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Aquatic Therapy For Patients with Neurological Conditions

 

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By Meredith Smythe, SPT

Background:

Growing up as a competitive swimmer I have always loved to be around the water. I was interested in seeing how aquatic therapy could benefit patients with neurological conditions. In the summer of 2016 I worked with Debbie Thorpe with a patient who had multiple sclerosis and saw first hand how aquatic therapy can be beneficial to this patient population.

 

Statement of Need:

The aquatic environment has much to offer patients with neurological conditions. Buoyancy, hydrostatic pressure and thermodynamics can be utilized in ways that improve spasticity3, increase range of motion, increase strength4 and improve functional mobility. Buoyancy decreases body weight and helps people move who have trouble moving on land.5 The water is a safe place to provide balance training because patients have a reduced fear of falling.6 Additionally preliminary studies indicate that aquatic therapy reduces pain7 and improves quality of life for patients with multiple sclerosis.8 Multiple studies have shown increased strength gains with aquatic therapy in a patients who have had a stroke.4,6 There is also promising data suggesting that aquatic therapy may improve balance in patients with Parkinson’s disease.9

 

The Project:

In the fall of 2016 I prepared a Critically Appraised Topic on strength training benefits of aquatic therapy for patients with multiple sclerosis. I then started to broaden my research to other benefits of aquatic therapy for patients with neurological conditions. In the spring I wrote an evidence-based capstone paper presenting evidence that aquatic therapy benefits patients with multiple sclerosis.

I then conducted an in-service presentation at the UNC Center for Rehabilitation Care on aquatic therapy for patients with neurological conditions. The goal of the presentation was to give physical therapists an overview of aquatic therapy, the properties of water, and to encourage them to refer patients with neurological conditions to aquatic therapy. I provided a power point presentation and a presentation handout. To prepare for my presentation I used information from a chapter titled Systematic Effective Instruction in the book Teaching and Learning in Physical Therapy by Plack and Discoll10 about designing an effective presentation for physical therapists. I also reviewed two videos about effective presentations by McMillian,11 and Wacknell12 about effective presentation skills in order to make my presentation more interactive.

I developed a strength training home exercise program handout for patients with moderate weakness. Multiple clinicians told me that it would be helpful to have a handout like this because many patients are not covered by insurance for many sessions of aquatic therapy. For the patient handout I incorporated the health literacy concepts from Jenson’s and Mostrom’s book Handbook of Teaching and Learning for Physical Therapist1. I worked to make the hand out readable, clear, focused, and achievable.13

 

Self-Evaluation:

Overall I received positive evaluations on both the use and performance of my presentation. If I were to do something differently I would do more to assess the needs of those I was presenting to. In preparation for the presentation I asked the questions about the expected audience as suggested by Plack and Discoll .10 When I did my presentation the audience unexpectedly included many aquatic therapists who were not in my original target audience. They therefore did not benefit as much from the presentation as the other therapists.

This project has taught me many things about communication, receiving feedback, and designing an effective presentation for my audience. I learned from feedback in my in-service the importance of promoting what I am selling. The feedback said that I was so effective at criticizing the quality of the evidence for my presentation that the therapists were not as convinced about the value of aquatic therapy. If I were to do the presentation again I would use more positive framing in presenting this evidence.

 

Acknowledgements: I would like to thank several individuals who gave me feedback on my materials including Carol Giuliani, PT, PhD, FAPTA, Deborah Thorpe, PT, PhD, Catherine Jacobs PT, DPT, and Karen McCulloch, PT, PhD, NCS. Thank you for providing me with feedback and encouragement throughout this process.

 

References:

  1. Spa HS. Physical therapy. http://www.h2xrx.com/physical_therapy.php. Accessed April 8, 2017.
  2. Therapy BP. Aquatic Therapy. http://www.biosports.net/services/aquatic-therapy.php. Accessed April 3, 2017.
  3. Kesiktas N, Paker N, Yilmaz H. The Use of Hydrotherapy for the Management of Spasticity. Neurorehabil Neural Repair. 2004;18(4):268-273.
  4. Zhang, Wang Y, Huang L-P, Bai, B, Zhou, S, Yim,M-M, Zhao, H , Zhou X-N. Aquatic Therapy Improves Outcomes for Subacute Stroke Patients by Enhancing Muscular Strength of Paretic Lower Limbs Without Increasing Spasticity: A Randomized Controlled Trial. American Journal of Physical Medicine & Rehabilitation. 2016:840-849.
  5. Bayraktar D, Guclu-gunduz A, Yazici G, Lambeck J. Effects of Ai-Chi on Balance, Functional Mobility, Strength and Fatigue in Patients with Multiple Sclerosis: A pilot study. NeuroRehabilitation. 2013;33:431-437.
  6. Plecash AR, Leavitt BR. Aquatherapy for Neurodegenerative Disorders. J Huntingtons Dis. 2014;3:5-11.
  7. Mar A, Matar GA, Lara-palomo I, Saavedra-hern M, Arroyo-morales M, Moreno-lorenzo C. Hydrotherapy for the Treatment of Pain in People with Multiple Sclerosis : A Randomized Controlled Trial. Evidence-Based Complement Altern Med. 2012;2012:1-8.
  8. Kargarfar, Mehdi, Etemadifar, Masoud, Baker, Peter, Mehrabi, Maryam, Hayatbakhsh R. Effect of Aquatic Exercise Training on Fatigue and Health-Related Quality of Life in Patients With Multiple Sclerosis. Phys Med Rehabil. 2012;93(October):1701-1708.
  9. Kurt EE, Büyükturan B, Büyükturan Ö, et al. Effects of Ai Chi on Balance , Quality of Life, Functional Mobility, and Motor Impairment in Patients with Parkinson’s Disease. Disabil Rehabil. 2017:1-6.
  10. Plack, Margaret, Discoll M. Teaching and Learnign in Physical Therapy: From Classroom to Clinic. 2nd ed. SLACK Incorportated.
  11. McMillian D. Life After Death by PowerPoint. https://www.youtube.com/watch?v=MjcO2ExtHso. Published 2012. Accessed March 2, 2017.
  12. Waknell P. What are the secrets of a great WikiTalk? Phil Waknell – WikiStage ESCP Europe. https://www.youtube.com/watch?feature=player_embedded&v=jT-H6UrinG0#at=45. Published 2013. Accessed March 1, 2017.
  13. Jensen, Gail M, Mostrom E. Teaching and Learning for Physical Therapists. 3rd ed. Elsevier Health Sciences; 2012.

 

 

6 Responses to “Aquatic Therapy For Patients with Neurological Conditions”

  1. Meredith Smythe

    Dear Debbie,

    Thank you so much! I am eager to become an aquatic therapist. I want to work this older adults and I think the water has a lot to offer that population. Thank you for your help and guidance with my project.

    Meredith

    Reply

  2. Debbie Thorpe

    Dear Meredith
    I enjoyed reviewing the materials that you submitted for your capstone on aquatic therapy. The presentation handout was concise and highlighted the important parts of your ppt. It looks like the presentation went well ! You provided the UNC therapists with good information on aquatic PT. I hope that you consider using it in your practice in the future. Aquatic PT is typically reimbursed at a higher rate than other PT billing procedures and there is a great need for this type of intervention in multiple patient populations.
    Good luck and great job.
    Debbie

    Reply

  3. Meredith Smythe

    Dear Dan,

    Thank you so much for reviewing my capstone. I came across two studies that used quality of life as an outcome for my patient population. There may be more studies looking at this with patients with osteoarthritis or musculoskeletal issues. One study was by Kargarfar and it found that patients with MS who did aquatic exercise experienced improved quality of life. Another by Kurt et al found that patients with Parkinson’s who performed Ai Chi aquatic therapy improved their quality of life. Thank you again for your comments. Here are my references:

    1. Kargarfar, Mehdi, Etemadifar, Masoud, Baker, Peter, Mehrabi, Maryam, Hayatbakhsh R. Effect of Aquatic Exercise Training on Fatigue and Health-Related Quality of Life in Patients With Multiple Sclerosis. Phys Med Rehabil. 2012;93(October):1701-1708.

    2. Kurt EE, Büyükturan B, Büyükturan Ö, et al. Effects of Ai Chi on Balance , Quality of Life, Functional Mobility, and Motor Impairment in Patients with Parkinson’s Disease. Disabil Rehabil. 2017:1-6

    Reply

  4. Meredith Smythe

    Dear Elizabeth,

    Thank you so much for your feedback! I did not remember seeing a study that compared two types of aquatic therapy in my research. Ai Chi is the most used type of aquatic therapy when it comes to studies with neurological conditions. I have seen a combination of different types of aquatic therapy as an intervention. You are correct that certain types work best with certain impairments. The evidence is “fair” in supporting the use of aquatic therapy in general. There is more evidence in people with OA on aquatic therapy. I did find a dose response study for low back pain. The reference is bellow. Thank you for reviewing my capstone.

    Reference:
    Klkjlj Baena-beato, P. A., Arroyo-morales, M., Delgado-fernández, M., Gatto-cardia, M. C., & Artero, E. G. (2013). Effects of Different Frequencies ( 2 – 3 Days / Week ) of Aquatic Therapy Program in Adults with Chronic Low Back Pain. A Non-Randomized Comparison Trial, 145–158.

    Reply

  5. Elizabeth Huber

    Meredith,
    I really enjoyed looking through your presentation and handouts! I especially liked the pictures and instructions you included in the handout that is for patient distribution. It is very clear and the pictures add so much to it, especially to those patients who have never done aquatic therapy and might not easily understand exercise descriptions. I remember during my first clinical rotation in Laurinburg, NC, my CI was showing me around the facility and told me that there used to be an indoor pool for aquatic therapy but that it got covered because no PTs wanted to use it. That made me sad to hear and after being at that clinic for a few weeks and seeing countless patients who could have benefitted so much from aquatic therapy, I wished they had not been so quick to cover it with a seldom-used conference room. You hit on this in your presentation, but I really do believe aquatics allow for a unique therapeutic experience that might not otherwise be possible on land. The different types of aquatic therapy you described are interesting, and a lot of those names are new to me. I have seen the Halliwick method mentioned in articles about stroke rehab, but did not recognize some of the other types. Did you find any research that compared the efficacy of one type of aquatic therapy with another for the same patient population? I know some of the characteristics make one type more appropriate for certain patients than another type but I would be curious to know how the different methods compare. I will definitely hold onto these handouts, and hopefully I will be in a clinic or hospital one day where I can put this information to use! Good job, Meredith!

    Reply

  6. Dan Steele

    Meredith, thank you for the extremely informative exploration of aquatic therapy! I saved your presentation as a quick reference guide for any of my future patients who might benefit from it. I remember during my years as a trainer, I worked with a client with rheumatoid arthritis in the pool at the gym. While this was obviously aquatic exercise, not aquatic therapy, I still would have benefitted from knowing some of this information then, because I felt lost as to coming up with specific parameters of exercise in the water. Having now treated patients with neurological injury, something that struck me about the information you gave is how it must make patients feel to be able to achieve that level of physical activity that might be impossible on land. It appears that your findings indicate a lack of high quality evidence for the effectiveness of aquatic therapy for a number of neurological injuries/impairments. This doesn’t seem surprising as I believe many of our classmates have discovered a scarcity of evidence supporting specialty topics that interest us individually, but I wonder have there been any studies conducted using quality of life outcome measures? While restoring or at least improving function is important and tends to be the driving force behind reimbursement for PT services, I don’t think QOL is given enough weight when it comes to evaluating things like aquatic therapy. If someone has CP or MS and aquatic therapy only minimally improves their physical function but greatly improves their sense of happiness, personal efficacy, and accomplishment, I would still consider that a successful intervention and a worthwhile investment. Hopefully our healthcare system will reach a point where the payers see things similarly.

    Reply

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