Tim is a 52-year-old male who experienced a C3-C4 spinal cord injury. In this image Tim is shown participating in the Bad Ragaz Ring Method. For this, the therapist utilizes pool noodles, a flotation belt and a cervical flotation collar with the purpose of enhancing passive and active range of motion in Tim’s upper extremities.

Tim is a 52-year-old male who experienced a C3-C4 spinal cord injury. In this image Tim is shown participating in the Bad Ragaz Ring Method. For this, the therapist utilizes pool noodles, a flotation belt and a cervical flotation collar with the purpose of enhancing passive and active range of motion in Tim’s upper extremities.

by Lauren Pocius, OTR/L, and Leigh Riley, MSOT

Aquatic therapy continues to grow in popularity all over the country in many rehabilitation settings. It is mainly used as a safe addition and/or alternative to land-based therapy due to the benefits of the water. At Gaylord Specialty Healthcare in Wallingford, Conn, aquatic occupational therapy is used on an inpatient and outpatient basis to improve patients’ overall daily functioning and quality of life. The focus of this article is to describe the benefits and goals of aquatic occupational therapy and the complementary role it plays in patient care. A case study will be used to further explain and discuss the benefits of aquatic occupational therapy intervention.

Facility Overview

Gaylord Specialty Healthcare in Wallingford functions as a long-term acute care hospital and outpatient rehabilitation facility. Individuals receiving medical treatment and therapeutic intervention at this facility are often referred for specialized care dealing with acute and chronic illness or injury. Gaylord is the only hospital in Connecticut, and one of two facilities in the country, with Commission on Accreditation of Rehabilitation Facilities (CARF) international accreditation for all inpatient rehabilitation programs, as well as additional accreditation for spinal cord injury, stroke, and brain injury. Gaylord Hospital aims to provide the most comprehensive and cutting-edge care for its patient population. The inpatient and outpatient therapy programs at Gaylord offer access to state-of-the-art equipment and treatment interventions to best meet rehabilitation needs. The Gaylord outpatient clinic in Wallingford treats a wide range of orthopedic and neurologic diagnoses, including stroke, spinal cord injury, traumatic brain injury, orthopedic injuries, hip and knee replacements, multiple sclerosis, and pulmonary disease.

Interventions Occupational Therapists Provide

Occupational therapy practitioners construct occupation-based interventions to facilitate functional change and growth for their clients. This process involves clinical evaluation, intervention, and targeting of outcomes. The process requires a collaborative relationship between the therapist and client.1 Keeping in mind the goal of improved engagement in meaningful occupation, occupational therapy practitioners focus on interventions that include the maintenance or improvement of joint and muscle active range of motion, flexibility, balance, fine and gross motor coordination, muscular and cardiovascular strength and endurance, sensory reintegration and re-education, and functional cognitive skills.

Goals established in occupational therapy may appear to be similar throughout the client population with respect to functional independence. However, the chosen interventions and activities used in treatment sessions can be vastly different due to the individualized path each client takes toward improved life engagement.

Aquatic Therapy Program: Occupational Therapy

The outpatient occupational therapy aquatic program was created this year to offer the most comprehensive treatment options for those transitioning from inpatient services, as well as for those being referred from other facilities. The aquatics program at Gaylord has been in place since 1987. Before the current therapeutic pool was built in 1992, patients would receive aquatic intervention at local fitness centers.

Gaylord Hospital’s aquatic center has a large 75-foot by 25-foot pool that is maintained at a constant 90 degrees. The pool is designed with specialized lifts, steps with handrails, and a 2-foot-high ledge that allows individuals of all functional mobility levels to enter the pool with ease. The pool includes a submerged bench, handhold cut-outs, a deep-water exercise station for modified pull-ups and push-ups, and warm-water jets located throughout the sides of the pool. Additional pool equipment includes step benches, buoyancy cuffs and belts, Velcro weights, webbed gloves, cervical collars, noodle floats, paddles, barbells, and dumbbells of varied thicknesses. The pool’s design and various aquatic equipment aim to address balance, strengthening, endurance, pain management, muscle relaxation, and modified functional task completion. The aquatic center also offers a program called Aquacize, which is an inclusive pool exercise program for all ages and ability levels.

Aquatic therapy offers a unique set of benefits for practitioner and client to maximize rehabilitation. The viscosity and buoyancy of water provides support for the client and assists in completion of balance tasks with improved safety and confidence. The properties of water in a therapeutic setting can facilitate decreased joint/soft-tissue edema, which can assist with pain management. Warm water temperature increases joint flexibility and range of motion, promotes relaxation, and improves circulation. Water’s natural viscosity and resistance can be utilized for muscle strengthening and endurance. Aquatic therapy also provides a zero-gravity environment for those with weight-bearing limitations. By reducing the load on joints during movement, exercises in water are often performed with improved range and tolerance. This zero-gravity environment also provides the opportunity for a treating therapist to position a client in the water in a way that is not safe or practical for those with mobility impairments on land.

The aquatic setting provides a less intimidating environment for practice of simulated functional tasks such as object carrying, stepping, item retrieval, and placement. There are instances for individuals receiving land-based therapy where these skills are unsafe or inappropriate to practice on land. Practicing a functional task in water assists in the progression toward safe and confident land-based activity for an individual receiving therapy. Aquatic therapeutic intervention is just as individualized as land-based treatment and relates to all aspects of the occupational therapy framework.

Goals of Occupational Therapy Aquatics

The ultimate goal is to maximize functional independence and ease in daily task completion, as well as transition the individual to an independent exercise program. For example, by improving upper extremity active range of motion, balance, and coordination, a patient will be able to reach up into their cabinets while cooking a meal more easily. With increased muscle strength and endurance, a patient can improve their safety while getting themselves dressed. Patients will also improve their overall quality of life with reduced pain levels. For certain diagnoses, including nerve injuries, the water can improve their body awareness and sensation due to sensory reintegration and neuromuscular re-education.

Case Study: Tim

Pmhx:

Tim is a 52-year-old male who was in good health when he fell off a forklift at work May 24, 2018, and experienced an incomplete C4 spinal cord injury as a result.

Tim had several surgeries following his injuries and was placed on a ventilator in an attempt to stabilize his condition for maximal recovery. Postoperatively, Tim began to regain some movement and sensation to his left leg. His recovery continued after being transferred to Gaylord Specialty Healthcare for inpatient rehabilitation. Tim’s recovery was remarkable, as he began therapy as a bedbound patient and walked out of the hospital with only a rollator on the day of his discharge.

Despite his improvements, Tim continues to experience increased muscle spasticity, which limits his upper extremity range of motion and functional use, as well as decreased strength, endurance, coordination, dexterity and gait disturbance.

Evaluation/Treatment on Land

Tim began outpatient occupational therapy in October 2018, 5 months following his injury. Initially, it was observed that Tim was doing very well despite his impairments. Therapy sessions began focusing on improving his upper extremity range of motion, functional use, and decreasing muscle spasticity. Activities of daily living (ADLs) were also addressed to improve Tim’s quality of life. Tim has made great progress during his time in outpatient, as he is now living independently in his own apartment. However, progress with Tim’s upper extremity function has been slow and began to plateau over the past several months. Tim has done well with learning how to compensate for his deficits and figuring out how to manage all of life’s challenges with about half the normal range of motion in his upper extremities.

Benefits of Aquatics

Due to his lack of progress, Tim and his therapists agreed that aquatic occupational therapy would be a great complement to his land-based intervention and would assist in his progress.

The focus of pool therapy sessions for Tim involved using the properties of water in a therapeutic environment to improve upon his bilateral upper extremity passive range of motion, active range of motion, tone management, and sensory reintegration.

Upon entering the water for the first time, Tim immediately commented on the weightlessness of his body. Since his injury, Tim has felt a constant pressure and strain on his joints. The buoyancy created in an aquatic environment reduced the load on Tim’s joints, allowing his body to relax in a way he had not been able to experience on land. This assists in decreasing muscle spasticity to allow for improved range of motion. Tim’s therapy sessions have focused on using the Bad Ragaz Method along with prolonged stretch of his upper extremities in the water to assist in improvement in active and passive range of motion.

The Bad Ragaz Method involves the therapist positioning an individual horizontally in water using the support of flotation devices. The therapist moves the patient through the water, creating resistance with the goal of promoting muscle relaxation, pain management, and improved neuromuscular functioning.2 Post therapy sessions, Tim reported reduced pain, improvement in active range of motion of his arms, and longer periods of decreased spasticity than with land-based intervention alone.

Functional Gains

Improvements in foundational skills such as range of motion, strength, coordination, and sensation, are areas that allow for overall improvement in independence and life quality. Outside of the physical benefits observed, Tim also reports that being in the water allows his body to move in ways he is unable to on land, which is an exciting and meaningful experience for him. Occupational therapy at its core aims to provide therapeutic intervention through meaningful occupations that are individualized from person to person. This aquatic environment not only assists in Tim’s overall function but has meaning to him personally and his rehabilitation journey.

Patients with both similar and different diagnoses to Tim can benefit from aquatic occupational therapy in an outpatient setting. For example, a patient with multiple sclerosis can benefit from aquatics due to water buoyancy for decreased strain on joints while improving their overall strength and endurance. A patient who has suffered multiple rib fractures in a motor vehicle accident can improve their upper extremity range of motion and decrease pain in water in a way he would be unable to on land. The properties of water can have a positive effect on almost any diagnosis, which is why aquatic therapy continues to grow in popularity.

Conclusion

Occupational therapy strives to improve patients’ function with their daily tasks through meaningful and purposeful interventions. Aquatic occupational therapy is a creative approach to rehabilitation that allows patients to maximize function in a completely different environment. The benefits of aquatic rehab are immense and can improve a patient’s overall quality of life. In Tim’s case, he continues to see improvements both in the water and on land. Aquatic occupational therapy will continue to provide patients with new meaningful and purposeful interventions and be an enjoyable addition in their recovery. RM

Lauren Pocius, OTR/L, is an occupational therapist at Gaylord Specialty Healthcare, Wallingford, Conn.

Leigh Riley, MSOT, is an occupational therapist at Gaylord Specialty Healthcare, Wallingford, Conn. For more information, contact [email protected]

References

1. Occupational Therapy Practice Framework: Domain and Process (3rd Edition). (2014). Am J Occup Ther. 68(Supplement_1). doi:10.5014/ajot.2014.68s1

2. Hands-On Aquatic Therapy Techniques for the Ortho/Neuro Client: A Survey Course (2014). Aquatic Therapy University