Research update: water works wonders: aquatic therapy has great potential for improving ailments and promoting general health.

More than 2,000 years ago, Roman soldiers used hot baths after recognizing the therapeutic effects (Reynolds, 1976). Today, water is still used as a common method of physical therapy, although the techniques and activities in water have changed drastically. Swimming techniques began water therapy in the form we know it today. The original teaching technique for swimming involved trial and error, which led to many drownings (Lyttle, 1976).

In 1914, the American Red Cross assisted in developing swimming programs with trained instructors, significantly decreasing the risk of drowning (Lyttle, 1976). At this time, swim instructional programs were only offered to individuals without disabilities. However, when injured American soldiers returned from World War I and World War II, aquatic therapy programs were developed to serve them (Lyttle, 1976; Reynolds, 1976).

Throughout history, aquatic programs--both swimming instruction and therapy--were segregated for people with and without disabilities. However, integration is one of the main goals of contemporary therapeutic recreation, as well as in aquatic therapy. Facilitators must enhance their awareness of the therapeutic values of a wide variety of skills, such as social awareness and interaction that can be taught through individualized programming in the aquatic environment (Melvin, 1976).

For example, the National Therapeutic Recreation Society (NTRS) Benefits Are Endless video (Broida, 2000) features participants with developmental disabilities enjoying a wave pool as part of their own personal recreation participation and social integration, which is the end stage of aquatic therapy. Aquatic therapy is used as a technique to better a person's life physically, socially, physiologically or psychologically. Because benefits are used to promote the outcomes of activity participation, it is useful to examine benefits a person could achieve from participating in aquatic therapy programs. In her review of the literature, Broida (2000) cites four studies of aquatic interventions that document the benefits of aquatics as a specific modality.

Benefits

Water has four main features that are not offered through land activity: buoyancy, resistance, support and hydrostatic pressure. Hurley and Turner (1991) suggested that for many individuals with disabilities, the buoyancy, the increased resistance and the warmth of the water creates an environment for exercise which is more conducive for achieving treatment goals than exercise conducted on land.

These features make movement easier and less painful than land-based programs (Broach & Dattilo, 2001; Cooper, 1976; Mobily, Mobily, Lessard & Berkenpas, 2000; Mobily & Verburg, 2001). Participants can typically participate with lower body temperatures, less muscle stress, less energy expenditure and less guarded actions associated with fear of failing and improved performance (Broach & Dattilo, 2001). The density of the water slows movement and supports bodily positions that would otherwise be unstable on land. Finally, the sheer weight of the water provides natural compression on joints and promotes reduction in swelling (Mobily, Mobily, Lessard, & Berkenpas, 2000).

Water provides a source of graded resistance conducive to improvement in muscular strength and endurance when the limbs are moved repeatedly through a range of motion over the course of an extended period of time (Mobily & Verburg, 2001). The physical benefits of activity performed in the water may include: relief of pain, decreased spasticity and increased relaxation, improved bone density, improved pulmonary function, strengthened muscles, improved endurance and improved range of motion and increased circulation (Broach & Dattilo, 1996).

Aquatic therapy (AT) can be used to foster physical and psychological improvement while helping the participant to learn how to swim or exercise in the water. AT appears to have numerous physical and psychological benefits including improved endurance, pulmonary function strength, self-concept, mood and decreased perceptions of pain.

In a study by Broach and Dattilo (2001), participants stated they felt that the most important outcome of AT included increased freedom of movement, relaxation, energy and social interactions. Aquatic activity, which can be done in therapy or in a community, provides an avenue for inclusive opportunity that is socially acceptable and in the mainstream of society (Conatser & Block, 2001).

Water provides more than just physical benefits for people. It also can promote psychological improvements for individuals with multiple sclerosis, cystic fibrosis, arthritis, orthopedic impairments, cerebral palsy and asthma (Broach & Dattilo, 1996). Psychological benefits of participation in aquatic therapy have been identified to include improved mood, enhanced self-esteem and body image and decreased anxiety and depression (Broach & Dattilo, 1996).

Swimming is an ideal therapeutic activity for older adults when the water is 82 to 90 degrees. Slow, stretching movements aid in increasing the range of motion in joints with restricted action. Metabolism rate lowers with aging so that an older person reacts less quickly and less adequately than a younger person to cold or rapidly changing temperature. Objectives of aquatic programs for older adults:

* aid in establishing a pattern of activity, which will be beneficial physiologically for the unique requirements of each individual as indicated by increased or maintained level of cardiovascular endurance and by increased range of motion in the joints;

* facilitate the socialization process by structuring paired or group interaction opportunities in the guiding and supporting roles during learning;

* structure an individual learning program within the general progression of swimming skills as measured by advances on an individually prepared checklist; and,

* help the elderly learn skills to the extent that activity in the aquatic medium is sought as a leisure activity as measured by attendance at recreational swims (Cooper, 1976).

Regular exercise is important to minimize the effects of biological aging, but can also increase mental alertness and amount of social interactions (Cooper, 1976).

Techniques

The techniques of aquatic therapy vary. Some popular interventions include Bad Ragaz, which employs principles of flexibility exercises using active and passive techniques for strengthening. (Broach & Dattilo, 1996). Watsu involves applying the moves of Zen Schiatsu to facilitate decreased tension and improved psychological well being (Broach & Dattilo, 1996). Halliwick facilitates normal patterns of movement and posture through water ambulatory exercise and therapeutic swimming in deep or shallow water (Broach & Dattilo, 1996).

When facilitating any aquatic program, it is important to consider the experience level of the participants. Participants may have a fear of the water for a variety of reasons-fear of abandonment, fear of inadequacy, interference with physical activity or sudden presentation of unexpected stimuli (Patrick, 1976).

There are five techniques that can be used in order to decrease a participant's fear: increasing sense of competency--such as self-confidence, permitting security props, explaining procedures, freedom of movement and being reassuring (Patrick, 1976). Another technique to use with fearful participants is called contact desensitization. First, the fearful participant watches a peer approach the water. Second, the model and instructor help the fearful pupil approach the water in various steps and stages. Third, the model is gradually removed as the pupil makes progress into the water (Patrick, 1976). Observed muscular tension should be the nonverbal message that the desensitization process has gone too far too fast.

Conclusion

A major advantage of aquatic therapy is that it may enhance functional ability that encompasses all areas of life and helps to develop a life-long leisure activity that can be enjoyed with other people (Broach & Dattilo, 1996). Insufficient training, experience and specific instruction in conducting aquatic programs are the major reasons aquatic programs fail (Conatser & Block, 2001). Certification in aquatics, academic coursework and experience are related to instructors' competence (Conatser & Block, 2001). In order to meet the needs of individuals with disabilities in the aquatic area, it is important to prepare instructors to work with individuals with disabilities within integrated programs and activities (Stein, 2002).

Aquatic therapy is a viable intervention, which can be employed by therapeutic recreation specialists. The number of physician referrals for aquatic therapy is increasing, and third-party payers are viewing aquatic therapy as a viable treatment. Therapeutic recreation specialists who have the educational training may use aquatic therapy to encourage participants to achieve independent leisure participation while realizing functional benefits and enhancing their life satisfaction and longevity (Broach & Dattilo, 1996).

The range of therapeutic recreation services needed in the community is expanding to include services such as aquatic therapy designed to achieve the treatment goals of participants. Aquatic therapy is valuable because it is conducted in water, which often improves participants' comfort and increases their confidence in achieving functional independence. The health care trend of shorter hospital stays and an emphasis on outpatient care has resulted in a need for therapeutic recreation interventions to be applied across a myriad of environments.

References

American Therapeutic Recreation Association. Retrieved 5/09/06, Web site: http://www.atratr.org/

Broach, E., & Dattilo, J. (1996). Aquatic therapy: A viable therapeutic recreation intervention. Therapeutic Recreation Journal, vol.(3), 213-229.

Broach, E., & Dattilo, J. (2001). Effects of aquatic therapy on adults with multiple sclerosis. Therapeutic Recreation Journal, 35(2), 141-154.

Broach, E., Groff, D., & Dattilo, J. (1997). Effects of an aquatic therapy swimming program on adults with spinal cord injuries. Therapeutic Recreation Journal, vol?(3), 160-173.

Broida, J. (Ed.). (2000). Therapeutic Recreation--The Benefits Are Endless ...[TM] Training Program and Resource Guide. Ashburn, VA: National Therapeutic Recreation Society.

Conatser, P., & Block, M. (2001). Aquatic instructors' beliefs toward inclusion. Therapeutic Recreation Journal, 35(2), 170-184.

Cooper, C. (1976). Swimming for senior citizens. Therapeutic Recreation Journal, (2), 50-54.

Lyttte, R. M. (1976). Integrating families of handicapped individuals into the public swimming facility. Therapeutic Recreation Journal, (2), 55-60.

Melvin, L. (1976). Aquatic games: A multidisciplinary teaching method for the handicapped. Therapeutic Recreation Journal, (2), 38-42.

Mobily, K. E., Mobily, P. R., Lessard, K. A., & Berkenpas, M. S. (2000). Case comparison of response to aquatic exercise: acute versus chronic conditions. Therapeutic Recreation Journal, (2), 103-119.

Mobily, K. E., & Verburg, M. D. (2001). Aquatic therapy in community-based therapeutic recreation: pain management in a case of fibromyalgia. Therapeutic Recreation Journal, 35(1), 57-69.

National Therapeutic Recreation Society. (2000). Therapeutic Recreation--The Benefits Are Endless ...[TM] Ashburn, VA: NRPA. [video]

O'Sullivan, E. (1999). Setting a course for change: The benefits movement. Ashburn, VA: National Recreation & Park Association.

Patrick, G. D. (1976). Allaying fear of the water. Therapeutic Recreation Journal, (2), 46-49.

Reynolds, G. D. (1976). Agency development of aquatic programs for special populations. Therapeutic Recreation Journal, (2), 61-64.

Stein, J (2002). Adaptive aquatics or just aquatics. Parks and Recreation, 46-54.

Research Into Action: Promoting the Benefits of Aquatic Therapy

Therapeutic recreation specialists can continue advocating the benefits of aquatic therapy as an effective outcome for service delivery with these practical efforts:

* Incorporate aquatic therapy as a facilitation skills training within therapeutic recreation college curricula. Colleges may hire CTRs certified to facilitate aquatic therapy as workshop intensives as ad hoc instructors. These professionals serve as models and mentors to future practitioners.

* Promote and advertise adaptive and regular aquatic programs within the community. Therapeutic recreation specialists can promote swimming as a leisure activity so that future clients might already be comfortable with an aquatic environment when aquatic therapy is a preferred method of treatment. This will be especially relevant with the surge of health care services to older adults with medical conditions that require rehabilitation.

* Continue promoting aquatic therapy. NRPA provides annual conferences such as NIRI. As the network expands, conducting and using efficacy research can help recreational therapists justify and initiate aquatic therapy services.

Stacy Bintzler is currently a graduate student at University of Wisconsin-La Crosse in the Therapeutic Recreation program and is completing an internship at the Courage Center, Golden Valley, Minn., in the aquatics department. She has been a certified lifeguard for the past nine years and a water safety instructor for the past four years. She was recently certified as an aquatic therapist and intends to continue her aquatic work as a therapeutic recreational specialist upon graduation in December.