Next up on Thursday’s CSM docket for me was Aquatic Therapy for Individuals with Neurological Disorders given by Yasser Salem PT, PhD, MS, NCS, PCS
What Yasser stressed through the whole course was that “anything you can do on land, you can do in the water.” He said if we learned nothing else, learn that for treatment strategies. He also wanted us to go back to the basics of aquatic therapy– what an aquatic environment can do by nature of the water:
— decreases joint stiffness with the neutral warmth of the water increasing ROM
— facilitates resistance/strength training with the water viscosity
— enhances cardiovascular function improving endurance with the water’s extra pressure on the circulatory system
— improves balance by providing support for people to further test their limits of stability
— edema control by increasing peripheral venous return with water pressure
— relieves pain and muscular spasms and increased relaxation with neutral warmth, slight compression with water pressure (I was just thinking that maybe the water pressure works like a weighted blanket in this sense.)
— makes for easier progression of weight bearing status– depending on how deep the water is, you can tell almost exactly how much weight is going through a leg in standing
— enhances quality of life and well-being– there’s just something about moving water that is so calming. I’ve heard something about the flow of positive and negative ions… I don’t know really.
— allows initiation of active rehab sooner than on land with the buoyancy that provides support to patients who have difficulty moving (I’ve started thinking about the water as another possibility for harness mobility candidates), maintaining posture, performing functional activities.
— reduction in proprioceptive feedback creates a sensory mismatch with the buoyancy which may induce the vestibular system to come more on line for balancing.
— increased sensory awareness with buoyancy, viscosity and resistance and could also go barefoot and many pools have textured bottoms providing a bit of accupressure
— dissipates body heat faster than air
— psychological benefits with faster advancement and being able to do more in water vs. on land
With all that watery goodness (I’m having Zoolander flashbacks), what’s not to love? Well, there are some contraindications and precautions to be aware of.
— UNSTABLE cardiac conditions, vital signs, hypertension, seizures, respiratory dysfunction
— open wounds
— severely limited vital capacity ie < 1 Liter
— severe peripheral vascular disease
— danger of bleeding/hemorrhage
— severe kidney disease
— infectious secretions– wounds, mucus, urine, etc.
— bladder or bowel incontinence
— tracheotomy– until healed (I will say I’ve seen video from… Scotland, I think, of a person actively on a trach with respirator doing aquatic therapy. I think they were a high injury level SCI. They were mostly just floating in the video, but I have long wondered about the logistics involved in that session.)
— fear of water. How fearful plays a role here. I have some little ladies that say they’re scared to the water and really what they’re scared of is making their hair wilt by getting it wet. Use a swimming cap if necessary for those.
— heat sensitivity. This can be a real thing especially in the MS, Parkinson, ALS, SCI, populations. Keep water 80-85 degrees for these folks. 82 seems to be the best.
— seizures. Have a plan on what to do if one happens while in the pool, just like you should on land as well.
— cardiac dysfunction. It does put extra strain on the cardiac system, can your patient handle that?
— uncontrolled diabetes. Have a plan on what to do if your patient’s sugar drops.
— autonomic dysreflexia in SCIs. Again, have an action plan if your patient starts showing signs/symptoms. Remember, AD is a MEDICAL EMERGENCY!
— cognitive/behavioral disorders. What are you going to do if your patient becomes agitated/combative or whatever their problem is? Have a plan!
— severe disability. This is more concerned with prep– how are we going to get them in and then out of swim gear? How are we getting them in/out of the pool? How are we getting them set up in/with aquatic equipment?
Adjusting the intensity of any exercise prescription can be challenging. Here’s what you can manipulate in the aquatic environment to adjust the intensity:
— speed of movements
— depth of water
— adding a timed component of task ie “walk in the water for 5 minutes”
— create turbulence in the water with jets or you (the therapist) can move the water around the patient by moving your arms or having the patient perform the activity in your own wake as you walk in the water.
— quick stops and turns
— architectural barriers like stairs, obstacles
— sensory condition– eyes open/closed, slippery surface
— use of equipment– floats, weights, noodles, water fins, etc.
— frequency of feedback
— dual tasks– motor and cognitive together
Just a few tid bits that I picked up in the course: the water assists when you perform the activity on top of the water and it resists when you perform the activity below the water; consider group aquatic therapy as it has been shown to have even better outcomes than individual aquatic therapy; tie your goals to function on land and speak to how your training in the water will cause these functional improvement to be seen on land when documenting; try to do similar activities on land as you do in the water so can demonstrate the previous and have good carry over; most of the accidents occur when getting in/out of pool so these are the areas you need to focus on for safety, not necessarily the water itself; however, have a plan as described above!
And finally, “wetter is better!” (My favorite aquatic PT’s moto.)