Aquatic and Pool-based Therapy

Optimizing the Aquatic Medium

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aquaticBy Veronica Paquette, PT, ATRIC, PRC

What kind of medicine is in this water to make me feel so good?” 70-year-old Rita asked at her first aquatic physical therapy session. What a strong statement about the benefits of the aquatic medium. Rita was referred to physical therapy specifically for treatment in the aquatic medium because of her diagnosis of osteoarthritis (OA). Due to her OA, she was experiencing pain, a decline in her mobility, and inability to tolerate land-based exercise.

Rita, for the first time in years, was able to walk without pain. Over her next several sessions, she noted a decrease in the pain typically associated with her mobility outside of the water. I suspect this is due in part to increased strength of her surrounding leg muscles as a result of her exercise in the pool. This, then, provided increased support to her arthritic joints.

Aquatic Healing Properties
So what was the medicine in the water that made Rita feel so good? The answer is: the physical properties of the water. Dr Bruce Becker and Dr Andrew Cole’s book, Comprehensive Aquatic Therapy, third edition, provides a thorough review of the physical properties of water. Briefly, these include density, hydrostatic pressure, buoyancy, viscosity, and thermodynamics. Among these principles, the most significant to the practice of physical therapy is buoyancy, which helps offload immersed joints. It is my belief that this is the property of water that provides patients with pain relief. This is particularly notable because with less pain patients are better able to move. This is key in helping halt the pain cycle. Studies have shown that neck depth immersion is 15 pounds (weight of the head) of compressive force on the spine, hips, and knees. Immersion to the pubic symphysis offloads 40%, immersion to the umbilicus offloads 50%, and to the xiphoid is 60%.

This is particularly beneficial for patients who have sustained a pelvic fracture or lower extremity (LE) fracture and have weightbearing limitations. The hydrostatic pressure provided by water is the force that aids in resolution of edema in an injured body part. It assists with increased circulation and muscle pumping action to circulate edema. The beauty of therapy in the water is that exercise in the pool can be made as easy or challenging as necessary. Increased speed of movement in the pool results in increased resistance or challenge of activity. Slowing down this movement will increase ease of movement along with assistance from buoyancy.

Increased Therapeutic Use and Pool Access
The use of the aquatic medium for treatment of a multitude of diagnoses is growing. From pediatrics to geriatrics, from athletes to more sedentary individuals or postsurgical patients, the use of the aquatic medium is facilitating functional outcomes for all. The relatively few contraindications associated with use of the aquatic medium include fever, infection, open wound without protective covering or with oozing, contagious skin conditions, diarrhea, unstable cardiac conditions, and uncontrolled seizure disorders. Many clients ask, “Do I need to know how to swim?” The answer is “No.” Feet do not need to leave the ground of the pool for an aquatic program to be effective. “Do I have to get my hair wet?” is another commonly asked question. Again, the answer is no. To address this concern, however, I explain that there are more benefits for those who are willing to put their faces in the water, but that it is not essential. The true effectiveness, in my opinion, is based on therapist creativity.

The utilization of aquatic lifts also reduces the limitations in using the aquatic medium. Lifts provide access to the pool for any patient affected by mobility limitations. Patients who use mobility devices need to be transferred from the mobility device to the chair lift, so they can use the pool. There are lifts available that can accommodate this need, such as Hoyer-type lifts, automated lifts, or lifts attached to a water hose that are designed to operate by using water pressure.

Assessing the Need for a Pool
The types of therapy pools that can be utilized are numerous, and they may be found in a variety of settings. For example, the use of a health club pool can be beneficial because patients can easily obtain a membership for continuation of their program. Health club pools work well for many physical therapy practices. Ability to rent a lane or a portion of a pool has many advantages. Under this scenario, the physical therapy clinic has no concern about maintenance of the pool, and the therapist enjoys the convenience of coming to the premises to treat the patient, then simply return home. In contrast, health club pools can be noisy, and there may be children’s swim lessons taking place at the same time as the clinic’s rental time. Also, the therapist does not have control over the pool temperatures, chemical levels, cleanliness of the pool or the facility, etc. There are several options for purchase of pools in the therapy industry as well. The advantages of a clinic owning its own therapy pool on the premises are numerous.

In my personal experience, patients prefer the privacy offered in the therapy clinic setting. Many people are not comfortable wearing a bathing suit and do not want to be seen in a public environment. The temperature of the water also can be adjusted according to patient needs. The majority of health clubs maintain pools at average temperatures of 80 degrees to 86 degrees. These are not therapeutic temperatures, and if patients are working too hard to maintain core body temperature, the therapy session will not be as effective. I also have found that some patients who are more frail and not moving as quickly may need warmer temperatures than more active patients. Because of the smaller dimensions of therapy pools designed specifically for clinics, temperature can be changed fairly quickly. There is also an advantage to choosing the type of chemical used for maintenance of the pool, whether chlorine, UV light, bromine, or salt water conversion. The cleanliness of a private pool is also controlled by the clinic.

Therapeutic Technology for Pools
Today’s therapy pools offer a variety of mechanisms and designs that support therapeutic applications. One example of these types of designs is pools that are built with a treadmill as the bottom. This type of device can have speed adjustments from .01 mph to 7.5 mph, so the patient can be treated at the slowest speeds up to running, as indicated. Other options are available with today’s therapy pools, including a video camera system to provide visual feedback to the patient regarding movement patterns while walking or standing to complete their exercises. There are adjustable jets for either swimming against or standing to complete balance activities, or provide added resistance to walking or upper extremity (UE) exercises. Some pools also are manufactured with a massage hose attachment that is designed to provide great work to scar tissue. Another advantageous option on some pool models is an adjustable platform for varying water depth.

There are many advantages to this including:
1) Increasing the amount of weight-bearing activity a patient is completing, thus changing their level of immersion.
2) Ability to change water level based on the height of the patient. Many times a 5-foot, 1-inch elderly woman will float away in the 4 1/2 foot pool, while this same level only comes to the navel of a 6-foot, 3-inch athlete.
3) For clients who can’t negotiate stairs to get in and out of the pool, simply raise the floor of the pool to the floor of the room and the patient can either walk on or wheel onto the platform; the platform is then lowered into the water to the level desired.

Equipped for Recovery
While the water environment can be very powerful, the therapist also can modify this with use of various equipment during treatment sessions. From pieces of equipment as simple as the noodle, to a drop-in motorized treadmill, these can enhance rehab outcomes. Some equipment offers more buoyancy to facilitate stretching, floating, or decompression. At the same time, these buoyant pieces also provide greater resistance to movement, therefore providing opportunity for strengthening. Some examples of these include cuffs, noodles, foam rings, and barbells.

Webbed gloves are beneficial for increasing resistance to UE activities. This also can help improve patient balance, proprioceptive, and kinesthetic awareness. These provide exceptional utility for added resistance with various arm movements while patients are completing walking activities in the pool. This can include breast stroke, reverse breast stroke, horizontal ab/add, and ab/adduction to name a few.

A few other favorite pieces of equipment include dumbbells designed to be used in the water. These provide resistance to UE movement. Increasing speed of movement with this piece of equipment also will increase the level of resistance and challenge of the activity.

The kickboard provides many options for varied activities in the pool. This can include the traditional flutter kick with the kickboard placed out in front, but therapists should look to their own creativity to determine how these accessories are used. on the kickboard while trying to maintain balance. First begin just with the resistance of the water and then add challenge by incorporating use of a resistance jet, or the therapist creating turbulence for the patient. Other activities with the kickboard to challenge upper body strength, balance, and stability, and lower extremity strength, include standing and pushing/pulling the kickboard at various levels of immersion and various positions. Also taking the kickboard flat in front and pulling down toward the thighs will challenge even the strongest patient’s balance, stability, and core strength. Add various depths of water to increase the challenge of all activities.

The noodle is another powerful yet inexpensive piece of equipment. Similar to the kickboard, patients can push the noodle down in front of them with their hands while maintaining their feet flat on the pool bottom. Single arm pushdowns at the side provide great resistance to the triceps. Let creativity flow and have patients straddle the noodle and bicycle using UE breast stroke pattern, reverse it, or have them bicycle backwards, sideways, or in diagonals, changing direction frequently to increase the challenge.

A piece of equipment that is vital for any patient affected by a shoulder or neck injury is the mask and snorkel. These allow patients to work in a prone position in the pool, which assists with inhibition of many cervical muscle groups, and in turn typically decreases pain levels and allows enhanced range of motion (ROM). This is true for work of the shoulder ROM. In standing, patients can typically only work on shoulder level activities, accomplishing about 90 degrees of motion. In the prone position, they can work in full range of motion. The opportunities for strengthening scapular muscle groups in this position are vast.

The use of water provides a powerful tool that can help facilitate a patient’s recovery in physical therapy. Most patients enjoy the aquatic medium, and in my observation compliance with these programs and appointments has been excellent. Depending on patient diagnosis, patients may pursue an independent membership at a local pool, or the therapy clinic will incorporate land-based activities in the patient’s program. RM

Veronica Paquette, PT, ATRIC, PRC, has been in physical therapy practice for 22 years, and developed a passion for treating patients in the aquatic medium. Paquette opened the doors to her own private practice 12 years ago, and adding private therapy pools has allowed her to continue to pursue her passion for treatment in the aquatic medium. For more information, contact