Most PTs practicing aquatic therapy today had to dive in, often learning the therapeutic procedure on the job. But the same approach does not work when incorporating the methodology into a practice. Every aspect of the service requires thoughtful planning, from finding a pool and referrals to effectively treating patients and obtaining reimbursement.

Linda Bernot, PT, clinical partner at Advanced Physical Therapy Associates in Cranford, NJ, acknowledges that aquatic therapy has unique challenges but notes that the same environment provides an excellent therapy option. “Aquatic therapy offers a wonderful adjunct to a practice. It provides a lot of options. We’ve been able to integrate aquatic procedures with land-based intervention to great patient benefit,” Bernot says.

Bernot shares the story of a stroke patient in her early 50s who was referred to the practice by a land-based therapist. Eight years after the stroke, the patient was still in an electric wheelchair and required maximal assist for all of her transfers. “She was a very large woman with poor sitting balance and little strength. The PT had limited options, because the patient was not able to do much on land,” Bernot recalls. So the PT, thinking hydrotherapy might help, referred the patient to Advanced.

“Because of the patient’s determination, we decided to try the pool. We started with very individualized sessions 30 minutes in length, increasing to 45 minutes and eventually an hour. We put her in supine and got her moving her limbs a bit. Then, we got her to change position. Then, stand in the water,” Bernot says.

After 9 months of visits twice per week, therapy has moved to dry ground. The patient now stands suspended between parallel bars and over a treadmill, and is beginning to take steps. “It took 9 months in the pool to get her strong enough to stand, but she and her family were so encouraged. She’s lost 90 pounds and is continuing to move ahead. She would never have been able to do it without the pool,” Bernot says, adding that the land-based treatment options were very limited.

Testing the Water
Aqua therapy, or hydrotherapy, has been used with success for years. “Putting people in the water is nothing new. It was used with polio epidemics years ago, but in the 1980s it received more attention as a result of the sports medicine craze and its use by notable figures such as [figure skater] Nancy Kerrigan and [the late] Pope John Paul II,” Bernot says.

Land-based therapists who would like to offer their patients aqua therapy should first test the water, so to speak. Bernot gained her experience as the PT in a hospital outpatient facility that offered aquatic rehabilitation, a job she accepted after graduating from New York University, New York, in 1981 with a bachelor’s of science degree in physical therapy. After roughly 10 years in this position, she was approached by David Van Brunt, PT, CHT, founder of Advanced, who asked her if she would be interested in developing an aquatic program for Advanced. That was in 1992.

Advanced did not have a pool at that time, so Bernot treated patients at an off-site facility, the Cranford Indoor Pool and Fitness Center. She saw patients during the morning and evening hours. “Every pool has downtime, so there are many opportunities for therapists to rent water space,” Bernot says, suggesting that pools at hotels and health clubs provide ideal opportunities for PTs.

Renting a pool allows a therapist to build a program and learn about the patient population while avoiding a large and risky capital investment. “Renting pool time gave us the opportunity to learn about referrals and patients so that eventually we could design the pool that would work best for our practice,” Bernot says.

Of course, having a pool on-site is ideal. “Renting is a great way to start, but there are limitations. You have no control over the environment,” Bernot says. A PT who rents pool time will not be able to dictate temperature, ensure cleanliness, or control all safety features. “For example, a pool may not have a lift, which limits who can go into the water,” Bernot says.

Bernot practiced in the health club pool for 5 years, until May 1997, when Advanced moved into a new, larger building built for the practice. About 12,000 square feet of the freestanding structure is used for therapy. The space also includes a pool, which was designed and installed specifically for Advanced. Bernot, who was made a clinical partner in 1992, guided the project with input from another Advanced therapist, Sally Kleeman, PTA, who also had prior aquatic therapy experience.

Population Pool
The work was guided by their previous experiences as well as their knowledge about Advanced’s patient population. “My previous job experience showed me what worked and what didn’t work in that particular pool, and a lot of what I learned there was used to design Advanced’s pool,” Bernot says.

Similarly, the 5 years of groundwork in building a patient base provided her with information about the population, which was also used to guide the pool’s design. “There are many different kinds of pools, and they work best for certain populations. You really need to know what types of patients you will be treating and how you will treat them before designing a pool,” Bernot says.

Advanced’s pool is 17 feet x 39 feet and holds 20,000 gallons of water. Three quarters of the pool features a depth of 3.5 feet to 4.0 feet; the last quarter drops to 6.0 feet and is roped off with a lane guide.

“We have an adult orthopedic population that tends to be more geriatric and on the lower end, intensity-wise, of exercise. So they need standing room and walking room. If we were treating an athletic population, we would have wanted a larger deep end. A primarily pediatric population would need a much more shallow pool,” Bernot says.

Safety features were also considered heavily in the pool’s design. The pool has a high-friction deck surface, a handlebar along its entire perimeter, grab bars and stair railings, and a mechanical lift for patients who cannot use the stairs. “There is always something to hold on to. And when in doubt, we use the lift,” Bernot says.

The proactive approach has worked: Advanced can boast an accident-free record. “We’ve been using the pool for close to 10 years and have never had a slip/fall incident in the pool,” Bernot says.

But that success stems from careful planning. Bernot and Kleeman provided the pool designer with specific guidelines, including design and safety features. “Our contractors did not have a lot of experience designing therapeutic pools specifically, but we worked with them to design what we knew we wanted based on our patient population,” Bernot says.

On Solid Ground
Advanced is a community-based practice with multiple specialties that, in addition to hydrotherapy, include pediatric physical and occupational therapy, hand therapy, industrial rehabilitation, women’s health, and vestibular and balance rehabilitation. Though the majority of its patients are adult orthopedics, the practice sees a wide variety of patients, particularly within the specialties. The practice also sees patients with spinal conditions, including degenerative disk disease, herniated disks, and postspinal-surgery recovery.

Pediatric patients are referred from the local school system and outpatient facilities. About 35% of the patient population has Medicare, Bernot estimates. That number rises to about 50% for patients who undergo hydrotherapy. “Aquatic therapy does attract a geriatric population,” she says.

Hydrotherapy offers benefits related to its buoyancy and weight-bearing capabilities, as well as its warmth and comfort. Bernot recommends the method for patients with pain related to weight-bearing, such as those with degenerative joint conditions, postsurgical recovery, or osteoarthritis of the hips or knees. Obese and chronic-pain patients may also benefit from water’s unique characteristics.

However, not all patients benefit in the pool. “Certainly, there are contraindications. You would not want to put anybody with an open incision in the pool. Or a patient with an unstable joint, whose immobility would be harder to maintain,” Bernot says. About 20% of Advanced’s patient treatments occur in the pool.

The decision stems from a thorough land-based evaluation, with the pool just another tool to achieve goals. “All patients are evaluated in the same way. Impairments and limitations are identified, and land-based goals are set. We never think about getting the patient to go from walking 5 feet in the pool to 10 feet—we are always looking at a land-based goal. No one lives in a swimming pool,” Bernot says.

Programs are individualized and varied. Before patients go into the pool, they complete a questionnaire that asks about prior aquatic experience. “Some individuals are comfortable in the water, and others are not. If a patient is fearful or scared, it needs to be addressed with some hand-holding,” Bernot says.

Patient-fatigue levels are also important. “People can fatigue out rather quickly in a warm-water environment,” Bernot says. Some people may start in the pool for 15 minutes, others for an hour. Some patients will be seen in both the clinic and the pool on the same day.

“It’s important to realize you don’t throw everybody in the pool. Aquatic therapy needs to provide what land-based treatment cannot. There has to be a reason to treat in the pool, because it’s messy,” Bernot says, pointing to the need to change clothes and get wet.

Staying Dry
Aqua therapy has its unique challenges. Just as patients must be safe, so must staff. “It can be draining to work in a pool environment, particularly in higher-temperature pools,” Bernot says. Staff is rotated throughout the day and kept hydrated. They also undergo considerable training.

“I think it’s challenging to train staff for the pool because, oftentimes, PTs don’t come with aquatic experience. Even with seminars, we still do a lot of on-the-job training,” Bernot says.

The goal is to create the safest environment possible for patients. “All of our staff holds water-safety, CPR, and Automated External Defibrillator certification,” Bernot says, admitting that it can be challenging to be sure everyone is kept up to date. Advanced has 12 full-time and 10 part-time therapists who are a mix of PTs, PTAs, and CHTs.

The pool must also be kept safe, a process that involves proper maintenance and sanitation. Bernot recommends having someone on staff who understands how to troubleshoot and take care of the pool. “What is the bathing code? What are the chemical levels?” Bernot asks. She, along with another colleague, is a certified pool operator. The two handle daily maintenance, with a pool-maintenance organization on contract.

“We’ve put in a lot of features to make the pool safe,” Bernot says. Part of that is using the pool only when it’s needed. “We want patients to become as functional as possible in the shortest time possible, and we only use the pool if it helps,” Bernot says. In other words, she wades in.

Renee DiIulio is a contributing writer for Physical Therapy Products.