CAPTION: Aquatic therapy is a great alternative to land-based therapy as it allows patients to move their limbs with ease and experience greater ranges of motion while in the water. Properties of water, like buoyancy and viscosity, help make aquatic therapy more comfortable and conducive to recovery.

This systematic approach to aquatic therapy takes into account patients’ evolving functional deficits for an effective, comprehensive plan of care.

by Scott Hankins, MPT, ART

Aquatic therapy acts as a multimodal approach to improving each patient’s pain and quality of life. The properties of water act in unison to drive out edema and toxins using hydrostatic pressure, while buoyancy unloads the joints as they move freely into greater ranges of motion. Aquatic therapy helps patients feel stronger due to the movement resistance created by the density and viscosity of the water.

There are many reasons why you might decide that aquatic therapy is the right treatment for your patient. Let’s say you have a lower extremity patient recovering from a fracture, surgery, or a soft tissue injury. The patient will be at the healing mercy of hydrostatic pressure which removes edema and metabolic waste from the injured site, as well as increased circulation due to improved vasodilation. When utilizing aquatic therapy, the patient will be able to move their limb with ease and experience a greater range of motion while in functional positions due to the buoyancy and viscosity of the water, making therapy more comfortable and conducive for recovery.

What about spine and upper extremity conditions? For spinal rehabilitation, the intrinsic properties of water—namely, buoyancy, viscosity, hydrostatic pressure, temperature, turbulence, and refraction—allow for graded elimination of gravitational forces, allowing patients to train with decreased, yet variable, axial loads and shear forces. This allows for a greater margin of error during postural and biomechanical movement correctional work by reducing compressive and shear forces on the spine. You can perform multiple-position, spinal stability exercises in the water to prepare the patient for gravity-loaded land work as their symptoms and biomechanical errors are reduced.

A Framework for Harnessing Healing

But how do we harness the healing properties of water in a systematic way that addresses the functional deficits of our patients caused by a myriad of conditions?

That was the question I asked when I added an indoor, warm water, multiple-depth pool to my outpatient clinic. I was instantly busy—no other therapy clinic in the area had an on-site pool—and the physicians and patients loved it. They both recognized that water is superior at minimizing the stresses on the body. I knew aquatic therapy would benefit my patients, but I needed a process to address their deficits with water while integrating manual therapy and land therapy into their plan of care.

I developed Phased Progression while pondering the question above. For each patient, I began creating a strategic plan of care using the functional movement limitations from the evaluation as therapeutic indications that align with certain properties of water. To formulate the right recovery plan, I had to identify the following:

1) What is the patient’s diagnostic classification?

I used pain, range of motion (ROM), instability, postoperative status, deconditioned or pathological and neurological conditions to classify the patient into specific progressions that use different properties of water to address the functional limitations these conditions cause.

2) How can the properties of water progress my patients with greater efficacy and expediency than land?

With this question, I used the classifications of ROM, pain, weakness (neurological), etc, to answer specific questions such as:

• How can water decrease my patient’s knee pain when walking and ascending stairs?
• How can the specific types of buoyancy help my shoulder patient increase their overhead reaching?
• How can I isolate and strengthen the hip patient’s gluteus medius muscle using viscosity and resistance?
• How can I help my back patient understand core stability?
• How do I progress my ankle patient’s plantar flexion strength?

3) What are the inclusion criteria from their evaluation to justify water?

Here, I used the classifications of pain, ROM, instability, postoperative status, deconditioned or pathological and neurological conditions to create inclusion criteria for each of their respective progressions. For example, if a shoulder patient rated their pain a 7 out of 10 when completing shoulder flexion or overhead reaching activities, then that is an inclusion criterion for a certain progression for the shoulder, either due to a high irritability pain classification, ROM, or postoperative classification. There are other inclusion criteria used for all progressions that are based on levels of pain with activities, percent of ROM compared to uninvolved extremity, and percent of functional and disability scores (SPADI, LEFS, ODI, etc).

Choosing a Phase and Progression

Only after these three questions are answered for a specific diagnosis or classification, can we choose which phase and progression to start the patient’s aquatic program with. Phased Progression is structured with three phases and three progressions within each phase.

Each phase has certain inclusion criteria that dictate where to begin the patient in their aquatic program. Phased Progression has many warm-up stretches, movements, and cardiovascular exercises. Each progression has Phased Progression Movements that are easy to understand and used by all physical therapists on land; we simply apply the properties of water to each of them to justify the use of water to insurance companies and our critically thinking minds. After deciding which phase to begin the patient on, we choose one or more movements that best match their functional or movement deficits.

This movement is then tested via an aquatic functional test (AFT), which is when a functional movement harnesses the properties of water to help find the individual’s relevant movement deficits. The AFT assesses three to four physiological variables depending on if it is a unilateral test (all four variables) or bilateral test (three variables). The physiological variables tested include:

• Repetition, which tests strength, stability, and balance;
• Pain, which tests for the injured tissue in question using forces such as tension, stretch, compression, or contraction;
• Technique, which tests for any compensatory motions due to an improper kinesthetic sense from their condition; and
• Time, which tests for endurance, stability, or balance.

There are specific criteria to pass the AFT. However, the goal is to determine which movement in the pool exposes the movement deficit noted in the evaluation. If patients do not pass their respective AFT within that phase and progression of their Phased Progression program, you would then choose the exercises in that progression and try to progress them to more difficult movements using the properties of water that these movements harness for their healing and biomechanical corrections. The goal is to perform successive AFT(s) when progress is noted or no later than 2 weeks afterward so patients do not become stagnant with their program.

The Value of Phased Progression

Phased Progression is the missing metric that helps the critically thinking therapist justify the use of water. Insurance companies will be satisfied due to the level of objectivity you rely on when applying and documenting this methodology. Meanwhile, patients will appreciate the benefits of aquatic therapy and Phased Progression, including the lower impact on their injured body and the swift recovery period.

A former patient who underwent total knee replacement surgery utilized aquatic therapy and the Phased Progression methodology. She noted that if she had the choice to do land or water therapy, she would choose aquatic therapy every time.

“The benefits of water for me are the way your joints feel, less stress on them, and I can do more and regain my strength back faster,” she says. “I get strong faster with less pain because of water.”

In using Phased Progression, therapists can harness the amazing properties of water during aquatic therapy to help improve the lives of patients and return them to their pain-free lives. RM

Scott Hankins, MPT, ART, is an outpatient physical therapist at Synergy Therapies in Oak Grove and Independence, Mo, specializing in aquatic therapy. Hankins developed Phased Progression, an objective approach to aquatic therapy that focuses on the progression from water to land therapy. For more information, contact