Compiled by Frank Long, Editorial Director
Within the realm of rehabilitation there is perhaps no specialty where creativity flows as deep as aquatic therapy.
To learn how rehab providers are using aquatic therapy technologies to leverage creativity in clinical treatment, Rehab Management offers this exclusive Q&A with a panel of aquatic therapy veterans. Each offers insight about how to use the properties of water and pool technologies to create effective, personalized treatment, as well as innovate new approaches for therapeutic activities.
Joining in this discussion are:
Travis Baughman, DPT, Cert MPT, Drayer Physical Therapy Institute (DPTI), a member of the Upstream Rehab family of clinics. Baughman has been employed by DPTI for 13 years and has been the Clinic Director for the Mechanicsburg, Pa, office for 8 years. He is certified in the McKenzie Method of Diagnosis and Treatment and sees a substantial number of patients who are affected by persistent pain.
Linda Bollinger, CTRS, ATRIC, is a recreational therapist in Good Shepherd Rehabilitation’s Fitness and Aquatic Wellness Programs at Good Shepherd Rehabilitation Network Health & Technology Center, Allentown, Pa. Bollinger uses a variety of aquatic equipment that includes a specialized underwater treadmill and a pool lift that allows individuals who cannot walk to enter and exit the pool safely.
Vicki Buchanan, PT, is CEO/Founder of Regional Physical Therapy Inc, a multi-site practice headquartered in Midwest City, Okla. She earned a degree in Physical Therapy from the University of Oklahoma Health Sciences Center and has 33 years of experience. Buchanan is certified in ASTYM, Dry Needling, and Kinesio taping, has completed her fellowship of musculoskeletal ultrasonography, and at the 2018 Hands-On Diagnostic Annual Symposium her practice won Practice of the Year for contributions to society.
Sue Goldstein, PT, Gaylord Specialty Healthcare, Wallingford, Conn, is one of the founders of the aquatic therapy program at Gaylord Specialty Healthcare. She assisted in designing Gaylord’s therapeutic pool in Wallingford, Conn, and has more than 35 years of experience working in the field of aquatic therapy.
What aquatic therapy equipment is installed at your clinic? What influenced your purchase decision?
Travis Baughman: We have the HydroWorx pool with an underwater treadmill. It also has a bench built in that flips up for more space and steps that contain a handrail to get into the pool. At the time when our pool was built, there wasn’t anywhere outside of inpatient rehab that had a pool. It was a need to fill in the area, and we felt we really couldn’t go wrong to be a transition to outpatient rehab and also to provide a service for patients who couldn’t tolerate land-based therapy.
Linda Bollinger: The pool at Good Shepherd’s Health & Technology Center is a 1,350-square-foot therapeutic pool that goes from 3 feet to 4 1/2 feet deep with a small 6-foot section for suspended exercise. The therapeutic pool is kept at 92-94 degrees Fahrenheit and serves a variety of patients (both pediatric and adults) in aquatic physical therapy and aquatic fitness/wellness programs. Patients/clients are seen on a one-on-one basis, as well as in group programs.
Vicki Buchanan: We have a SwimEx unit. We needed a unit that allowed patients to perform running and agility drills all in a small space. We chose the SwimEx 13 years ago, and the choices for aquatics was much more limited.
Sue Goldstein: Gaylord Specialty Healthcare’s state-of-the-art therapeutic pool is an impressive 75 x 25 feet, with a depth that ranges from 3 feet to 9 feet. It features one of the most handicapped-accessible pools and locker rooms in New England. Before building its own pool in 1992, Gaylord therapists established a successful aquatic therapy program by treating people with orthopedic and neurological disorders in community pools. Having its own self-designed, accessible pool on campus helped grow the program’s caseload substantially and expanded the variety of diagnoses that could be treated.
How has the treadmill affected the possibilities for the therapeutic interventions you provide?
Travis Baughman: We can work on gait patterns and break down the mechanics easier. Speed and duration can be increased in a variety of positions that the patient can’t tolerate on land—the water is chest deep, giving them 85% body weight support. We use the treadmill to get as much strength as we can by adding arm swing and weights as able. These patients typically don’t tolerate land positions, so the treadmill lets them feel like they are working and they will tell me they feel “alive again” and that they are accomplished. There is real value in using the treadmill in that the patient feels like they can participate in a “gym program” like other people. The treadmill has also been a great adjunct for athletes as well to introduce running at an early phase.
Linda Bollinger: There are two AquaGaiter Treadmills which are heavily used by our patients and fitness clients. The treadmills assist patients with increasing ambulatory skills (spinal cord injury, stroke, back pain) as well as range of motion and endurance as the water’s warmth and buoyancy (uplifting force) make it easier to walk. The pool also is equipped with two sets of parallel bars in the 4-foot section so patients/clients can practice standing and ambulation skills. Additionally, the pool has Hydrorider bikes for increasing strength and range of motion for patients following hip and knee replacement surgeries as well as other orthopedic or neurological impairments.
Vicki Buchanan: We don’t have an underwater treadmill as such. However, the SwimEx pool we use allows for a laminal flow for the patient to run/walk in place against the flow of water. I feel it is vital to be able to perform walking and running tasks in a non-weighted environment for early return to sports. The water allows for very early mobility that land therapy prohibits.
Sue Goldstein: Gaylord did not find it necessary to include an underwater treadmill, but the pool has many unique therapeutic features. The water temperature is maintained at 90 degrees. A deep cut-out area is present along the entire pool edge, allowing for grip with a hand or forearm for gait, balance and exercises. An overhead sling lift provides body weight support during gait. The pool has numerous warm water jets to massage and relax painful muscles and decrease spasms. There is a large deep-water area for performing cardio exercises, vertical stabilization and deep water running. There are bars in this area for pull-ups and push-ups, which incorporates core training. An in-water seat bench enables seated balance tasks, arm and leg exercises, and stretches.
What are your go-to pool accessories and favorite ways to apply them?
Travis Baughman: I really enjoy using pool noodles to help with distraction of the spine and mediate pain. Hand paddles also provide good resistance to push against. Hydrotones also provide a lot of resistance for core and shoulder strengthening. A lightweight ball is a simple product that can be used as reactive balance like catching, but can also be used as a tool for balance in various positions and doing a forward press allowing the ball to rest on the water and then can be moved to overhead movements. I also do functional activities like squats or sit-to-stand with ball reaches for function, balance, core, and postural activities because our patients need to function outside of the pool, and I feel that a lot of their symptoms are caused by the postures they are in throughout the day. I use the paddles for PNF patterns. I have kickboards to help with seated stretching and movements instead of the typical intended use of swimming. We also see pediatric clients that have had neurological impact. We will use rings to promote reaching and balance.
Linda Bollinger: There are a multitude of pool accessories used both during physical therapy, aquatic fitness and wellness programs. They are divided into equipment that provides weight, resistance or floatation and are used in a variety of ways: Noodles are used for floatation during relaxation in the 6-foot section. They are also used for abdominal exercises and resistance exercises for any part of the body that needs strengthening or stretching. Kickboards are used for abdominal stabilization and strengthening, as well as for lower extremity kicking or resistance while ambulating in the water. Dumbbells are used for strengthening exercises of the arms or core stabilization. Resistance paddles are used for strengthening exercises and can also be used to challenge balance. Weights are used to stabilize patients who may have difficulty keeping their feet grounded to the pool bottom. Weights also increase stability for patients during ambulation. Resistance tubing is used for strengthening and stretching while in the aquatic environment.
Vicki Buchanan: We use noodles for so many things, floating to allow unweighting of the spine, balance when doing single leg tasks, and resistance by pushing it under the water in various ways. We use water dumbbells for resisted activities and water weights for buoyance resistance. We often add ankle weights to our athletes when they advance from simple non-weight bearing running to improve speed as well as strength.
Sue Goldstein: Water ski belts and cervical floats are used for deep water cervical and spinal vertical traction, deep water running and swimming, and for manual techniques, such as Bad Ragaz for facilitating strengthening of the core and extremities. A thick kickboard is used for seated balance tasks, including maintaining vertical stabilization positions. Buoyant dumbbells, pool noodles, webbed gloves, and paddles add resistance for arm and core exercises. Noodles and ankle weights provide resistance for leg exercises, support with standing/gait tasks, or for deep-water tasks. A long floating barbell is used for gait assistance, arm exercises, or support in deep water during core and leg exercises. Four- and 10-inch step benches enable step exercises, plyometrics, and balance tasks. A weighted vest decreases ataxia and allows core stabilization for gait and deep-water exercises.
How has having aquatic therapy changed your competitive position in the local market?
Travis Baughman: We get a lot of patients with chronic pain diagnoses that allows them to have an alternative to typical land-based exercises. We also see a number of patients after surgery, such as athletes, that need to stay engaged and maintain endurance, and this has given us a unique opportunity to improve our position in the area.
I really hate when people say, “You can’t do aquatic; you have to do exercises on land.” I don’t buy that. I’ve had decent results by getting patients strengthened and they also “feel good” and can lose weight…while other people go to the gym to do aerobics, they are going to go “work out” in the pool. It’s a really nice progression with some other wellness centers in the area that have heated pools as well to help keep these people active. It’s been a great addition to the clinic to help an underserved population.
Linda Bollinger: The therapeutic pool increases Good Shepherd’s ability to serve a wide variety of patient populations to increase functional skills and abilities. These populations include patients with spinal cord injury, head injury, stroke, back pain, orthopedic patients following surgery, autism and developmental delay.
Vicki Buchanan: Our pool is the only one in the metro area, and we get patients who drive 45 to 60 minutes to use our pool. Often it is the only choice for early return to sports.
Sue Goldstein: Gaylord’s specialized aquatic therapy program is one of the most comprehensive and well-known in the country. Gaylord utilizes both PT and OT staff in the pool, and treats all diagnoses, including TBI, postsurgical, chronic pain, arthritis, CVA, amputation, concussion, spinal cord injuries, sports-related injuries, MS, and Parkinson’s. Through positive marketing and public awareness, both patients and physicians have become more aware of the success rate for aquatic therapy treatment and seek out rehab facilities that offer these services. The stellar reputation of Gaylord’s aquatic program attracts both inpatients and outpatients to the facility, boosting the facility’s revenue and competitive position. RM
This article is titled “Deep Dive Into Aquatic Therapy” in the print issue of Rehab Management.