Physical therapy is all about movement—restoring, correcting, strengthening, and making movements more functional. Much of the time, this can be accomplished in the clinic, but often it becomes more difficult when the patient has a reduced tolerance for weight-bearing, impaired balance, or when movement itself is painful.
For those patients, we turn to the water. The effects of immersion and movement in the water are numerous: weight-bearing on the joints and spine is reduced by buoyancy; movement is slowed and cutaneous feedback is enhanced; balance is challenged, yet the body is supported; and resistance is provided and increases exponentially with velocity. Additionally, floating the patient in supine—or prone with a snorkel—allows positioning of the patient in a comfortable, supported, and accessible manner.
Diving Right In
When I contemplated opening my own clinic, a major requirement was that the space had to be conducive to the placement of some sort of pool. I found an ideal space—a former 2,000-square-foot private-training gym, complete with showers and lockers. Of course, I could have built a pool directly in the ground, but the engineers advised otherwise (the building is constructed on landfill). And, since I am only renting the space, I wanted something that could be removed, if necessary.
When I was investigating my options, there were quite a few pools to choose from, including those by SwimEx, HydroWorx, Ferno Performance Pools, and Endless Pools. The first four are fiberglass shells with various types of steps, seats, "stations," and propulsion systems. Additionally, Ferno offers a stand-alone underwater treadmill called the AquaCiser III. Interestingly, the AquaCiser I was the device that, 20 years ago, first demonstrated to me the benefits of exercising in the water when I was an assistant in a PT clinic. The AquaCiser is a treadmill enclosed in a tank. The water is then pumped into the tank from a reservoir for exercise, and then drained back into the reservoir after use. With its small footprint, this device can be used in virtually any office. Check your engineering first, however, as water weighs a lot.
The Endless Pool I ended up selecting consists of stainless steel panels that bolt together and to a concrete base, with a vinyl liner. The standard depth is 39 inches, but this can be customized for those desiring deeper or multiple depths. After working in several public pools, I quickly realized that non weight-bearing exercise requires at least 5.5 feet of depth for the average person to avoid scraping their toes. For standing exercises, a 4-foot depth allows immersion to the chest with knees slightly bent. Our pool incorporates all three depths.
As it turns out, putting in a pool was truly a great idea. Currently, we have an average of about four to five patients per day in the pool, who usually spend one-on-one time with a therapist. The type of patient who uses the pool varies widely, from those with chronic low back pain to patients recovering from knee injuries, surgical repairs, and joint replacements, as well as those with upper-extremity injuries. We also introduce aquatic therapy to patients with neurological conditions—namely, stroke and traumatic brain injury victims.
Some patients require only a few sessions to get them going on their own, especially if they have access to a pool at home or in the community. Others require numerous treatment sessions, with some needing as many as they would have on land. Furthermore, we have found that combining land-based sessions with pool treatments promotes the carryover that we desire. After all, we live on land, not in water!
Many of the pools on the market today have wonderful options, including underwater treadmills, rowing devices, massage jets, steps, and benches. Several companies, like Ferno and HydroWorx, offer a treadmill that is actually built into the pool. HydroWorx also offers an adjustable platform that can be used to vary the depth of the entire pool. Both SwimEx and Endless Pools have propulsion systems that produce a smooth, laminar flow of water that allows swimming with a normal stroke that is not affected by the flow of the current. (Some of the jet-created streams tend to push the swimmer's hand around upon entry and catch.) The current can also be used to add resistance to exercises with paddles, gloves, or other devices.
Endless Pools are built with a stainless steel bench along all four walls. In addition to providing seating for exercise and rest, the bench serves as a return for water going to the swim current generator. Grab bars can also be installed as desired for support and as points of attachment for tubing or straps. At the suggestion of one of our patients, we implemented suction-mounted grab-handles in the pool, which stick perfectly to the stainless steel benches.
Depending on the construction, entry into and exit from the pool may be an issue. If the pool is in-ground, steps or a ramp inside the pool may be all that is needed. If it is entirely surface-level, some sort of decking will probably be necessary with a ramp leading up to the pool. These additions will naturally add considerably to the space required. To accommodate patients who want to sit and swing their legs into the water, I placed my pool partially in-ground, with a 2-foot-high wall that circles its length. A step and the built-in bench further facilitate entry and exit. We also have a Hoyer portable lift in case patients should require additional assistance.
There are many options for lifts, as well, from manual/hydraulic, to water-powered, to electronic lifts with waterproof remote controls. The individual characteristics of the pool, clientele, and budget will help determine the appropriate device.
A myriad of treatment and training tools are available for use in the pool. Paddles and webbed gloves provide increased resistance for upper-body exercise. Some of my favorites are Sprint Aquatics' paddles with vanes that can be opened or closed to vary the resistance, and multi-directional paddles by Aqualogix, which come in three sizes. The latter allows PNF patterns to be performed easily, without the need to rotate the paddle. Upper-extremity resistance exercise while sitting isolates the upper body, while using them in a standing position can emphasize trunk stabilization while strengthening the arms, chest, and back. Straight-arm "lat pulls" performed with the ubiquitous noodle work the lats and abs simultaneously. Similarly, float bells can be used for these exercises where the resistance is now created by the buoyant effect of the water rather than gravity. (For instance, what would look like a bicep curl with a dumbbell is actually a tricep exercise with a float bell.)
Noodles can even be used for lower-extremity exercise by standing on one or two of them and maintaining balance or performing squats in deep water. Swim fins may also be used to increase the workload on the lower extremities. Zoomers are made in individual sizes, while Aqua Sphere makes an adjustable fin. There is even a mono-fin made by FINIS for more advanced trunk strengthening. The fin helps keep the feet together, allowing patients to perform a dolphin kick (picture a mermaid with six-pack abs). These can be used for kicking into the current with a kickboard, swimming, or kicking while holding onto the various handles that may be available in the pool.
Flotation devices vary from the noodle, to closed-cell foam flotation belts, to neoprene vests and jackets. These can be used for deep-water running, or for buoyancy while performing other exercises. My favorite is a closed-cell foam belt from WaterGym. It has an elastic belt and a low profile that allows unimpeded arm movement. Float bells—both dumbbell and barbell types—provide upper-body exercise resistance, as well as buoyancy. The resistance they provide is primarily in the opposite direction that weighted dumbbells would provide on land. Kickboards, and the V-shaped Kiefer Wonderboard, can be used for flotation, resistance, and trunk-stabilization exercises. Walking in the pool with the kickboard in a plow position increases the workload considerably and can be used with more advanced clients.
The effectiveness of manual therapy can be enhanced by the buoyancy of water. Noodles, belts, arm-rings, or simply the therapist's arms can be used to support the patient in a comfortable position, allowing the muscles to relax and movement to be performed with minimal resistance. Slow, gentle rocking, side-bending, and even trunk flexion/extension motions can be initiated with minimal effort by the patient or the therapist. The same movements can be performed with resistance as the speed or direction is changed, depending on the desired effect. Also, manual traction may be applied at the neck or lumbar spine with the patient floating in a supine position. Lumbar traction can also be achieved using ankle weights along with flotation, allowing the patient to relax comfortably in an upright position while pressure is removed from the spine.
Water has the potential to enhance the way we treat a wide variety of patients due to its properties of buoyancy, support, warmth, and resistance. Fortunately, increasing numbers of physicians are realizing this and prescribing aquatic therapy for their patients. And patients are asking for it!
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