Aquatic therapy: making waves in therapeutic recreation.

Therapeutic recreation specialists use a battery of techniques to incorporate movement with healing and improved fitness for their patients. Aquatic therapy, the use of water to improve physiological and psychological functioning, is often a valuable and enjoyable technique used by therapeutic recreation specialists. Improvements associated with aquatic therapy have been observed for many people with disabilities including individuals with multiple sclerosis, cystic fibrosis, spinal cord injury, arthritis, orthopedic impairments, cerebral palsy, acquired brain injury, ALS, development disability, and autism.

Through activity in the water, patients have shown physiological benefits, including improved circulation, mobility, strength, coordination, range of motion, pulmonary function, perceptual/spatial awareness, muscular and cardiovascular endurance, relaxation, and decreased pain and bone loss. Furthermore, participants experience psychological benefits such as improved mood, enhanced self esteem and body image, and decreased anxiety and depression. In addition to physiological and psychological benefits, aquatic therapy may promote the development of swimming or water activity as a lifetime leisure skill which, subsequently, can contribute to individuals' health and happiness.

Aquatic Therapy Methods

Aquatic therapy draws from a broad spectrum of activities and movements, many of which are land-based, but become less rigorous when performed in the water. Various aquatic therapy techniques include: (a) Watsu which applies the movements of Zen Schiatsu to decrease muscle tension, promote self awareness, relaxation and emotional release; (b) stabilization techniques for improving balance, coordination, strength and circulation to joints using the freedom of movement possible in the water; (c) Bad Ragaz which uses the water to provide proprioceptive neuromuscular facilitation patterns rather than using a therapist to provide resistance; and (d) deep or shallow water strength or endurance exercises. Each of these--as well as other methods--require proper training for proper and safe utilization.

The use of swimming as a therapeutic medium is a technical process that requires the combined skills of teaching swimming and water safety, as well as understanding the hydrodynamics of the water and implications and contraindications associated with use of water for therapy. For example the Halliwick Method of instruction applies the principles of hydrodynamics and body mechanics to advance a participant through four phases of skill development: mental adjustment, rotational control, controlling movement and balancing in the water, and independent movement in the water.

In another example, a professional using the sequential swim method of instruction will apply water properties to specific characteristics of the client's disabilities to enhance physiological and psycho-social functioning, as well as independent water activity. No matter which method is used to achieve independence, each incorporates all muscle groups, enhances proprioceptive skills, and provides neurodevelopmental treatment (which facilitates normal patterns of movement and posture). The potential of swimming to be adopted as a life-long leisure and fitness activity makes it extremely appealing for therapeutic recreation specialists.

Water as a Therapeutic Environment

The combination of water's physical properties and the prescribed activity creates a unique environment for many physiological benefits. There are many physical laws of the water that therapists should apply in aquatic therapy. Of them, buoyancy and hydrostatic pressure, are the most important. Archimedes' principle states that when a body is wholly or partially immersed in a fluid at rest, it is acted upon by a buoyant or lift force, equal to the weight of the displaced fluid. It is this buoyancy, applied to activity in the water, that is of such value in physical treatment. Buoyancy can be used in three ways: as assistance, as support and as resistance. In addition an individual has enhanced freedom in the water.

For example, a person who is fully immersed in water experiences approximately a 90% reduction in body weight, thus reducing the impact on the muscular skeletal system often associated with land-based activity. Another property, hydrostatic pressure, supports the body in the upright position with equal water pressure on all aspects of the body. This support enables people who have difficulty walking on land to walk in the water. Although, there are many aspects of water physics that contribute to the therapeutic potential of treatment in the water, hydrostatic pressure, buoyancy and the warmth of the water create an environment that often is more conducive to achieving therapeutic goals than some land-based exercise.

Water Temperature

Water temperature should be considered when examining the best environment to achieve therapy goals. The literature presents various opinions of the ideal water temperature depending on the disability and the level of activity in the water. Temperatures between 89.6 and 97 degrees Fahrenheit are most commonly cited as temperatures to achieve relaxation, decreased pain and reduced spasticity. Some professionals suggest that water temperatures above 95 degrees may produce debilitating consequences. To further complicate the water temperature debate, temperatures of 78 up to 86 degrees Fahrenheit have been recommended for individuals with multiple sclerosis who are susceptible to heat-induced fatigue.

Although professionals disagree on the ideal temperature of the water to achieve therapeutic outcomes, it is clear that there are many factors beyond water temperature that contribute to a person's body temperature in the water. Conditions such as the activity level, duration of treatment, the participant's physical health, and the nature of their disability all contribute to body temperature and should be considered when using aquatic therapy.

Typically, aquatic therapy is thought of as an intervention provided in residential treatment settings. However, community recreation settings are considered equally appropriate for this type of therapy. One professional publication documents a community program initiated by a therapeutic recreation entrepreneur. The authors reported 85% reimbursement for treatment from medical insurance made possible by continuous communication with physicians and case managers. Consequently, therapeutic recreation specialists who work independently or for a community park and recreation department have an opportunity to meet the treatment needs of many individuals with disabilities who reside in their communities and may not have access to the high cost of some health care services.

Therapeutic recreation specialists who use aquatic therapy can facilitate the achievement of treatment goals, while promoting a positive lifestyle through participation in an independent activity and inclusion in a community setting. In addition, individuals who need therapy are usually searching for alternatives to expensive health care. With rising costs and a reduction in hospital lengths of stay, the range of needed community services is expanding. Aquatic therapy in park and recreation settings is ideal for encouraging individuals with disabilities to achieve therapeutic outcomes while they remain at home.

Professional Training and Development

Aquatic therapy can be provided in residential and community settings by therapeutic recreation specialists. These specialists should be properly trained and experienced in independent and dependent exercise techniques for therapy, as well as the techniques of progressive swimming. To achieve this expertise, professionals must attend seminars and work-shops in addition to working in an environment where these methods are practiced.

As aquatic therapy expands, a wealth of instructional sessions and training opportunities are developing. The National Therapeutic Recreation Society (NTRS) and the American Therapeutic Recreation Association (ATRA) are sponsoring workshops, forming working committees, networking to address aquatic therapy concerns, and establishing resources for interested professionals. Through NRPA, NTRS sponsors an annual, three-day institute on aquatic therapy prior to the National Congress for Recreation and Parks.

In addition, NTRS has an active aquatic therapy committee that includes representatives from physical rehabilitation, psychiatric rehabilitation, community, university, and park and recreation settings. The NTRS committee has established a network of practitioners who are interested in, or practice, aquatic therapy. The network coordinator distributes an updated list of network members and information on upcoming events, books and issues of interest to network members. The committee's goal is to be a resource for practitioners and to help promote quality aquatic therapy interventions.

ATRA has also formed a treatment network with experts in aquatic therapy who serve as advocates on interdisciplinary committees and resources for practitioners. In addition, ATRA offers aquatic therapy workshops throughout the year in various parts of the country.

Beyond these two professional organizations, Constellate, a recreation therapy consulting service, has begun to offer the first series of Halliwick certification courses in the United States. All these efforts demonstrate some of the increased opportunities for instruction in aquatic therapy available to therapeutic recreation practitioners.

Promotes Healthy Lifestyle

Although more research is needed, the literature provides support for the psychological and physical benefits of aquatic therapy Furthermore, aquatic therapy has the potential to promote a healthy lifestyle. Aquatic therapy can improve individuals' comfort and increase their confidence in achieving functional independence. Considering the health care trend of shorter hospital stays and an emphasis on outpatient care, therapeutic recreation interventions can be applied in a variety of contexts and in a myriad of environments. Aquatic therapy is one technique that can result in individuals participating in an enjoyable activity that allows them to improve their functional ability. Thus, it appears useful for therapeutic recreation specialists to incorporate aquatic therapy into the array of services which they may provide.

RELATED ARTICLE: To Learn More Contact:

NTRS Aquatic Committee Chairs: Melissa Stratton, CTRS Aquatic Specialist Shepherd Center 2020 Peachtree Rd. NW Atlanta, GA 30309 [phone]

Barb McQuaid, CTRS St. Francis Medical Center 400 45th St. Pittsburgh, PA 15301-1198 [phone]

ATRA Treatment Network Coordinator for Aquatic Therapy Karen Foster-Badgzon, CTRS ATRA P.O. BOx 15215, Hattiesburg, MS 39404 1 [phone]

RELATED ARTICLE: To Learn More Read:

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Carter, M. J., Dolan, M. A., & LeConey, S. (1994). Designing Instructional Swim Programs for Individuals with Disabilities. Reston, VA: AAHPERD.

Davis, B. C., & Harrison, R. A. (1988). Hydrotherapy in Practice. New York: Churchill Livingston.

Dull, H. (1993). WATSU: Freeing the Body in Water. Harbin Springs publishing.

Jamison, L and Ogden, D. (1993). Aquatic Therapy Using PNF Patterns. Tucson, AZ: Therapy Skill Builders.

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