Aquatic and Pool-based Therapy

Aquatic Management for Patients with Arthritis and Joint Replacement Conditions

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Creating an aquatic environment that manages pain and fosters success.

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by Daniel Seidler, PT, MS

A growing percentage of the US population is currently living with conditions such as osteoarthritis, rheumatoid arthritis, fibromyalgia, psoriatic arthritis, and gout. As a result, the prevalence of joint replacements, particularly knees and hips, is rapidly increasing. Individuals living with one of these chronic conditions or having undergone a joint replacement surgery typically experience severe pain, swelling, stiffness, and fatigue. Daily life can be extremely challenging. Rising from a chair or taking a few steps often results in crippling pain. Many will seek any relief they can get from these symptoms and they often want to return to normal life, if possible.

Rehabilitation in a warm-water environment is an effective solution for someone with a chronic pain condition to reverse the feedback cycle of pain and decreased activity. Once initiated, an aquatic rehab program can transition into land-based rehab and/or a long-term aquatic exercise program.

Assessing the Patient Prior to Water Therapy
Prior to working with a patient in the pool, the PT needs to conduct a thorough assessment. This involves objective observations of skin, posture, vital signs, range of motion (ROM), manual muscle testing, ambulation, transfers, and functional movement assessments. A neurological screen also should be performed. If the patient has undergone a recent surgery, surgical sites should be closely examined for skin quality and edema. A standardized outcomes measure such as an Oswestry or Get Up and Go (GUG) should be used as a baseline at this time. The physical therapist assessment should guide the patient’s treatment plan, highlighting the issues that will be the focus of the aquatic therapy program.

For instance, if a patient is having difficulty rising from a chair due to myofascial restrictions, reduced knee ROM, and gluteal weakness, the PT will be sure to have the patient perform squats in the water when ready. The warm water will assist movement of the knee and the water’s buoyancy will facilitate rising from a squatted position. Squats can even be done while holding the side of the pool or in a set of parallel bars. Eventually, the patient will progress to resisted squats at a faster speed in shallow water, to greater simulate a squat on land. If scar tissue is creating a barrier to ROM, the aquatic therapy program may include deep tissue massage using a specialized warm-water massage hose.

The assessment also helps the patient understand their current ability and provides the opportunity for the PT to discuss practical rehabilitation objectives. If a patient is overweight or obese, the initial assessment can afford an opening for the PT to talk about lifestyle and behavioral issues such as nutrition and exercise.

Introducing the Patient to the Pool
The initial step in any program involving aquatic therapy is to introduce the patient to the therapy pool. Many patients have heard of water therapy, but may never have had this kind of rehabilitation. Others may be squeamish about getting into the water, or hesitant about putting on a swimsuit (which could indeed be uncomfortable or difficult depending on their weight, flexibility, and/or ambulatory status).

The PT must be prepared to tackle such worries by preemptively preparing the environment to ensure the highest possible degree of patient comfort and safety. Below are several key reasons for patient resistance and suggestions about how to overcome them:
Fear of falling
• Many patients with arthritis or who have undergone a total knee or hip replacement have balance issues. Without an assistive device, they may feel terrified to take even one step.
• PTs can help them by using a warm-water therapy pool. To be ADA compliant, such a pool would be outfitted with stairs, a chair lift, sling lift, and/or variable-depth floor. This way, the patient can be gently lowered into the best water depth to allay falling worries.
• In addition to addressing the fear of falling, pool stairs, chair lifts, sling lifts, or variable-depth floors offer a variety of advantages for any patients having difficulty with ascending or descending stairs who would benefit from this type of equipment. So a postsurgical patient with weight-bearing restrictions, a patient with chronic lumbar pain, or someone who has recently incurred a CVA and is unsafe on stairs all would be significantly more comfortable and safe with the assistance of a lift or other device.
• Lifts are widely available in a variety of designs, including in-ground or portable, and are battery-powered or water-powered. Manual-lift models are also available and offer standard, hi-lo, and extended-reach lifting capabilities. Pool lifts and slings are also useful for individuals affected by paralysis or spinal cord injuries who need to enter the water for therapeutic activities.
Difficulty or embarrassment wearing swimwear
• It is not uncommon for patients in these categories to be clinically overweight or obese. In addition to having physical difficulty donning a swimsuit, they might feel emotional discomfort at the thought of being “exposed” in the pool.
• The PT should encourage the patient to wear what will feel comfortable to and from the pool and while in the pool.
• Staff members may be on hand to help individuals get in and out of clothing.
Fear of the water
• If a patient cannot swim, or cannot swim well, he or she may be hesitant to set foot in a therapy pool.
• A pool with a variable-depth floor can be a huge asset to a therapy facility. Once the patient realizes that no swimming is involved, and that they will not be at risk of being submerged, the fears of being in water usually subside.
• To aid in diminishing this fear, flotation belts may be used to offer security to patients learning to tread water, ensuring a vertical position is maintained in the pool and allowing for added mobility for the arms during exercises. Collars may also be integrated to reinforce a sense of security in the water when executing full body exercises and to provide head support while in the supine position.
Fear of pain
• This is a large problem with some patients. Because they live in tremendous pain every day, they cannot help but assume that movement in the pool will also be uncomfortable.
• Typically, it only takes a few minutes in a 90-degree therapy pool for patients to realize that the properties of water help to reduce their aches significantly.
Once PTs have achieved a strong connection between themselves and their patients, via the therapy pool, aquatic therapy can begin.

Introducing the Patient to Aquatic Exercises
Patients generally look at the pool as a place where they have the ability to perform activities they cannot do on land. Walking five steps may be difficult for them, but in the water, they may find they can walk comfortably for 5 minutes on an underwater treadmill at a decent pace. The water’s natural buoyancy gives them a sense of freedom. Although up to 80% of their weight is being offset by the aquatic environment, their muscles are still getting a workout. Therefore, land-based activities will eventually become easier.

While the exercises available to physical therapists working in a therapy pool are really limited only by imagination, there are many that could be considered “go to” for the person who has worked for several years with patients in water. The key is to remember that water is both a facilitator and a resistor; hence, it can make movement either easier for the patient, or more difficult.

A few of the best practices include the following exercises, meant to lead to stronger movement and comfort on land. Note that if the pool has two levels, those levels can be used to add challenges and variation to each of the exercises:
• Four-way standing hip exercise involving internal/external rotation along all planes.
• Mini-squats in a simple up/down rhythm, which can eventually become deeper squats as therapy progresses.
• If arthritis is indicated in the knee, or the joint has been replaced, hamstring curls and stretches can help movement and flexibility.
• Lateral ambulation.
• Functional squats with resistance.
• Standing on one or both legs and using hydrobells to work on stabilization with the legs and core. Use the resistance jets as balance improves for an additional challenge.
• Treadmill walking (and jogging, if applicable).

In addition to hydrobells, flotation belts and collars can be used to enhance therapeutic activity in the pool and maximize outcomes during aerobic training. Of course, every patient is unique in their rehab time, progression, and needs. This is where ingenuity and confidence on the part of the PT play a huge role. Generally speaking, improvements may take weeks; however, with consistency of treatment, improvement will occur. It is extremely important that the PT and the patient have an open forum to discuss how aquatic therapy is affecting land activities and life skills. Reassessments and outcomes measures should be performed regularly.

Opening the Door to Water Workouts Beyond Therapy
One of the most heartening experiences aquatic PTs discuss is the desire for patients to continue working in the therapy pool beyond their prescribed treatment plans. For some facilities, this opens the door to the possibility of water-based classes and individual workout times as a secondary source of income for the clinic, hospital, or medical center.

While this may not be an option for every PT, it is a huge indicator of the powerful “pull” of water therapy for those suffering from arthritis, or the after-effects of joint replacement surgery. These individuals may not be able to tolerate true land exercise beyond regular lifestyle activities, but they crave intense workouts, and the only way they can fulfill their cravings is in the warm-water pool.

Is aquatic therapy the fountain of youth? To some patients, it feels that way.
As people live longer, they want to continue to live with a high quality of life. One of our wellness members had a total hip replacement and cancer that required the removal of a lung. He walks and jogs in our pool three mornings each week. For him, the pool is a place where he can be young and active. Another success story is a female patient in her late 60s from the Bronx who had bilateral hip replacements and arthritis in both knees. She was about to lose her part-time job driving a bus because she could barely walk or get in and out of the bus. Her therapy with us was initiated with aquatic therapy twice a week followed by a gradual transition to land therapy and functional activities. She has been able to get back to work and participate in normal activities, including shopping with her granddaughter.

It is not a miracle that puts these patients into better mental and physical health. It is hard work on their part, facilitated by their PT. We provide the environment for them to succeed, and they appreciate the opportunity to feel great. RM

Daniel Seidler, PT, MS, is the Executive Director of WSPT, a physical therapy, aquatic therapy, and wellness center in the northeast Bronx, NY. Seidler is a Columbia University graduate with a Masters in Physical Therapy. His areas of expertise are aquatic therapy and orthopedic manual physical therapy based on the Maitland technique of assessment and treatment. For more information, contact