Maintain hip, knee and ankle alignment (av oid using a breast-stroke
leg mov ement, especially when fatigue starts to set in).
Drill 2: Upright running This form of aqua running (see Figure 2, right) is predominantly used for
recov ery specific to upright running musculature, cadence dev elopment and max imal resistance work.
It also helps improv e flex ibility and range of mov ement, which has particular benefits for slow runners
who shuffle along with a short stride length. Wev e also found that our horizontal jumpers returning
from injury like this technique because the large range of mov ement helps to stop them from tightening
up during their rehabilitation.
T echniquel Maintain almost upright body position, with just a slight forward lean from the pelv is (5 to
1 0 degrees) l Keep trunk tight l Reach straight forward to full ex tension with one arm. Pull arm back
with palm leading (scoop action), until the elbow bends to approx 90 degrees. Continue to pull through
to y our hip l Bring opposite knee forward towards y our chest (keep foot flex ed), ex tend the leg
forwards. Once fully ex tended in front of the body , pull leg straight back through the water, aiming to
keep the leg as straight as possible. Push toes out (plantar-flex ) at the bottom of the leg driv e l Maintain
hip, knee and ankle alignment.
Drill 3: Cross-country ski running In this drill the legs remain straight throughout and the major
mov ement comes from the pelv is, rather than the knee, which creates much greater gluteal
contraction. This is a great drill for warming up and prov ides increased gluteal function and pelv ic
control. Good for lower limb recov ery .
T echnique l Maintain almost upright body position, with just a slight forward lean from the pelv is (5
to 1 0 degrees l Keep trunk tight l Adopt an opposition position, ex tending y our right arm and left leg
forward at the same time l Keeping both arms and legs straight, begin to scissor walk l Y ou should aim
to swing y our arms and legs an equal distance in front and behind the line of y our body l Keep hands
relax ed with relax ed thumbs pointing up. If y ou want to increase the intensity y ou can turn y our hands
to form a paddle, flex each foot as it driv es forwards, and point it pushing back.
For anaerobic cardiov ascular training, see Table 2 (below), which giv es an illustrativ e session that I run
with participants using a flex ed running position. Strength and power training Pool-based ply ometrics
can be ex cellent for strength and power dev elopment. While Iv e had some interesting conv ersations
(arguments) with coaches who dont believ e y ou can dev elop power in the pool, my own ex perience
suggests otherwise and there is ev en some research to back me up. In 2001 researchers found that it
was possible to make improv ements in v ertical jump performance by using a pool-based ply ometrics
programme and that there were no significant differences between land and water-based training
methods(1 0). More recently , in 2005, US researchers showed that pool-based ply ometrics can produce
significant increases in v ertical jump scores and prov ide similar benefits to land-based ply ometrics
(1 2). This is great news for any one looking for a low-risk power-based training tool. Iv e also used this
v ery successfully with athletes returning from injury . Research has shown that on dry land the
musculoskeletal sy stem is subjected to minimum impact forces of three to fiv e times body weight when
landing during ply ometric drills such as depth jumps. For this reason, most high-intensity land-based
ply ometric drills are out of bounds for athletes returning to fitness. But ply ometric training in water
allows them to slot back into the training programme early . A 7 0kg male performing a ply o drill in a
pool will reduce the impact forces from a range of 21 0kg to 350kg to a range of 35kg to 57 kg. Not bad if

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y our knees are a bit on the dodgy side! The Ohio-based team found that many healthcare professionals
now use the pool for injury rehab, and sev eral publications ex pound the v irtues of pool-based
ply ometrics(1 0). Y ou can change the intensity lev el simply by changing the lev el of the water. The
water prov ides support as the athletes body mov es downwards, and resistance as the athlete ex plodes
upwards. The water will also add resistance to lateral mov ements, with the potential benefit of
improv ed strength (a massiv e bonus for athletes attempting to get back to full fitness after an enforced
injury lay off). As water-based strength and power training is still v ery underdev eloped, there seem to
be no hard and fast rules. The Ohio Univ ersity team suggests y ou adopt the same training principles as
on dry land (v olume, intensity , frequency ). Table 3 is an illustration of sessions I hav e used with
athletes, including netball play ers with chronic knee injuries preparing for international competition.
The play ers were able to maintain strength and power without the need for land-based ply ometric
training sessions.

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