Clinic Director Scott Wesche looks on as Sam Flemming coaches a patient through leg extension exercises using the fully integrated underwater treadmill.  The treadmill’s soothing acceleration from .1 to 10 MPH allows users to correctly simulate land-based walking, running, or multi-directional activities without body weight and joint impact.

Clinic Director Scott Wesche looks on as Sam Flemming coaches a patient through leg extension exercises using the fully integrated underwater treadmill. The treadmill’s soothing acceleration from .1 to 10 MPH allows users to correctly simulate land-based walking, running, or multi-directional activities without body weight and joint impact.

by Scott Wesche, DPT, and Samantha Fleming, PTA

Jane was active, athletic, and always in motion—until a car accident left her with a traumatic brain injury that robbed her of her ability to walk. Her new disability upended her whole world; she was forced to relearn even the most basic daily tasks. A traditional, land-based course of physical therapy helped her regain her upper-body muscular control, but her greatest goal eluded her: the ability to walk, unassisted, just as she had before the accident. Jane’s proprioceptive challenges were difficult to overcome with traditional physical therapy and, perhaps more importantly, Jane had developed a serious fear of falling. Her legs simply wouldn’t obey her commands and, time after time, she lost her balance and fell. Handrails and padded floors weren’t enough to ease her anxiety. With her confidence gone and her morale sapped, she resigned herself to a wheelchair for 7 years.

On the advice of a friend, Jane came to consult with the therapists at Salt Lake City-based Intermountain Health Care. The therapists at Intermountain realized that aquatic therapy would address her issues and began treating her in the facility’s specialized therapy pool complete with underwater treadmill, varying height floor, and resistance jets. Once in the water, she stepped out of her wheelchair and her enthusiasm became clear: the buoyancy reduced the weight on her joints by approximately 90%. Suddenly, standing and walking were within reach, and she no longer feared falling. Even if she lost all control, the water gave her plenty of time to steady herself and regain her footing. She could move in ways that had not been possible since before the accident, and for the first time in many years, Jane felt hope for a return to a fully ambulatory life.

Why Water?

Aquatic therapy provides benefits for neurological patients that we haven’t been able to duplicate any other way. Patients suffering the effects of stroke, spinal cord injuries, or traumatic brain injuries regularly exhibit wide-ranging loss of muscle control. Immersion in a therapy pool reduces gravitational forces through buoyancy, reducing perceived weight. Many otherwise wheelchair-bound patients can stand in the pool with relative ease and begin gait training on the submerged treadmill—and they can do it within days instead of the months often required by land-based therapy.

As Jane learned, water’s natural buoyancy and resistance reduces the risk of falls. The psychological boost that this feeling of safety provides cannot be overestimated. Neurological patients frequently exhibit loss of confidence and self-esteem. When a patient enters the pool, they begin to regain the sense of self-control that their condition had taken away from them. This renewed confidence, the feeling that recovery is possible and within the patient’s reach, is an essential ingredient of any physical therapy program, and our aqua facility allows patients to achieve it in short order. Aside from the obvious mental health benefits, this positive, can-do attitude both eases and expedites the entire physical recovery process.

The warm water in the pool promotes muscle relaxation, diminishes pain sensitivity, and provides natural resistance for strength training, providing an ideal environment for many patients who, like Jane, are otherwise challenged by land-based options. One 62-year-old runner was desperate to return to the sport that she loved, but her neuropathic knee pain made it unlikely. Strengthened by only 3 weeks in the pool, she returned to a land-based therapy program and completed it within 2 months. Aquatic therapy was an indispensable part of her speedy recovery, and her story is far from unique. One of the clinic’s patients asked if “a bubble of water” could be provided that she could walk around in wherever she went.


The properties of water—including hydrostatic pressure, buoyancy, and metacentric forces—help patients regain balance and build confidence in a safe environment. The water and the handrails offer plenty of support and mitigate the fear of falling, which is an ever-present issue in land-based therapies. Once a patient is comfortable in the aquatic environment, the water level can be changed to simulate differing weight loads on the patient’s joints, helping to transition to a full-gravity, land-based regimen. Using the properties of water, therapists are able to challenge patients in a safe environment and give them the confidence they need to work on form and to move more freely.

When it is time for gait training, the treadmill component is essential. Those with traumatic brain injuries, spinal cord injuries, and stroke symptoms often have difficulty relearning the proper mechanics of leg movement. The water helps their arms and legs move more freely and, with the aid of the underwater cameras and a video monitor mounted at the patient’s eye level, they can actually see what their limbs are doing. Combining tactile and visual cues helps patients make faster and more accurate corrections, accelerating the overall rate of recovery.

Computer and camera systems allow underwater movement to be easily monintored so corrections can be made in real time.

Computer and camera systems allow underwater movement to be easily monitored so corrections can be made in real time.

Proven Programs for Success

There are two methods of aquatic therapy staff members use at Intermountain Healthcare. One is the Halliwick Ten-Point Program, a step-by-step plan that focuses on developing balance and core stability. Beginning with mental adjustment (developing confidence and a good attitude) and disengagement (learning to separate from the therapist and work independently), the Halliwick Program progresses through an increasingly sophisticated regimen of rotation and balance exercises culminating in basic swimming movements.

The second method is the Bad Ragaz Ring Method. Inspired by the proprioceptive neuromuscular facilitation exercises common to land-based therapies, the Bad Ragaz Ring Method requires the patient to recline in the water, suspended by floatation devices (rings) around the trunk and legs. The therapist moves the patient’s limbs in specific patterns through the water and instructs the patient to relax, resist, or to do both in succession. Bad Ragaz involves specific hand placements, verbal cues, and water properties to provide resistance, facilitating quick stretch, balance, motor control, mobilization, strength-building, and relaxation exercises. We use it to help decrease tone, stretch tight muscles, strengthen weak muscles, and teach motor control in the upper extremities, lower extremities, and trunk.

Both methods incorporate a land-based exercise called proprioceptive neuromuscular facilitation (PMF), a collection of stretching patterns that improve motor performance and aid rehabilitation. The Halliwick and Bad Ragaz methods allow us to take the PMF patterns into the water to decrease thermal effects and work on mobility and strength. The safe aquatic environment aids neuromuscular education, building confidence and helping speed patients toward their goals.

Aquatic therapy programs can utilize a number of different types of pool accessories to add versatility to the types of activities therapists can offer. Among these accessories are pool noodles that can aid in positioning and stability. Likewise, tools such as dumbbells designed for use in the water allow the therapist and patient to use the resistance of water for therapeutic exercise. Water walking devices also can be used to provide stability to patients as they ambulate through the aquatic environment and build lower extremity strength.


Safe entry and exit is also a consideration where in-ground or above-ground pools and spas are used, and can be especially important for pool users who have mobility impairments, use mobility devices, or are otherwise affected by significant weakness in the lower extremities. Facilities have several options for installing ADA-approved pool lifts to serve this population of users, including water-powered pool lifts that do not require batteries or electricity for operation, and feature seat belts and flip-up foot rests for added safety. Motorized lifts designed to transport a user from wheelchair to water provide another entry/exit option for aquatic therapy facilities and are available in compact designs for mobile use.

Healing Commitments

Each employee at Intermountain Healthcare is committed to creating a healing environment through skills, attitudes, and service. This is expressed through the practice’s “Healing Commitments,” which are as follows:

I help you feel safe, welcome and at ease
I listen to you with sensitivity and respond to your needs
I treat you with respect and compassion
I keep you informed and involved
I ensure our team works with you
I take responsibility to help solve problems

The aquatic therapy program makes it easy for the staff to keep the first and most basic of its commitments: “I help you feel safe, welcome and at ease.” As has been noted by staff members, one of the primary benefits of an aquatic environment is that it lifts fear and restores confidence. Above all, patients must feel safe. Only then can healing truly begin. The clinic’s aquatic therapy pools make that possible.

Jane, the accident patient, is still in therapy, but she is progressing, gaining the strength and mobility that aquatic therapy provides. With every session, she regains skills and abilities she feared that she had lost forever. RM

Scott Wesche, DPT, is manager, McKay Dee Hospital Outpatient Sports Medicine, Ogden, Utah.

Samantha Fleming, PTA, is the Aquatic Therapy Lead at McKay-Dee Orthopedics and Sports Medicine, Ogden, Utah. For more information, contact [email protected].