Aquatic therapy refers to treatments and exercises performed in water for
relaxation,
fitness,
physical rehabilitation
Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patient ...
, and other therapeutic benefit. Typically a qualified aquatic therapist gives constant attendance to a person receiving treatment in a heated therapy pool. Aquatic therapy techniques include
Ai Chi,
Aqua Running,
Bad Ragaz Ring Method, Burdenko Method,
Halliwick The Halliwick Concept focuses on biophysical principles of motor control in water, in particular developing sense of balance (equilibrioception) and core stability. The Halliwick Ten-Point-Programme implements the concept in a progressive programm ...
,
Watsu Watsu is a form of aquatic bodywork used for deep relaxation and passive aquatic therapy. Watsu is characterized by one-on-one sessions in which a practitioner or therapist gently cradles, moves, stretches, and massages a receiver in chest-deep ...
, and other
aquatic bodywork forms. Therapeutic applications include
neurological disorders
A neurological disorder is any disorder of the nervous system. Structural, biochemical or electrical abnormalities in the brain, spinal cord or other nerves can result in a range of symptoms. Examples of symptoms include paralysis, muscle weakness ...
,
spine pain,
musculoskeletal pain
Musculoskeletal disorders (MSDs) are injuries or pain in the human musculoskeletal system, including the joints, ligaments, muscles, nerves, tendons, and structures that support limbs, neck and back. MSDs can arise from a sudden exertion (e.g., ...
,
postoperative orthopedic rehabilitation,
pediatric disabilities, and
pressure ulcers
Pressure ulcers, also known as pressure sores, bed sores or pressure injuries, are localised damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combi ...
.
Overview
Aquatic therapy refers to water-based treatments or exercises of therapeutic intent, in particular for
relaxation,
fitness, and
physical rehabilitation
Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patient ...
. Treatments and exercises are performed while floating, partially submerged, or fully submerged in water. Many aquatic therapy procedures require constant attendance by a trained therapist, and are performed in a specialized temperature-controlled pool. Rehabilitation commonly focuses on improving the physical function associated with illness, injury, or
disability
Disability is the experience of any condition that makes it more difficult for a person to do certain activities or have equitable access within a given society. Disabilities may be Cognitive disability, cognitive, Developmental disability, dev ...
.
[Becker, BE and Cole, AJ (eds). 2011. Comprehensive aquatic therapy, 3rd edition. Washington State University Press. .]
Aquatic therapy encompasses a broad set of approaches and techniques, including aquatic exercise, physical therapy,
aquatic bodywork, and other movement-based therapy in water (hydrokinesiotherapy). Treatment may be passive, involving a therapist or giver and a patient or receiver, or active, involving self-generated body positions, movement, or exercise. Examples include Halliwick Aquatic Therapy, Bad Ragaz Ring Method, Watsu, and Ai chi.
[
For orthopedic rehabilitation, aquatic therapy is considered to be synonymous with therapeutic aquatic exercise, aqua therapy, aquatic rehabilitation, water therapy, and pool therapy. Aquatic therapy can support restoration of function for many areas of orthopedics, including sports medicine, work conditioning, joint arthroplasty, and back rehabilitation programs. A strong aquatic component is especially beneficial for therapy programs where limited or non-weight bearing is desirable and where normal functioning is limited by inflammation, pain, guarding, muscle spasm, and limited range of motion (ROM). Water provides a controllable environment for reeducation of weak muscles and skill development for neurological and neuromuscular impairment, acute orthopedic or neuromuscular injury, rheumatological disease, or recovery from recent surgery.][Koury JM. 1996. Aquatic therapy programming: guidelines for orthopedic rehabilitation. Human Kinetics. .]
Various properties of water contribute to therapeutic effects, including the ability to use water for resistance in place of gravity or weights; thermal stability that permits maintenance of near-constant temperature; hydrostatic pressure that supports and stabilizes, and that influences heart and lung function; buoyancy that permits flotation and reduces the effects of gravity; and turbulence and wave propagation that allow gentle manipulation and movement.[Becker, BE. 2011. Biophysical aspects of hydrotherapy. pp 23-75. Chapter 2 In Becker, BE and Cole, AJ (eds). Comprehensive aquatic therapy, 3rd edition. Washington State University Press. .]
History
The use of water for therapeutic purposes first dates back to 2400 B.C. in the form of hydrotherapy, with records suggesting that ancient Egyptian, Assyrian, and Mohammedan cultures utilized mineral waters which were thought to have curative properties through the 18th century.
In 1911, Dr. Charles Leroy Lowman began to use therapeutic tubs to treat cerebral palsy and spastic patients in California at Orthopedic Hospital in Los Angeles. Lowman was inspired after a visit to Spaulding School for Crippled Children in Chicago, where wooden exercise tanks were used by paralyzed patients. The invention of the Hubbard Tank, developed by Leroy Hubbard, launched the evolution of modern aquatic therapy and the development of modern techniques including the Halliwick Concept The Halliwick Concept focuses on biophysical principles of motor control in water, in particular developing sense of balance (equilibrioception) and core stability. The Halliwick Ten-Point-Programme implements the concept in a progressive programm ...
and the Bad Ragaz Ring Method (BRRM). Throughout the 1930s, research and literature on aquatic exercise, pool treatment, and spa therapy began to appear in professional journals. Dr. Charles Leroy Lowman's ''Technique of Underwater Gymnastics: A Study in Practical Application,'' published in 1937, introduced underwater exercises that were used to help restore muscle function lost by bodily deformities. The National Foundation for Infantile Paralysis began utilizing corrective swimming pools and Lowman's techniques for treatment of poliomyelitis in the 1950s.
The American Physical Therapy Association (APTA) recognized the aquatic therapy section within the APTA in 1992, after a vote within the House of Delegates of the APTA in Denver, CO after lobbying efforts spearheaded starting in 1989 by Judy Cirullo and Richard C. Ruoti.
Techniques
Techniques for aquatic therapy include the following:[
*Ai Chi: Ai Chi, developed in 1993 by Jun Konno, uses diaphragmatic breathing and active progressive resistance training in water to relax and strengthen the body, based on elements of ]qigong
''Qigong'' (), ''qi gong'', ''chi kung'', ''chi 'ung'', or ''chi gung'' () is a system of coordinated body-posture and movement, breathing, and meditation
used for the purposes of health, spirituality, and martial-arts training. With roots in ...
and Tai chi chuan
Tai chi (), short for Tai chi ch'üan ( zh, s=太极拳, t=太極拳, first=t, p=Tàijíquán, labels=no), sometimes called " shadowboxing", is an internal Chinese martial art practiced for defense training, health benefits and meditation. T ...
.[Lambeck J and Bommer A. 2011. Ai Chi: applications in clinical practice. pp 171-192, Chapter 7 In: Becker, BE and Cole, AJ (eds). Comprehensive aquatic therapy, 3rd edition. Washington State University Press. .]
*Aqua running: Aqua running (Deep Water Running or Aquajogging) is a form of cardiovascular conditioning, involving running or jogging in water, useful for injured athletes and those who desire a low-impact aerobic workout. Aqua running is performed in deep water using a floatation device (vest or belt) to support the head above water.[Wilder, RP and Brennan DK. 2011. Aqua running. pp 155-170, Chapter 6 In: Becker BE and Cole AJ (eds). Comprehensive aquatic therapy, 3rd edition. Washington State University Press. .]
*Bad Ragaz Ring Method: The Bad Ragaz Ring Method (BRRM) focuses on rehabilitation of neuromuscular function using patterns of therapist-assisted exercise performed while the patient lies horizontal in water, with support provided by rings or floats around the neck, arms, pelvis, and knees. BRRM is an aquatic version of Proprioceptive Neuromuscular Facilitation (PNF) developed by physiotherapists at Bad Ragaz, Switzerland, as a synthesis of aquatic exercises designed by a German physician in the 1930s and land-based PNF developed by American physiotherapists in the 1950s and 1960s.[Ainslie T. 2012. The concise guide to physiotherapy - 2-volume set: Assessment and Treatment. pp 1096-1106, Bad Ragaz Ring Method. Elsevier Health Sciences. .][McAtee RE and Charland J. 2007. Facilitated stretching: PNF stretching and strengthening made easy, 3rd ed. pp 11-18, Focus on facilitated stretching. Human Kinetics. .][Gamper U and Lambeck J. 2011. The Bad Ragaz Ring Method. pp 109-136, Chapter 4 In: Becker BE and Cole AJ (eds). Comprehensive aquatic therapy, 3rd edition. Washington State University Press. .]
*Burdenko Method: The Burdenko Method, originally developed by Soviet professor of sports medicine Igor Burdenko, is an integrated land-water therapy approach that develops balance
Balance or balancing may refer to:
Common meanings
* Balance (ability) in biomechanics
* Balance (accounting)
* Balance or weighing scale
* Balance as in equality or equilibrium
Arts and entertainment Film
* ''Balance'' (1983 film), a Bulgaria ...
, coordination, flexibility
Stiffness is the extent to which an object resists deformation in response to an applied force.
The complementary concept is flexibility or pliability: the more flexible an object is, the less stiff it is.
Calculations
The stiffness, k, of a bo ...
, endurance
Endurance (also related to sufferance, resilience, constitution, fortitude, and hardiness) is the ability of an organism to exert itself and remain active for a long period of time, as well as its ability to resist, withstand, recover from a ...
, speed
In everyday use and in kinematics, the speed (commonly referred to as ''v'') of an object is the magnitude of the change of its position over time or the magnitude of the change of its position per unit of time; it is thus a scalar quanti ...
, and strength
Strength may refer to:
Physical strength
*Physical strength, as in people or animals
* Hysterical strength, extreme strength occurring when people are in life-and-death situations
*Superhuman strength, great physical strength far above human c ...
using the same methods as professional athletes. The water-based therapy uses buoyant equipment to challenge the center of buoyancy in vertical positions, exercising with movement in multiple directions, and at multiple speeds ranging from slow to fast.[Audette JF and Bailey A. 2008. Integrative pain medicine: the science and practice of complementary and alternative medicine in pain management. Humana Press. .]
*Halliwick Concept: The Halliwick Concept The Halliwick Concept focuses on biophysical principles of motor control in water, in particular developing sense of balance (equilibrioception) and core stability. The Halliwick Ten-Point-Programme implements the concept in a progressive programm ...
, originally developed by fluid mechanics engineer James McMillan in the late 1940s and 1950s at the Halliwick School for Girls with Disabilities in London, focuses on biophysical principles of motor control in water, in particular developing sense of balance (equilibrioception) and core stability
In kinesiology, core stability refers to a person's ability to stabilize their Core (anatomy), core (all parts of the Human body, body which are not Limb (anatomy), limbs). Stability, in this context, should be considered as an ability to Motor co ...
. The Halliwick Ten-Point-Program implements the concept in a progressive program of mental adjustment, disengagement, and development of motor control, with an emphasis on rotational control, and applies the program to teach physically disabled people balance control, swimming
Swimming is the self-propulsion of a person through water, or other liquid, usually for recreation, sport, exercise, or survival. Locomotion is achieved through coordinated movement of the limbs and the body to achieve hydrodynamic thrust that r ...
, and independence
Independence is a condition of a person, nation, country, or state in which residents and population, or some portion thereof, exercise self-government, and usually sovereignty, over its territory. The opposite of independence is the statu ...
. Halliwick Aquatic Therapy (also known as Water Specific Therapy, WST), implements the concept in patient-specific aquatic therapy.[Lambeck J and Gamper U. 2011. The Halliwick Concept. pp 77-108, Chapter 3 In: Becker BE and Cole AJ (eds). Comprehensive aquatic therapy, 3rd edition. Washington State University Press. .][Dutton M. 2011. Orthopaedics for the physical therapist assistant. Jones & Bartlett Learning. .][Ainslie T. 2012. The concise guide to physiotherapy - 2-volume set: Assessment and Treatment. pp 1106-1116, Halliwick Concept. Elsevier Health Sciences. .]
*Watsu: Watsu Watsu is a form of aquatic bodywork used for deep relaxation and passive aquatic therapy. Watsu is characterized by one-on-one sessions in which a practitioner or therapist gently cradles, moves, stretches, and massages a receiver in chest-deep ...
is a form of aquatic bodywork, originally developed in the early 1980s by Harold Dull
Harold Dull (1935-2019) was an American aquatic bodyworker and poet best known as the creator of Watsu, originally developed in the early 1980s at Harbin Hot Springs, California. He is also known for his poetry, as founder of the Worldwide Aquat ...
at Harbin Hot Springs, California
Harbin Hot Springs is a non-profit hot spring retreat and workshop center at Harbin Springs in Lake County, Northern California. Named after Matthew Harbin, a pioneer who settled in the Lake County area. It is located about two hours northeast of ...
, in which an aquatic therapist continuously supports and guides the person receiving treatment through a series of flowing movements and stretches that induce deep relaxation and provide therapeutic benefit. In the late 1980s and early 1990s physiotherapists began to use Watsu for a wide range of orthopedic and neurologic conditions, and to adapt the techniques for use with injury and disability.[Schoedinger P. 2011. Watsu in aquatic rehabilitation. pp 137-154, Chapter 5 In: Becker BE and Cole AJ (eds). Comprehensive aquatic therapy, 3rd edition. Washington State University Press. .]
Applications and effectiveness
Applications of aquatic therapy include neurological disorders,[Morris DM. 2011. Aquatic rehabilitation for the treatment of neurological disorders. pp 193-218, Chapter 8 In: Becker BE and Cole AJ (eds). Comprehensive aquatic therapy, 3rd edition. Washington State University Press. .] spine pain,[Cole AJ, Johnson J, Alford JM, Hard K, Moschetti M, Fredericson M, Eagleston RA, and Stratton SA. 2011. Spine pain: aquatic rehabilitation strategies. pp 219-244, Chapter 9 In: Becker BE and Cole AJ (eds). Comprehensive aquatic therapy, 3rd edition. Washington State University Press. .] musculoskeletal pain, postoperative orthopedic rehabilitation, pediatric disabilities, and pressure ulcers.[
A 2006 systematic review of effects of aquatic interventions in children with neuromotor impairments found "substantial lack of evidence-based research evaluating the specific effects of aquatic interventions in this population".]
For musculoskeletal rehabilitation, aquatic therapy is typically used to treat acute injuries as well as subjective pain of chronic conditions, such as arthritis. Water immersion has compressive effects and reflexively regulates blood vessel tone. Muscle blood flow increases by about 225% during immersion, as increased cardiac output is distributed to skin and muscle tissue. Flotation is able to counteract the effects of gravitational force on joints, creating a low impact environment for joints to perform within. The temperature changes, increase in systolic blood pressure to extremities, and overall increase in ambulation are factors which help immersion to alleviate pain. Aquatic Therapy helps with pain and stiffness, but can also improve quality of life, tone the muscles in the body, and can help with movement in the knees and hips. Protocols using a combination of strengthening, flexibility, and balance exercises resulted in the greatest improvements in Childhood Health Assessment Questionnaire scores, whereas aerobic exercise did not result in greater improvements in CHAQ scores compared to a comparison group performing Qigong. Not only does aquatic therapy help with pain, but can benefit postural stability, meaning it can help to strengthen balance functions especially with people who have neurological disorders. For people diagnosed with Parkinson's disease
Parkinson's disease (PD), or simply Parkinson's, is a long-term degenerative disorder of the central nervous system that mainly affects the motor system. The symptoms usually emerge slowly, and as the disease worsens, non-motor symptoms becom ...
, aquatic exercise has been proven to be more beneficial than land-based exercise for two important outcome measures. The Berg Balance Scale and Falls Efficacy Scale score were reported to have significant improvement when implementing aquatic exercise over land-based exercise. These results suggest that aquatic exercise can be extremely helpful for Parkinson's disease patients with specific balance disorders and fear of falling.
Aquatic therapy in warm water has been shown to have a positive effect on the aerobic capacity of people with fibromyalgia
Fibromyalgia (FM) is a medical condition defined by the presence of chronic widespread pain, fatigue, waking unrefreshed, cognitive symptoms, lower abdominal pain or cramps, and depression. Other symptoms include insomnia and a general hyp ...
. It is still inconclusive whether land therapy is better than aquatic therapy however it has been demonstrated that aquatic therapy is as effective as land base therapy. There are advantageous outcomes for patients with fibromyalgia
Fibromyalgia (FM) is a medical condition defined by the presence of chronic widespread pain, fatigue, waking unrefreshed, cognitive symptoms, lower abdominal pain or cramps, and depression. Other symptoms include insomnia and a general hyp ...
resulting from aquatic therapy such as decrease of articulate load regarding an individual's biomechanics
Biomechanics is the study of the structure, function and motion of the mechanical aspects of biological systems, at any level from whole organisms to organs, cells and cell organelles, using the methods of mechanics. Biomechanics is a branch of ...
.
Currently there is no standardized aquatic therapy protocol for people post stroke
A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functionin ...
however it is safe to conclude that aquatic therapy can be more effective than land based therapy for improving balance and mobility. There is insufficient evidence regarding improvements in functional independence of people post stroke.
From a cardiopulmonary standpoint, aquatic therapy is often used because its effects mirror land-based effects but at lower speeds. During immersion, blood is displaced upwards into heart and there is an increase in pulse pressure due to increased cardiac filling. Cardiac volume increases 27-30%. Oxygen consumption is increased with exercise, and heart rate is increased at higher temperatures, and decreased at lower temperatures. However, immersion can worsen effects in cases of valvular insufficiency due to this cardiac and stroke volume increase. The aquatic environment is also not recommended for those who experience severe or uncontrolled heart failure.
Professional training and certification
Aquatic therapy is performed by diverse professionals with specific training and certification requirements. An aquatic therapy specialization is an add-on certification for healthcare providers, mainly including physical therapists and athletic trainers.
For medical purposes, aquatic therapy, as defined by the American Medical Association (AMA), can be performed by various legally-regulated healthcare professionals who have scopes of practice that permit them to offer such services and who are permitted to use AMA Current Procedural Terminology (CPT) codes.[Salzman, AP. 2007. Aquatic therapy: procedure or profession? Aquaticnet.com web site. http://www.aquaticnet.com/qualifications.htm, accessed 20-Mar-2014.] Currently, aquatic therapy certification is provided by the Aquatic Therapy and Rehab Institute (ATRI), which aims to further education for therapists and healthcare professionals working in aquatic environments. The ATRI prerequisites for certification include 15 hours of Aquatic Therapy, Rehab and/or Aquatic Therapeutic Exercise education, which can be completed hands-on or online. Once completing the prerequisites, those pursuing certification can take the Aquatic Therapy & Rehab Institutes Aquatic Therapeutic Exercise Certification exam.
References
{{Aquatic therapy
Hydrotherapy
Manual therapy
Massage therapy
Physical therapy
Rehabilitation medicine