Ron Kleinman, PT, leads a patient in gravity eliminated shoulder mobilization. PHOTOS BY ROBIN MILLER

As a PT, you may or may not know all the advantages of aquatic therapy for your clients. To name a few, it is a low-impact modality because the water provides buoyancy and support for the body. It’s virtually gravity-free and gets the blood moving faster through an injured area to aid in quicker healing. In addition, water pressure helps keep down the swelling that often accompanies an injury. In this article we will explore the latest products/pools being used, trends in the industry, and treatment insights from your colleagues who use aquatic therapy with their patients.

DIFFERENT APPLICATIONS, DEPENDING ON NEED

Resistance swimming pools, for example, provide a powerful current and sometimes even a wall of water for swimming, exercise, or therapy, which can be controlled or changed for a more or less rigorous workout. Pools with an adjustable current allow the therapist to create a systematic routine of exercises while being able to supervise progress. It’s a helpful method for developing muscular strength and endurance in place of swimming pool lengths.

Ron Kleinman, PT, owner, Professional Therapy Associates Inc in the Cleveland/Akron, Ohio, area, uses the HydroWorx 500 series pool (www.hydroworx.com) with an underwater treadmill. It’s also a resistance pool that the practice has had for about 6 years. “One of the main reasons that we use the system is that it allows us to eliminate up to 75% of a patient’s body weight,” he says, as it puts them in a non-weight-bearing position. “For patients who have had severe ankle injuries or knee, hip, or back problems where weight-bearing bothers them, gravity is not their friend.” When they are put on the underwater treadmill, however, they can work on their strength, work muscles against the water resistance, work on cardio fitness, and increase endurance. “We don’t have to worry about the weight-bearing because the water is holding them up,” Kleinman adds.

The pool features two windows—one in the front and one to the side—to monitor a patient’s gait pattern and give feedback.

Kleinman says that the HydroWorx 500 is good for fibromyalgia patients because the water is heated and maintained at about 90°F. “We can stress their muscle systems—the arms, legs, back—without irritating or inflaming them. The water acts as a brace because it has hydrostatic pressure,” he notes. The deeper the body is submerged in the water, the more pressure the water puts on patients. It supports them while they’re working.

Ron Kleinman, PT, uses Hydra Tones for upper quarter strengthening.

Kleinman says that his practice uses the system with its young clients and bariatric patients as well. “It’s extremely good for patients who have had joint replacements (knee, hip). We can get them moving much quicker because weight-bearing is not an issue. Gravity can be your enemy sometimes,” he stresses.

One of the other options his practice has with the HydroWorx 500 is jet control. “We can control both the direction and intensity of the jet so they can walk or run against resistance, do functional activities, or swim in place,” Kleinman says.

WHO BENEFITS?

“Almost any patient can benefit from aquatic therapy,” says Caryl Sircus, MS, PT, executive director at Aquatic Therapy Associates in San Rafael, Calif (www.aquatictherapy.org). “We treat children with low tone or high tone. They benefit from the warm water for relaxation and the ability to move in ways they cannot on land. [There’s] a progression of their function as well as a big fun factor that does not involve pain,” she adds.

Sircus says she sees adults who’ve had recent strokes and those living with the effects for years. “We see children and adults with orthopedic injuries and postsurgeries, and many with back pain,” she notes. “Again, the water allows for movement without all the limitations of gravity, which helps work the muscles. The buoyancy decreases pain.”

“We treat one-on-one,” Sircus explains. “Those with chronic diagnoses tend to come in on a regular basis. Those with acute issues come in for a shorter time. We also provide a comprehensive evaluation and set up a program for those who want or need to be more independent.”

Other recipients of aquatic therapy include people with arthritis, osteoporosis, multiple sclerosis, asthma, and chronic joint or back pain. Again, buoyancy comes into play here because of the decreased load on the joints.

Ron Kleinman, PT, performs reciprocal muscle training for stabalization.

“Patients who benefit the most are those who are affected by osteoarthritis, particularly of weight-bearing joints such as the lumbar spine, hips, knees, and ankles,” adds PJ Landers, DPT, MPT, MTC, OCS, Landers Physical Therapy in Covington, La (www.landerspt.com).

“All patients can benefit from aquatic therapy as the water massages, provides pressure that helps reduce swelling, provides buoyancy so that movement is easier than on land, [and] adjusts to what the person is able to do—ie, try to move really fast and it resists you, try to go slow and it is easier,” explains Gayle Olson, ATC, Partners Healthcare in Foxboro, Mass. “If warm (above 82°F), it’s relaxing.”

Olson uses the SwimEx (www.swimex.com) line of products. “SwimEx is better than most because you can get all the benefits listed above plus add the flow of the current for the patient to work with or against, and the results are dramatic,” she emphasizes. “Just making someone walk with a cross current, forward and backward, is great for core strength but also wonderful for any and all lower-extremity issues.”

Joshua T. Green, PT, and Ryan J. Mullin, PTA, at Advance Physical & Aquatic Therapy (www.advancephysicaltherapy.biz) in Springfield, Pa, treat a variety of diagnoses, including but not limited to arthritis, back and neck pain, gait and postural deficits, overall deconditioning, postsurgery care, hip and knee pain, stroke, and a variety of other neurological and orthopedic conditions. They purchased the Waterwell model from Endless Pools (www.endlesspools.com) for the specific customization elements, cost-effectiveness, and to be supportive of local business. The Waterwell can be configured to your liking and specific clinic needs as far as size, depth, and optional therapeutic components, while maintaining a low cost. The 92°F to 94°F temperature allows for buoyancy and endorphin release in their patients, increasing comfort, compliance, and results in outpatient physical therapy.

Kathy Kirby, OTR/L, is the director of rehabilitation and wellness coordinator at Nye Senior Services (www.nyeseniorservices.com) in Fremont, Neb. Her practice chose a Ferno Pool (custom model E1216) (www.fernoperformancepools.com) because they could custom design it to meet their needs. “We were building from the ground up and specifically designed the pool to our space and clientele,” she says. “The ability to have flexible seating options and the treadmill were major factors in our decision to purchase a Ferno pool.” Kirby says they see a variety of clients in the pool, ranging from people with strokes, generalized weakness, back pain, arthritis, and more. “We have seen people in the pool anywhere from age 30 to 98, all with much success,” she adds. “People who might be hesitant to get in initially find that they hate to see their therapy end. The effects of the warm water and one-on-one attention from the therapists is soothing, both physically and emotionally.”

LATEST PRODUCTS, TRENDS

Ron Kleinman, PT, and his patient practice functional diagonal patterns for the shoulder.

“I am very partial to the noodle. It’s a versatile piece of equipment,” Sircus says. A noodle is also known as a pool floater. Clients can hold the noodle down in front of themselves and push it down until their arms are fully extended. Then, while still holding the noodle, they can let their arms come up to the surface. Noodles can also be sat on like a swing. Both knees are brought upward toward the chest and then pushed outward again to improve abdominal breathing and balance. A person can stand on a noodle and push it down to the pool floor for balance and flexibility or walk on the noodle with small steps from one side to the other. This activity improves balance, muscle strength, and flexibility. “There are other products that can be used to increase resistance like gloves and belts. Belts are great for deep-water work,” Sircus says.

A growing market where the pools are being used now is for professional athletes. NFL teams such as the Cincinnati Bengals, Pittsburgh Steelers, and Philadelphia Eagles, and a lot of the major colleges, are starting to put in the same system for rehab, according to Kleinman.

PTs are actually using the modality a lot more often because of its properties. “Shoulder patients who have had a rotator cuff repair—one of their biggest problems is that they are always guarding that shoulder,” he emphasizes. “We can put them in the water and float them on their stomach. We give them a mask, snorkel, and floatable mat, and their arms are very relaxed. We can mobilize their shoulders much easier.” Kleinman says that if they were to put patients on a treatment table and try to move their arms, they will try to lower the [affected] arm and protect it.”

“Speedo (www.speedousa.com) has an upper-body exerciser that is really nifty,” Olson says. Other accessories include hydro-resistant dumbbell disks, swim gloves, arm trainers, hand weights, leg trainers, barbells, and belts, to name a few. “Otherwise, noodles, balls, bands—just about anything—can be adapted to the water, so there are lots of products. You don’t have to have a ton of them to do it; just think about how someone is moving in the water and adapt.”

“I think the trend is toward education,” Landers says. “People are becoming more aware of the advantages of aquatic physical therapy in which you can create a safer environment for progressive rehabilitation,” he says.

Kleinman’s patient practices weightless gymnastics in the pool.

With the evolving changes in health care, Advance Physical & Aquatic Therapy’s personalized aquatic therapy program improves motivation of patients, overall desire to attend outpatient physical therapy, and willingness to spend elevating co-pays because they see faster results and goal achievement. Endless Pools and, specifically, the Waterwell system has allowed them to provide this care and reach a population in need of its services.

INSURANCE ISSUES

“Insurance does not always cover,” Sircus says. “At this point I am literally trying to stay afloat with the decreases in reimbursement.” Although it varies among carriers and plans, in most cases a prescription from the physician and/or a precertification from the insurance company are required in order to receive aquatic therapy. There are certainly issues of medical necessity, and to some carriers/plans there is a difference between aquatic therapy and aquatic exercise.

Nina Silberstein is a contributing writer for Physical Therapy Products. For more information, contact .