Over the last few years, PTs have added an array of tools to their arsenal, but none have the same transformative power as one of the most basic substances in the world: water.

Aquatic therapy offers therapists a number of advantages over land-based modalities. And, in fact, except for the addition of water, it differs little over what a therapist would do outside of a pool. "What I do in the water would be called the same thing on land," explains Caryl Sircus, MSPT, executive director of Aquatic Therapy Associates, San Rafael, Calif.

But while it may be called the same thing, aquatic therapy offers the therapist greater flexibility and the ability to help their patients by doing a sort of multitasking style of therapy. "[Therapy] takes on a different look [in the water]," Sircus continues. "It's more three dimensional with rotation, mobilization, and stretching being done all at the same time."

And with the techniques—rotation, mobilization, and stretching—that the therapists bring to the table, many of the same pieces of equipment are used as well, albeit with an aquatic twist.

ADAPTED EQUIPMENT

With her background as a former aquatic equipment provider, it is not surprising that Melody Medley-Keith, PTA, owner of Lakeway Aquatic Therapy, Austin, Tex, relies on aquatic therapy equipment to help meet her patients' therapy needs. The equipment she and her PTs use runs the gamut from gloves and paddles to aquatic barbells to cuffs to aquatic belts to equipment that, at first glance, looks as if it belongs on dry land and not in a pool. The basic equipment—for example, barbells and gloves—are from Water Gear Inc, Pismo Beach, Calif.

Medley-Keith explains that one of the key aspects of this basic equipment is that it has a rating system—one to four—that helps therapists match the equipment to the patient's needs. For instance, a very deconditioned patient will use a level-one barbell or cuff in their regimen, and someone who has a high level of conditioning—a college athlete, for example—will be given a level-four barbell to use. What is not different is the amount of resistance the patients will experience in the water. Medley-Keith estimates this is between 14% and 16%, and this resistance alone will help the patient's conditioning.

Because many of Medley-Keith and Sircus' patients are unable to participate in land-based therapy, aquatic therapy becomes their only option. Both women note that many of their patients are in constant pain not just because of a recent surgery on a joint, but from other conditions such as a back injury. Aquatic therapy is helpful to get these patients moving and working again not only because of the natural resistance of water, but also because the water-based environment unweights the patient. "We use the properties of the water to help maintain balance," Medley-Keith says. "And there's no weight-bearing issues to worry about."

The relative weightlessness is helpful in helping patients improve their condition, such as their gait, Sircus notes. "If a patient has a lower-extremity problem—such as having back pain—in the pool that is minimized, and they will have a regular gait," she says. Similar improvements may take longer or be impossible on land.

Medley-Keith points to another simple piece of equipment that she calls a "must have" to help patients. "Channel locks are PVC pipes that are mounted into the walls of our pool. The patient is supported by two pipes under their armpits. It's useful for unweighting and for patients who aren't used to being in the water," she says. Once the patient is placed in the channel lock, they will begin their regimen of weight or other resistance training.

Sircus relies on basic equipment as well. These include balance mats, kickboards, water walkers, belts, step-up boxes, and "noodles." Though the latter is not necessarily a therapeutic tool, she says that for her this is her "must-have" piece of equipment. "The noodle is an incredibly versatile piece of equipment," she says.

Another key piece of equipment she uses is a board that has holes drilled into it, offering variable resistance when the patient moves it through the water. According to Sircus, the device is fairly old and she believes it is no longer being commercially manufactured.While simple items like barbells and noodles are the cost-efficient backbone of aquatic therapy, technology has caught up and has taken the next step—adapting equipment like treadmills, bikes, and steppers for use in the pool. For Medley-Keith, these have become equally important in getting her patients well.

UNDERWATER GYM EQUIPMENT

The underwater gym equipment used at Lakeway Aquatic Therapy is from H₂0 Gym, Austin, Tex. The practice uses the manufacturer's stepper, treadmill, and bike.

The stepper combines stair climbing with a pad for abdominal twists. The twister includes roller balls on cams to massage the patient's feet while they exercise their midsection. The stepper is also helpful in improving balance and has a 2-inch steel grip bar. Medley-Keith says that she uses the stepper because it offers no resistance and it helps patients recovering from hip surgery to start the hip motion again.

The treadmill is self propelled and has handrails for added support. Medley-Keith uses the treadmill for gait training, increasing stride length, and relieving plantar fasciitis. Patients will be put on the treadmill and use it without resistance or, if resistance is deemed to be beneficial, they will use ankle cuffs.

The bike is a multifunctional system that combines a full-size treadmill with a seat for cycling. The water offers resistance while flowing around the patient's legs. "We use the bike for knee range of motion," Medley-Keith says.

The combination of treatments—such as weights, gloves, and the aqua bike—is one recipe Medley-Keith has used for patient success.

SUCCESS STORIES

Medley-Keith says that many of her patients are "complex" and experience either a serious medical condition or a combination of injuries that leave them in constant pain. She points to one of her recent patients—a woman who has myofacis gravis—who has made almost miraculous improvement thanks to the work of the PTs, aquatic equipment, and her own determination.

In a 3-month period, the patient who was fitted with cuffs and gloves at level one resistance is now virtually spasm- and pain-free. She began only being able to work out on the aqua bike for 2 minutes before having to rest for 3 minutes.

She now can drive herself to medical appointments or to go shopping. "She got her life back," Medley-Keith says.

She also recalls another patient—a woman who over the years had surgery to both knees, one of her shoulders, and her back. The patient is enrolled in the aquatic wellness program and comes in every morning at 7 am to work out. The patient has admitted to Medley-Keith that she is not pain free, but it's the "only way she can make it through her day."

REIMBURSEMENT

According to Sircus, aquatic therapy has a growing base of knowledgeable patients. "People know more about it today, or at least they're more aware of it," she says.

This means that many patients know that there is a benefit to pursuing aquatic therapy. However, in her experience, aquatic therapy is hard to get reimbursed and is rarely prescribed initially. (Many of her patients come to her late in their treatment.) She says that in her experience, HMOs do not reimburse for aquatic therapy.

For Medley-Keith, reimbursement is rarely a problem, though she notes that she gets reimbursed about the same amount for an aquatic treatment that she would get for an equivalent land-based one. She uses a general billing number, and she says that the only thing she has to guarantee is that she is doing an aquatic modality with the patient and not just a land-based treatment in the water.

No matter the ease or difficulty of getting reimbursed—which may be a function of the individual payor market—there is one thing that both woman agree on: Aquatic therapy is here to stay.

AQUA TRENDS

Medley-Keith sees that the market for equipment such as that provided by H₂O Gym will continue to be "hot," but points to a difficulty with pursuing the Lakeway model. "Getting big equipment is hard in terms of space," she says. "The big challenge is getting [a big pool]."

Instead, she foresees the development of "swim spas" that will provide aquatic therapy by a highly trained therapist. These will be more one-on-one and delivered in a smaller space. In terms of modalities, she sees techniques such as Watsu as growing in popularity.

The future of aquatic therapy for PTs will continue to become a bigger component in terms of training, Sircus says, particularly for those who are being educated in places like Southern California. "There's a lot more choices to be trained [in aquatic therapy]," she says.

Increased popularity and usage for patients and PTs—no matter the challenges involved in getting pool space—is undoubtedly the future for aquatic therapy and the equipment that is needed to provide it. And there is one other reason why aquatic therapy may continue to grow. "Aquatic therapy is the best way to go for so many people," Sircus says.

C.A. Wolski is a contributing writer for  Physical Therapy Products. For more information, contact .