Expand pediatric treatment options through aquatic therapy.

Nothing says “summer” like the sounds of youngsters splashing, laughing, and enjoying themselves in a cool, refreshing pool. But for children with physical impairments, the water is often off-limits. Thankfully, that’s changing, due in part to pediatric aquatic physical therapy programs similar to those at the Roosevelt Warm Springs Institute for Rehabilitation.

Located in Warm Springs, Ga, the Roosevelt Institute boasts two indoor pools filled with spring-fed, mineral-rich water that naturally maintains a comfortable 88°. The Institute’s 10 inpatient and 12 outpatient physical therapists served approximately 6,000 clients in 2004. Children account for between 15% and 20% of patients, and all are treated on an outpatient basis.

“The parents see they can use aquatic environment to treat kids with physical impairments and to help work toward land-based goals,” says Kathryn Smith, a physical therapist at Roosevelt Institute, who has worked with both land-based and aquatic therapy for almost a decade. “Seeing what their kids can do in water gives parents a chance to see what is possible.”

Benefits abound: the basics of aquatic treatment

Aquatic therapy is one of the fastest-growing areas in physical therapy and is the perfect fit for pediatric patients.
“I think parents want their kids to be involved in more and more activities,” says Smith. “And therapists and parents are finding that even severely impaired children can participate in aquatics.”

Buoyancy deserves a lot of the credit for aquatic therapy’s broad application. Patients are supported by the warm water, eliminating the possibility—and fear—of falling. Without this anxiety, patients are often able to relax and move in ways that are impossible for them to accomplish on land, such as standing or sitting upright.

Braced by water, patients—especially those who have difficulty controlling their trunks or have limb weaknesses—discover improved freedom of movement. By helping patients assume these new postures in a safe environment, the physical therapist can continue to realize the patients’ ultimate land-based goals.

“Even though we’re working in aquatic environments, we’re always working to progress toward functional land-based goals,” says Smith. For example, flutter kicking is a reciprocal movement of legs, as is walking. “A lot of kids have a hard time coordinating reciprocal movement on land, but can manage it in water.”

Working in water—warm water in particular—has well-documented benefits, including increased flexibility, decreased pain, increased relief from muscle spasms, and improved circulation. Once partially submerged, the hydrostatic pressure and turbulence of the water increases the sensory input to the body part under water. This improves the children’s body awareness.

The treatment lengths are based on the patient’s tolerance, but sessions generally run between 30 minutes and 1 hour. Whether it is used with impaired children or those recovering from injuries, water-based therapy provides unique benefits.

“The pool is a functional place to treat kids,” says Smith. Simply being in the water helps patients strengthen their muscles and improve their coordination. “Moving against the viscosity of the water is strengthening. Just having the kids in the water and playing with them is helping them.”

The Pool’s Tools

In aquatic sessions, physical therapists make the most of conventional swimming toys, household items, and traditional physical therapy equipment to keep the patient interactions challenging and, just as important, entertaining.

“With kids, it has to be fun, so we use a variety of toys and games,” Smith explains. Holding a child’s attention can be as simple as having them pour water from one cup to the other, or as complex as using dive toys that patients can pick up.

Children also enjoy swimming toward floating toys, maneuvering through hoops, and splashing with flippers. And like any child, young patients are eager to play with pool noodles. It all helps. In fact, a creative physical therapist can make any pool toy work, including the pool itself.

“Bubble-blowing can help kids with swallowing, feeding, and some speech-delay issues,” says Smith. Additional progress can be made with inflatable toys and “flip eggs.” Blowing these objects across the surface of the water helps increase breath control.

One pool staple that might be better left on the deck are flotation devices. Smith prefers to work with patients without aids, when possible.

“To be independent in the water, children must learn to control rotation around their center of buoyancy. When you use floatation, it changes the location of the center of buoyancy,” says Smith. “So when you remove the float, the child has to relearn the balance reactions necessary to control their body in the water.” She notes that this translates to extra work for children with neurological impairment who have a harder time learning motor skills. “I use handling with most clients first and add floatation as a last resort,” she says.

Bringing aquatic therapy to your community

There is no magic formula for determining if a pediatric aquatic program will thrive in a specific city or town. As with any business venture, the first step in the process is to analyze the existing market.

Find out if other facilities are offering water-based therapy for children, and if so, find out how great the interest is. Before getting involved, be certain that there is enough demand to sustain additional providers—and not just when the sun is shining.

“Parents often think about pool activities in the summer,” says Smith. “To be successful, a business will need to have parents interested and involved throughout the year.”

This can be a daunting task for some families because many parents find aquatic therapy to be more effort. In addition to getting their children to the pool, they have to dress them for the water and change them again after the session. This increased level of effort means that parents must be committed to active involvement.

Once the need for and interest in aquatic physical therapy is established, facility operators must consider if offering these sessions fits into their existing approach to business, in particular the flexibility of the physical therapy staff. Scheduling aquatic therapy sessions for children often demands patience beyond that required with typical therapy work. Facility operators who offer water-based treatments must be open to this.

“Children tend to get sick more often and have other therapy and doctor appointments,” says Smith. Families may have other children and other activities scheduled throughout the week. “Before offering aquatic therapy, a facility must decide if it can tolerate the inherent need for scheduling flexibility. It may also be necessary to have therapists available in late afternoon and evening for children who can’t get to sessions during school hours.”

All that it takes

Once there is a definite interest in making aquatic therapy available to pediatric clients, it is vital to have proper staffing and facilities in place.

The first item on the list—a pool—may be obvious. But all associated factors are likely less apparent. Unlike land-based physical therapy, acquiring, accessing, and maintaining a site for sessions can be a tedious and involved process. Every aspect must be evaluated carefully, because just one component—the pool size, for example—is critical to successful therapy.

“The absolute minimum is probably about 10 feet x 10 feet, and obviously that’s not ideal if you’re working on swimming skills,” cautions Smith. “And even more important is the depth. Kids need a variety of depths they can work at.”

For facilities interested in building a therapy pool, a variety of considerations come into play outside the basic costs for building and maintaining the facility. For example, in addition to physical therapists, it’s important to account for the time and effort involved in maintaining staff required by local codes, such as a certified pool operator.

If building a pool isn’t realistic, simply running to the neighborhood pool isn’t always an option, either. Many aspects of aquatic therapy make sessions more complicated than is sometimes allowed in “open swim” time at community pools.

After locating a prospective pool, physical therapists or facility managers should take time to visit with the pool’s operator and discuss the following topics:

Equipment. Are physical therapists and clients allowed to bring in toys and equipment? Physical therapists often adapt pools to accommodate their clients’ needs, with slip-proof mats, for example. What can be used is limited in some public pools, which can interfere with planned activities.

Steps. Do persons with physical disabilities have easy access into and out of the pool? Children participating in aquatic therapy are often unable to use poolside ladders and other common entry methods.

Temperature. Is the pool indoors or outdoors? What is the pool’s average temperature? “Children can’t regulate their body temperature as easily as adults, so if the pool is too hot or too cold, it will impact the effectiveness of the therapy,” explains Smith.

Scheduling. How busy is the pool? If it’s swamped with children during sessions, the splashing, noise, and activity can limit the amount of room available or upset some children.

Costs. How much does the pool cost to access? Some public pools charge by the hour, while others have flat fees—all of which can quickly add up. Keep these additional costs in mind when determining the feasibility of an aquatic program.

Locker rooms. Are they available and comfortable for people with limited mobility? “It’s important to keep in mind that it may be a dad bringing in his daughter or a mom bringing in her teenage son,” says Smith. Such situations demand a private, unisex area for changing and showering. The Roosevelt Institute built a private family dressing room, complete with a large padded changing table, shower, and wheelchair access, for just this purpose. Similar accommodations may not exist at a community pool.

Incontinence policies. Many pediatric clients are in swim diapers or have accidents. “If the pool is filled with an adult client group, they may have a lower tolerance for this,” says Smith. It’s advisable to address the possibility before a conflict arises.

Staffing needs

Establishing a location is only part of the equation. Equally important is an eager and qualified staff. “Pediatrics is a specialized area in physical therapy, and so is aquatics, so you need a staff with experience and interest in both areas,” says Smith. “If this is a niche they’re interested in, it’s important to make sure they’re qualified.”

A high level of interest from physical therapists can make a difference in the program’s success or failure, because additional time is required for physical therapy sessions. On top of treatment time, physical therapists must also allow time for documentation, showering, and cleaning equipment. Depending on the specific situation, therapists might also be involved in scheduling, developing programs, and marketing.

“It’s also important to stay in communication with referring physicians and other therapists,” says Smith, who stresses the importance of coordinating treatments with other therapists. “At the Roosevelt Institute, we really work well as a team, with a lot of pediatric clients who are seen on land once a week and in the pool once a week.”

Part of the process of open communication between all involved physical therapists is to compare notes on each patient and conference as needed. “That type of collaboration is extremely important, especially with kids, because you can see changes quickly,” says Smith.

And while it should go without saying, it is worth noting that the physical therapist must enjoy being in and be confident around water, where they can spend as many as 25 hours a week working with children.

Making the grade

In most instances, adding pediatric aquatic therapy as a patient option means additional training—or hiring—to ensure the staff is equipped to provide exceptional treatment.

“Get the training before you offer the services,” advises Smith. “Pediatric and aquatic physical therapy techniques are very different than adult- and land-based therapy.” Hiring a qualified, experienced pediatric aquatic physical therapist is a viable option as well, she adds. “That person can train and work the staff, acting as a mentor.”

The first step in educating professional staff is getting physical therapists involved with the existing aquatic community. The American Physical Therapy Association’s Aquatic Section, of which Smith is also vice president, offers conferences and both entry-level and advanced courses. “The Aquatic Section is a good place to start, providing a lot of information and making quality mentoring available,” she says.

The Roosevelt Institute, along with a number of other facilities offering pediatric aquatics, provide internships, courses, and seminars for outside therapists.

“We have a great education department that brings in some really qualified speakers,” says Smith. She also recommends attending courses that specifically offer pool labs. “Some courses teach only through classroom work, but you really want to get experience in the water.”

It’s also critically important to seek out ongoing educational opportunities focused specifically on working with pediatric patients.

“Most physical therapy schools give a minimum of training on aquatic therapy in general, and oftentimes it’s not specific to pediatrics,” says Smith. “Ideally, interested physical therapists should take an advanced aquatic therapy course and obtain training in specific advanced treatment techniques.”

When seeking training specific to pediatric and aquatic therapies, staff will need to be familiar with and be able to implement aspects of Neurodevelopment Treatment (NDT), Bad Ragaz, Halliwick, and Watsu (water shiatsu), the four primary physical therapy techniques used when working with children in water sessions.

Courses that touch on all four techniques are most likely available at a professional conference. But more commonly, physical therapists interested in learning more will need to attend individual courses. Smith also recommends that anyone working in the water be certified in life-saving techniques.

Building a community

If the decision is made to include pediatric aquatic therapy at a facility, the next step is to let people know it’s available. Smith feels word of mouth is one of the best marketing approaches, and it starts with providing excellent customer service.

“You also want to visit physicians, especially orthopedists, pediatricians, and pediatric neurologists,” advises Smith. Physicians may not be familiar with the variety of benefits, so be prepared to explain how physical therapy in an aquatic environment helps children.

Developing relationships with other pediatric physical therapists can also create a valuable network. Contact land-based pediatric physical therapists, speech therapists, and occupational therapists. By coordinating referrals and care, therapists can provide patients with access to a complete therapy program.

Perhaps the best way to build interest in a budding aquatic program is to make the pool accessible. Open up the pool and services to the community by hosting pool parties, “water tots” programs, and swimming lessons.

Draw crowds and increase interest by making programs open to children of all abilities; but as part of this outreach, be sure to include free classes specifically for children with impairments.

“Offering free swimming time—with staff assistance—to local special-education programs is a good way to get them in the pool,” says Smith, who recommends that one parent or school staff member be required to accompany each child in the pool. “It’s not considered therapy, but we give them ideas and at the same time provide a community service.”

Dana Hinesly is a contributing writer for Physical Therapy Products.