Aquatic Therapy Tip
AN INTEGRATED APPROACH TO AQUATIC THERAPY
Combining both water and land therapy in the same session for an improved outcome
Many times Aquatic Therapy is often viewed as a place to initiate treatment when land therapy is intolerable or it is seen as a last resort after land treatment is not successful. Numerous articles and research studies have been written regarding the benefits of aquatic exercise compared to land based exercise.1-3 Therapists that use a combination of water and land exercise usually perform them on varied treatment days or in different timeframes in the rehabilitation process. By combining both treatment mediums in the same session I feel that patients usually have an improved outcome and report less discomfort during their rehabilitation.
I have found that there are many diagnoses that benefit from an integrated protocol such as total joint replacements.
With the total knee replacement patient I use the integrated protocol from day one. I evaluate the patient on land for the first 30 minutes to obtain objective measurements and to ensure a comprehensive home exercise program. Immediately following the evaluation the patient is started on aquatic exercises to assist in promoting flexibility, reducing pain and improving overall functional mobility. If the patient’s incision is not fully closed then a layer of Tegaderm is applied to the incision before entering the water.
After the first session, the client is scheduled usually for 2 sessions per week for 60 minutes that will consist of both water and land based therapy. My theory is that by utilizing the water first, the 92° water temperature will improve the muscles extensibility to prepare the tissue to stretch. Also, by using flotation such a pair of hydro-fit cuffs on the lower extremity, the patient can start some active assistive and active range of motion exercises. In the SwimEx having the client perform closed chain exercises and incorporating the numerous workstations, the client can be challenged in a way not always possible on land in the early rehabilitative stages. During the land component of the treatment session, the patient is initially placed on a recumbent bike to work on ROM. Following is a series of open and closed kinetic chain exercises that emphasize strength, balance, proprioception, and coordination. To finish the session, manual therapy, consisting of joint and incisional mobilizations and PROM is performed. In my experience the patients report much less discomfort with the integrated protocol versus the traditional land based program.
Obviously we do not live in the water so the patient eventually is completely transitioned onto land after they have maximized their potential in the water. This however, usually does not occur till the much later stages in the rehabilitation process. I feel that we as therapists can get very aggressive and creative with our patients in the water as long as proper alignment and stabilization is occurring.
In the Swimex, the therapist can get very creative with their patients because of the controllable laminar flow current. This laminar flow acts as a second pair of hands that will improve feedback, alignment, flexibility, and stabilization for the patient. The controllable current really can challenge any level of patient from the very deconditioned all the way up to the professional athlete. It is a true aquatic isokinetic machine that allows the therapist unlimited possibilities and potential with all their patients.
Reimbursement is something I am sure all of you may be questioning for incorporating an integrated protocol into your patient treatments. This will most likely vary depending on your individual state and insurance provider. I have not had too may issues in New Hampshire where I am currently employed. For the patient whose insurance company limits number of visits, or the patient who has a hefty co pay, an integrated treatment is much more cost effective.
At my clinic we offer a transitional swim program as well that the patient can join; this is somewhat like a health club membership. The patient will often participate in that program for their aquatic component and then after they are done with their water session, they are treated immediately after with land based physical therapy. By incorporating integrated therapy into your programs I hope you have as much success as I do with my patients.
Sources:
1. Lenkowitz SE, Hasson SM. Aquatic Physical Therapy and treatment of patients with simultaneous bilateral total knee arthroplasties. J of Aquatic Physical Therapy. 2003; 11(1):6-13.
2. Wyatt F, Milam S, Manske R, Deere R. The effects of aquatic and traditional exercise programs on persons with knee osteoarthritis. J Strength Conditioning Res. 2001;15:337-340.
3. Hinman RS, Heywood SE, Day AR. Aquatic Physical Therapy for Hip and Knee Osteoarthritis: Results of a Single-Blinded Randomized Controlled Trial. Phys Ther. 2007; 87(1):32-43.