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Criteria for Ethical Excellence in Aquatic Therapy
by Lynda Huey, MS
Aquatic therapy programs around the country are inconsistent at best. Few schools teach in-depth programs in aquatic therapy, so physical therapists are left to create their own programs based on information gathered from whatever sources they can find. Since we’ve been doing this longer than most (since 1983) and have taught aquatic therapy programs around America, Europe, and Australia, we would like to stand up and propose some essential standards for aquatic therapy. Below, in order of importance, we’ve listed what we consider to be the most important criteria to consider when developing a pool program. If you can meet only three or four of these criteria, choose the first ones.
1. Deep Water
When patients wear flotation belts in deep water and are able to run, walk, and do other non-weightbearing exercises, they are freed from the limitations they face on land. These non-weightbearing exercises are vital to reduce joint stress and allow patients to exercise without pain. Without access to deep water, the patient’s ability to reach their full potential of dynamic strength is severely limited. Two-thirds of our thorough program takes place in deep water – that’s where two-thirds of the benefits are, so don’t compromise on this! Shallow-water aquatic therapy program are just that, a compromise. Do whatever it takes to get deep water for your patients: lease space at a high school, college, or YMCA pool. Or build your own pool if you can’t find a pool built more than thirty years ago. At that time pools all had deep ends. That was before the ubiquitous health club shallow pool and the lap pool came into vogue.
2. Therapists in the water with the patients
A therapist who is deckside is doing less than half the job. Most of the job is hands on: positioning patients, giving manual cues, physically checking alignment, moving arms and legs through the correct planes of motion, touching patients to help them relax, and being within earshot so the conversations patients save for their therapists can be held in confidence. Successful treatment outcomes are afforded through proper technique instruction and supervision which is not possible with a deckside therapist. Mimicry is the foundation of learning; and since it is virtually impossible to demonstrate the floating quality of water exercises while on land, the therapist should be immediately next to the patient in order to demonstrate, observe, and correct the patient’s alignment on all exercises.
3. Water temperature of 87-92 degrees
Dedicated therapy pools often keep their water temperature at 94-96 degrees, but this limits the pool strictly to those patients who are moving slowly; high-level patients can’t tolerate such heat. The ideal temperature is 90-92 degrees, but if you’re inside a YMCA or other pool, you can’t control the temperature. Keep looking for your ideal pool until you find one that is at least 85 degrees. Anything below that, even one degree, will mean discomfort for both the patients and the therapists. Since therapists are in the water for an extended time, they’ll need to wear shortie wet suits to remain comfortable in any water temperature that is below 88 degrees. And patients appreciate it if there is a zip-up neoprene jacket handy for their use.
4. Individualized treatment, no groups
All over America, groups of “patients” are being treated in class formation with one instructor squatting deckside offering ideas to eight to fifteen people in the pool. This may be an extremely well-taught exercise class, but this should not be called physical therapy. One-on-one is the ideal and is the requirement for reimbursement by Medicare, Motion Picture Insurance, and other carriers. We’ve learned that two patients can often be treated by one therapist and high-quality care administered, but anything more than a two-to-one ratio erodes our high standards. Subtleties, such as the cues needed for symmetry and trunk/core stabilization, cannot be addressed in a larger group.
5. Weekly progress in plan of care
This ties in with treating patients individually, not in groups. Just as in land therapy where new exercises and additional repetitions are added specific to the diagnosis and symptoms of the patient, so , too, must they be added in the pool. Flow sheets showing each pool exercise helps make it easy to document this. Week Two in most patients’ charts will already show that more speed, more buoyancy, more resistance, more weightbearing, more repetitions have been added and such progress should continue weekly. The lack of progress would justify discharge or transition to another therapeutic medium. After all, PT is a results-based endeavor.
6. Increase ROM with the correct gradient of buoyancy pieces
A buoyancy cuff strapped around the ankle will allow for increased ROM by gently floating the distal limb to the surface of the water. Start with a mini buoyancy cuff* when performing lateral leg raises, anterior and posterior leg raises, and leg circles for hip patients; and when doing quad extensions and hamstring curls for knee patients. Progress to the standard size ankle cuff* (approximately twice as much lift) for increased buoyancy.
7. Increase strength with the correct gradient of resistance pieces
Various pieces of equipment provide low, medium, and high amounts of resistance while performing lower extremity exercises. Start with a low-resistance 4-Fin* around an ankle when doing lateral leg raises, anterior and posterior leg raises, and leg circles for hip patients; and when doing quad extensions and hamstring curls for knee patients. Progress to medium resistance, then the high resistance 4-Fin, then if the patient can tolerate the highest resistance, move to the Hydro-Tone boot*. For upper body work, start with webbed resistance gloves*, then progress to the low-, medium-, and high-resistance Aqua Bells* before trying the Hydro-Tone bells*.
8. Bars on the sides of the pool
In the deep end, bars allow for easy stretching and for tethering to keep the patients attached to the side of the pool for stability and improved form. In the shallow end, bars give patients a solid hand-hold when doing lower extremity exercises.
9. Laminated exercise cards for patients when discharged
Patients often fall in love with their pool programs and want to continue to do them in neighborhood pools once they are discharged. They’ll need guidance, so give them a list of the nearby pools that allow access. Organize your own photos or drawings into a sheet that can be laminated for poolside use by patients or order our laminated back, hip, and knee exercise sheets online Here.
10. Deckside charting
Therapists need towels and a slightly elevated work station where they can do their charting as treatments are happening without leaving the pool. Water proof bins for patient charts plus trays of pens, post-its, and paper clips make this possible. A walkie-talkie or phone to the office helps keep communication and paperwork flowing properly.
Lynda Huey’s four books on water rehabilitation are considered the foundation of aquatic therapy worldwide.