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Aquatic Therapy for Amputees: Diving in to Rehabilitation, Exercise, and Recreation

Hannah Zimmer, SPT

University of North Carolina at Chapel Hill

DPT Capstone Project 2021


Background & Statement of Need

The purpose of this project is to create an evidence-based resource for clinicians and amputees regarding functional and psychosocial effects of aquatic therapy and how to incorporate aquatic activity into therapy and exercise/recreation. There is currently limited evidence to provide specific parameters for aquatic intervention for many neuromusculoskeletal conditions, including amputation. Therefore, aquatic therapy is not commonly utilized or recommended for individuals with amputation. However, it is known that patients experience psychosocial and functional benefits following aquatic therapy and long term aquatic activity. Current barriers to amputees receiving aquatic therapy include lack of literature to specifically support aquatic therapy in amputees, thus diminishing implementation of and referral to aquatic therapy. Additionally, new amputees report fear or discomfort associated with pool activity and self-modify previous exercise and recreation habits, assuming that aquatic activity is no longer feasible for them to do. This project aims to address the gap in physical therapy knowledge and practice regarding amputees and aquatic therapy, and begin to establish a standard of care for this population and intervention.


Objectives for the Learner

  • Gain an in-depth understanding of the benefits, risks, and clinical challenges associated with aquatic therapy for patients with musculoskeletal conditions, including amputees.
  • Understand the different stages of amputee rehabilitation, and how aquatic therapy may or may not be an appropriate method of care in these different stages.
  • Understand barriers to aquatic therapy that amputees may face, and solutions to overcome these barriers.
  • Provide a list of local resources for clinicians and patients that will improve access to care and long term self-management of neuromusculoskeletal health via aquatic activity.
  • Understand how to safely initiate aquatic activity with a patient with lower extremity amputation in order to make clinical recommendations for physical therapists and practical recommendations for patients



VoiceThread Presentation for Clinicians:

Patient/Caregiver Education Handout: Aquatic Therapy for Amputees Handout

Summary of Evidence: Aquatic Therapy for Amputees Evidence Table


Health Literacy

There are two intended audiences for the learning materials provided in this Capstone project: physical therapists/DPT students and patients/caregivers. The content of the VoiceThread and associated slides provide detailed information, including a summary of evidence, stages of amputee recovery and rehabilitation, suggestions for interventions throughout these stages, and recommendations for long term self-management. A short list of local resources is also provided as a starting point for local clinicians to make recommendations to their patients. Because the target audience for this presentation has higher level knowledge and understanding of medical and PT jargon, the content utilizes this language in slides and voice-over communication in a clear, concise manner.

To further apply concepts of health literacy, I developed a secondary patient education resource that summarizes the benefits of aquatic therapy and aquatic exercise. This document focuses on the patient experience—what they can expect and what they should do—in order to encourage the patient (and members of their support system) to feel comfortable in seeking out or participating in aquatic therapy or exercise. The content of this document has been optimized for patient understanding at a basic reading and comprehension level.



Thank you for taking the time to view my capstone project and materials. Please fill out the following survey to provide feedback regarding this presentation and supplementary materials:

Throughout the process of completing this project, I received regular feedback and advice from my committee members (Dennis Bongiorni, PT and Michael Murray, DPT, PT) and faculty advisor (Debbie Thorpe, PT, PhD). This constructive insight and guidance helped to narrow the focus of my project and create materials that are clinically relevant and useful.


Self Reflection

This Capstone project has been a series of unique learning opportunities and challenges, but has also come with great reward. Upon completion of this project, I believe I am well-equipped to work with amputees in the aquatic setting at any appropriate stage of rehabilitation. From the review of evidence to full completion of the presentation and supplementary educational materials, I have learned in great detail how many important layers there are when caring for an individual post-amputation. While the evidence gap still exists in this population and setting, I believe this project accomplished the goal of providing recommendations and resources to clinicians and patients/caregivers for rehabilitation of amputees in the aquatic setting.



Thank you to Dennis Bongiorni, Michael Murray, and Debbie Thorpe for your feedback, guidance, and encouragement throughout this project. I am grateful for your time and the support you have provided me from the initial brainstorming stages through to completion of the Capstone course.


10 Responses to “Aquatic Therapy for Amputees”

  1. Erin Griffith

    Your capstone project is a great addition to the amputee community for patients and clinicians alike. As someone who also dove into the literature of aquatic intervention in the last few months, I know how much time and effort this required, and I commend you for that. Your VoiceThread presentation and patient/caregiver educational handout are organized, informative, and user-friendly. Since the target audience of your lecture includes both students and licensed physical therapists, it might be a good idea to reference specific aquatic exercises with descriptions or pictures. This would provide even more direction when treating this patient population, thereby instilling confidence in everyone involved.
    I agree with Dr. Debbie Thorpe that this information needs to be communicated near and far. The synthesis of what you’re providing is an excellent tool. Good luck in taking this to the next level. I enjoyed reading about it.

  2. Anna Brown

    Hey Hannah!
    First off, great project! I think health literacy is a big part of amputee rehabilitation. Amputation comes from all different pathologies but one of the biggest is through vascular disease. These patient’s often have a lower health literacy and are often unaware of way to rehabilitate themselves. As your evidence table alludes to, aquatic therapy can increase activity tolerance, reduce contractures, increase hip ROM, and help manage pain. If we consider an ICF model of disability, aquatic therapy is helpful in addressing impairments in structure and function and ultimately can lead to greater participation outside of the pool. I also loved the resources you provided on local facilities that offer aquatic therapy. Even as an SPT I would still struggle with where to direct someone if they asked where they could receive aquatic PT. Thank you!

  3. Debbie Thorpe

    Really great job on this project! One of your committee members recommended that you submit this as a short presentation in aquatic section to CSM for next year. The abstracts for programs are due soon. I think you should seriously think about it. Maybe submit with Dennis and Michael as co-presenters. I learned a lot from your presentation. It would be great to have your permission to add the voice thread as supplemental content to the aquatic content for the DPT students next year! I also want to say how professionally you handled the glitch of not being able to do videoing of patients. You bounced back with a very nice patient/caregiver resource handout that provides valuable information! All around a great job on this project and you should feel very proud! You will make an amazing aquatic PT!!

    • Hannah Zimmer

      Thank you for your encouragement and support throughout this project! I would love to explore the idea of submitting my materials for presentation at CSM; I will connect with you about the next steps in this process. I’m hopeful that these materials will provide benefit for clinicians and patients/caregivers alike, and I’m happy with the final result of each of these deliverables.

  4. Sarah Richardson

    Congratulations on an amazing capstone project! I know this topic is so important to you as it relates to a patient population that you hope to serve upon graduation. I’m currently involved in aquatic therapy on my clinical rotation, so I really enjoyed learning about how individuals with lower extremity amputations can be candidates for aquatic therapy. Although you mentioned the limitations in current research for intensity and dosage parameters, I think you were able to gather some great information and resources for providers and patients. You mentioned in your presentation that potential equipment considerations include “water legs” for individuals with lower extremity amputations. I’m curious if you have any insight as to how buoyancy and resistance impact the use of “water legs”? Are individuals able to bear weight equally in the water using “water legs” and if so how does the resistance of the water impact the movements of the prosthetic?
    Sarah R.

    • Hannah Zimmer

      Thank you for your support and kind words about my project! I appreciate your questions too–you bring up great points about the logistics of prosthesis use in this environment. Based on my research, “water legs” are still fully functional prosthetic limbs that allow for weight bearing and ambulation, but are better suited for submersion in the water (i.e. the components are not quite as sensitive to water, salt, chlorine, etc. as typical daily devices). Because of the difference in surface area, mass, and neuromuscular control of the prosthetic limb compared to a full-length natural limb, there will likely be differences in the effects of the physical properties of water, like buoyancy and viscosity/resistance. However, with a proper fitting socket, the prosthetic limb can still function as a natural limb would in the water in order to strengthen the residual limb, improve functional mobility (i.e. gait, balance), and decrease overall pain levels. This case study by TJ Cutler was a great resource throughout my project–check it out for more information and insight on an individual using a prosthetic leg during aquatic therapy!
      Cutler TJ. Rehabilitation of an Individual with Transfemoral Amputation Combining Aquatic Ambulation With Prosthetic Socket Incorporating High-Fidelity Skeletal Capture. Journal of Prosthetics and Orthotics. 2017;29(4):206-212. doi:10.1097/JPO.0000000000000147

  5. Brianna Colello

    Congratulations on an amazing capstone project! Its wonderful to see you combine your love for aquatics and passion for amputees. I know how much the prospects of working with Veterans and Military personnel has shaped your PT education and I think this is a great aspect to bring with you in your professional career. Your Voicethread and handout are very informative! I especially like how you highlight that an amputee may be fearful of the water and that aquatic PT can ease those fears and provide a multitude of benefits. I’m grateful to have you and these products as resources for my future career. Thank you for sharing your passion for amputees and aquatic therapy with us, I look forward to seeing the amazing things you will do at the VA!

    • Hannah Zimmer

      Thank you for your encouragement and support throughout this project! One thing I have come to really understand throughout my experience with aquatic therapy is that high levels of pain can often contribute to high levels of fear associated with movement and therapy, but a safe and supportive environment like the therapy pool can provide such meaningful relief for these individuals. I’m hopeful that these capstone materials will provide clinicians and patients with information and resources that help to decrease the individual’s pain levels and improve their day-to-day function and quality of life. Thanks for viewing and reflecting on my materials!

  6. raiyaf

    This is awesome! I absolutely love that you chose this topic for a capstone. I have always been interested in working with amputees and I have to say prior to exploring your capstone I had never thought of aquatic therapy as an intervention option. The clinic I am currently at for my rotation has a therapeutic pool so I now have a bit of experience working with patients in a pool and seeing first hand the incredible outcomes it can have. The handout that you made for patients is really great! I love the information you provide along with the resources of where to find aquatic therapy options. At first glance, I assumed aquatic therapy for a patient with an amputation would not include a prosthetic; however, I never thought of the benefits a patient could get from using a waterproof prosthetic or waterproof cover to ease into prosthetic training in a weight limiting environment. I learned so much from watching your voice thread presentation as well. You spoke clearly, created informational slides, and kept the presentation engaging! I know sometimes presenting without an audience can be difficult but you did a great job. I am so proud of you and your hard work on this project! This is information that I am absolutely going to take with me into my future as a clinician.

    • Hannah Zimmer

      Thank you for your kind words and support! I am glad to hear that these materials will serve you well in future clinical practice, and I hope you are able to pass these resources along to patients who would benefit as well! My current rotation has a therapy pool as well, and it is encouraging to see how much meaningful change an individual can experience after a few weeks in the pool. It’s so important to advocate for patients who would benefit from these services, especially when public awareness is a bit lower, as in cases like this. Thank you for reviewing my materials!


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