PHOTO CAPTION: Therapist assists her patient, diagnosed with a spinal cord injury, with gait training, by facilitating step lengths and contact with the floor. Precautions using a mask and faceshield are used, as per COVID guidelines in this outpatient setting.

COVID-19 is said to be the worst pandemic in more than 100 years. It halted schools, travel, sports, businesses, healthcare, and wellness, creating a lockdown around the globe during its peak, devastating many more lives, and lingering far longer than anyone anticipated. As the world awaits a vaccine, many struggle to figure out how to re-open in a safe manner, for employees and clients alike, and the aquatic therapy domain is no different. The aquatic environment for rehabilitation purposes is known for being effective for various musculoskeletal, cardiopulmonary, and neurological diagnoses such as multiple sclerosis, stroke, Parkinson’s disease, osteoarthritis, chronic pain, cerebral palsy, and spinal cord injury.1,2 However, aside from its advantages, aquatic therapy generally remains underutilized.3,4

Those suffering from spinal cord injuries (SCI), in particular, lead a more sedentary lifestyle compared to those without paralysis, resulting in various comorbidities and a reduced lifespan.5 Furthermore, the unexpected quarantine that was thrust upon our world due to a highly infectious disease left patients unable to attend in-person therapies and wellness facilities that exist to curtail their impairments and functional limitations. Buoyancy, drag force, hydrostatic pressure, and the thermodynamic properties of water allow for significant improvements for those with spinal cord dysfunction.3

The aquatic atmosphere improves respiratory efficiency and function and reduces spasticity in those with SCI.2,3 In addition, aquatic therapy led to increased lower extremity strength, balance, and walking ability while reducing walking heart rate for those specifically with incomplete SCI after using an underwater treadmill.5,6 As a result of the many benefits accessible pools have for patients with spinal cord disease, it is important to facilitate water-based therapy, with thoughtfulness and guidance, even in the midst of a worldwide pandemic.

Equipped for Every Patient

Our facility is the International Center for Spinal Cord Injury at Kennedy Krieger Institute, located in Baltimore. We treat adults and pediatric patients with SCI and paralysis from both traumatic and non-traumatic origin. Quickly after the COVID-19 crisis began, our facility was able to provide telehealth services to our patients who were unable to be seen in person due to the disease restrictions and/or medical complications. Telehealth therapy for patients with paralysis allows our therapists to guide strengthening, stretching, balance, and endurance training through video-based web conferencing, but it is limited without crucial equipment that exists in our clinic such as body-weight supported exoskeletons and treadmills, vibration, and functional electrical stimulation devices.

Our aquatic department, specifically, is comprised of key aquatic technologies to assist in-person patient care. We have two in-ground pools: one that holds 14,200 gallons of water and another that holds 5,750 gallons of water and includes an underwater treadmill spanning the entire floor. We also utilize one self-contained above-ground water structure that has adjustable pool depths from 1-50 inches plus an underwater treadmill. Both of the in-ground pools contain elevating floors for easy transitions into and out of each pool via aquatic wheelchairs, an overhead lift system, or ambulation. Patients enter the self-contained above-ground unit by foot, though an overhead lift system can similarly be utilized.

All of our pools include therapeutic jets for resistance training, massage hoses for soft tissue release, bars for upper extremity support, and video monitoring for visual feedback. Therapists also use various pool accessories to supplement their treatments including floats, kick boards, noodles, foam dumbbells, extremity cuffs, fins, weights, waist belts, resistance shoes, sitting boards, and portable underwater benches and steps. Bromine levels range from 3-10 parts-per-million, pH levels range from 7.2-7.8, and the therapeutic temperature range is from 89 to 94 degrees Fahrenheit.

Making it Pandemic Safe

To encourage safety during the contagious outbreak of COVID-19, Kennedy Krieger Institute’s aquatic program made several adjustments to its policy and procedures by following guidelines set forth by medical professionals and infection control specialists. From April to June of 2020, 64 patients received aquatic therapy services from our facility without incident. The Centers for Disease Control and Prevention (CDC) has confirmed that COVID-19 is not transmitted through water in pools, determining that it is safe to participate in aquatic therapy given the following guidelines:

• Patients will enter the pool via the main entrance and exit the pool through the locker rooms to provide one-way traffic flow.
• Persons on the pool deck will follow all Institute policies regarding social distancing by maintaining distance of greater than 6 feet and the wearing of personal protective equipment (PPE). A surgical, procedural or cloth face mask is required for everyone over 2 years, unless he/she has trouble breathing or who is otherwise unable to remove the mask without assistance. This includes staff and caregivers.
• Pool chemistry will continue to be checked and maintained every two hours per state and city guidelines.
• All surfaces outside the pool will be cleaned with Oxivir wipes after use.
• Patients will be scheduled with staggered start times, allowing 30 minutes between sessions to allow for optimal sanitation.
• A maximum of two patients can be scheduled at any given time. Those patients may be seen in the large pool while maintaining social distancing or by having one patient in each pool.
• There will be one patient per locker room at any given time.
• Patients can be accompanied by one caregiver and therapist.
• Face shields are required by the Institute for direct patient care, therefore, face shields and masks will be worn by all pool therapists.
• Patients will wear face masks as tolerated and appropriate, following Institute guidelines (eg, patient must be able to doff his/her own mask independently, should not have trouble breathing with a mask, and is over 2 years of age).

Protection Outside the Water

These guidelines created for the aquatic department balance institute policy. In order to enter any institute building, people are screened for symptoms of COVID-19 including fever or feeling feverish, cough, shortness of breath, new loss in taste or smell, headache, sore throat, body aches, chills, and diarrhea. Also, there is a mandatory temperature check, only one adult visitor per patient is permitted to visit, no visitors under the age of 18 are allowed, and inpatients are tested for COVID-19 before admission. If a positive case occurs, contact tracing begins immediately, and those effected are quarantined for 14 days.

It is important to note that the CDC does not recommend masks in the water for increased risk of drowning. However, our aquatic department uses paper masks, there is a lifeguard and a physical or occupational therapist present at all times to assist in the event of an emergency, and most of our tasks for therapy are performed vertically. Therefore, we have allowed patients the opportunity to don a mask for their safety, if preferred, so long as the patient can doff his/her mask independently.

Rehab Reopened

Coronaviruses are not new to the world, and emerging infectious diseases caused by coronaviruses are anticipated by scientists and medical professionals, posing a grave universal threat.7 The United States of America (USA) has struggled with an adequate response to the COVID-19 pandemic which is reflected in their number of deaths at 124,424 as of June 26, 2020, more than double any other country in the world.8 Therefore, whether you or your facility are looking to re-open your doors in response to the current COVID-19 health crisis or prepare for a future outbreak to attempt to curb unnecessary spread early on, it is our hope that therapists and aquatic programs can look to these strategies as a guide to ensure the needs of our patients can continue to be met with proper caution and care. RM

Rachel Mertins, PT, DPT, has been a physical therapist with the International Center for Spinal Cord Injury (ICSCI) since September 2008. She received her Doctorate of Physical Therapy from the University of Maryland, Baltimore, in 2008. She was Aquatic Therapy and Rehabilitation Institute certified (ATRIC) from March of 2009 through 2014, transitioning to a Certificate in Aquatic Physical Therapy Clinical Competency (CAPTCC) in July of 2015. Her clinical interests include proprioceptive neuromuscular facilitation (PNF), functional electrical stimulation (FES), and aquatics. She published two articles in the Journal of Aquatic Physical Therapy (JAPT) in 2014 and in 2017. She has also created a webinar for regarding aquatics
and SCI in 2016.

Albert Cruz Recio, MD, RPT, PTRP, is a licensed physical therapist, board certified Physiatrist, and board-certified Spinal Cord Injury Medicine specialist. He is the Clinical and Research Director for the V Sail Access Program at The International Center for Spinal Cord Injury, Kennedy Krieger Institute, as well as the Medical Director of the Aquatherapy Program. Recio is committed to providing excellent medical treatment and innovative rehabilitative interventions to individuals living with spinal cord injury.

Christy Sachs, TRS, has her degree in Therapeutic Recreation and is a certified Personal Trainer and Nutrition Consultant. She is the Adapted Aquatics and Wellness Manager at the International Center for Spinal Cord Injury, Kennedy Krieger Institute. For more information, contact [email protected].


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