Monday, November 23, 2020

Intro to Aquatic Therapy


As an Occupational Therapy professional working in a Level 1 Trauma Hospital for over 26 years, I've always enjoyed aquatic therapy as a therapeutic intervention to promote independence with activities of daily living and community integration.  Simply said, I love water and being mostly water myself makes it pretty essential.  Personally to keep myself fit, I've enjoyed snorkeling the most but of course cross training using swimming or simply playing with the kids in the water is fun too.  Kayaking and other types of boating activities have always been fun.  

Snorkeling and basic SCUBA in Curacao is awesome!

Flow Riding

Here I am riding some waves at the Great Wolf Lodge in Williamsburg Virginia.  This was much harder than it looked!

Here I am coming out of the swimming portion of the Raleigh 70.3 Ironman

I started teaching aquatics simply by accident.  I had taken several of my patients in the water and learned many interventions at that time from Donna Mooneyham RT and Susan Callis RT.  At the time Janice Blatt OT was teaching an aquatic class to Occupational Therapy students but one year she was unable to teach due to other plans.  She gave me her current lecture notes and the rest is history as she soon resigned and moved away.  Not only did I teach that year, I am still teaching that course with lots of added features and an aquatic lab in a therapeutic pool to reinforce the lecture portion.  Once I even taught a land course at the NC OT State Conference and I've actually taught this course virtually due to the 2020 Covid19 situation.  How crazy life is that one decision creates a career or life change?  Later I would attend other aquatic certification courses including but not limited to an Advanced Halliwick course by Johan Lambeck, PT, Aquatic Therapy by Donna Mooneyham RT, and a National Aquatic Arthritis Foundation Community Class Instructor Course.  Currently, I teach mandatory aquatic guest lectures for Pitt Community College's Occupational Therapy Program, optional East Carolina OT's program SOTA club, and Occupational Therapy, Physical Therapy, and Recreational Therapy staff at Vidant Medical Center formerly Pitt County Memorial Hospital in Greenville NC.  This blog was prompted when a Webex I did on aquatics was a near epic fail as some videos worked and some didn't regardless of being from one of my YouTube Links or simply from a file.  I figured this would be a good back up and who knows?  Maybe some others out there may enjoy the information too.  Keep in mind, I'm no expert but simply a Jack of many things... so take everything in with a grain of salt or two.  I'll also try to add more clarifying information that I would discuss in an open lecture as I gradually do updates.

Benefits and Goals of Aquatic Therapy

Total Pressure Free Environment
Non-weight bearing or initiation of weight bearing
 Increase freedom of movement and mobility
 Increase circulation and cardiovascular fitness
Increase strength and endurance
Increase coordination and balance
Increase ROM and flexibility
Decrease Pain
 Increase relaxation
 Promote Normal Tone
Proprioceptive and sensory stimulation
 Muscle Re-Education
Promote Social Interaction
Enhance Self-Image
Facilitate leisure skill development
 Experience Success

Physiological Effects of Immersion in Thermoneutral Water 

Increase circulation:  60% increase in blood volume
Increase blood supply to the muscles
Increase respiratory rate (work of breathing is 60% more difficult)
Increase metabolic rate
Decrease sensitivity of sensory nerve endings by increasing endorphin release which decreases pain reception
Decreases Pain Perception due to sensory overflow
Heart Rate with time will actually decrease
Diuresis increases
Decrease Blood Pressure
NA(10 fold) and K excretions increase
Increase muscle relaxation

Potential Contraindications

Contact Isolation with Open, Draining or oozing Wounds that cannot be covered with occlusive dressings (i.e. Tegaderm)

Unstable Vital Signs

Uncontrolled Incontinence of Bowels

Urinary Tract Infections

Infectious diseases

Contagious Skin Rashes

Yeast Infections

Premature Rupture of Membranes in Pregnancy

Potential Precautions

Excessive Fear of Water
All other patient devices will be evaluated by a case by case basis by aquatic staff and referring physician (i.e casts, external fixators, oxygen)

Potential Patient Populations Treated
 in Aquatic Therapy

Orthopedic Injuries & Joint Replacements
Neurological Conditions such as CVA, Guillian-Barre Syndrome, Multiple Sclerosis
Spinal Cord Injuries
Low Back Injuries
Chronic Pain
Muscular Dystrophy
Cerebral Palsy
Cystic Fibrosis
Traumatic Brain Injuries
Mental Illness
Developmental Disability
Cardiac Rehab

10 Basic Properties of Water (don't laugh too much)

Feels wet
Distinctive Sound
Dissolves nearly everything
3 forms: solid, liquid, and gas
Can absorb Heat
Sticks together
Part of all living things

Time to think about physics with properties of water...


Archimedes Principle states, A body fully or partially immersed in a fluid at rest experiences an upward thrust equal to the weight of the fluid displaced.” 
Basically when an object is in the water, it pushes down on water and the water pushes up.  If the water can push up as much as the object can then the object will float but if it can’t the object will sink.  
 With this in mind then buoyancy can either assist or add resistance to movements performed in water.   Using floats and other properties of water will then help us be more buoyant.

Relative Density(specific gravity)

Relative Density(specific gravity): The relative density of a substance equals the ratio of the weight of the substance to the weight of an equal volume of water.  The average specific gravity of a person is .974.   The relative density of water is 1.  If the specific gravity <1 then the substance will float.   If the specific gravity  is >1 then the substance will sink.  Children are most buoyant because their average specific gravity is  .8.  

Fat % can effect this but tension or spasticity does not significantly effects this

This is neat information if your patient has weight bearing precautions but also good information for a deconditioned patient to grade their activity up or down based on how deep they are positioned in water.

Waist Deep = ~50% weight bearing
Chest Deep = ~25-30% weight bearing
Neck Deep = ~10-20% weight bearing

So let's say you weigh about 200lbs.  If you are in waist deep water then you only weigh about 100lbs.  At chest deep you are about 50-60lbs and at neck deep about 20lbs.  This is a great way to grade activity levels so you can experience success.  Keep in mind that there are many different body types so percentages can vary if someone is shaped differently.  That being said, it's a great way to get a general idea.

Moment of Force (Moment of Buoyancy)

Moment of Force (Moment of Buoyancy):  The moment of force is the turning effect of the force about a point.  In the water the point is a human joint and the force is buoyancy.  Usually when I am doing therapy in the water I'm either focused on the shoulder or the hip when using this property of water.

F=Force of Buoyancy
d= The shortest distance of the Center of Buoyancy from a vertical line through point P
P=The point about which the turning effect of Buoyancy is exerted.
L= Lever Arm
CB= Center of Buoyancy
Moment of Buoyancy = F x d

Sorry I'm not an artist haha...  think about the large letter P being the shoulder or hip and the L could be your arm or leg.  As you raise your arm or leg upward toward the surface of the water, the moment of force/buoyancy increases.  This is neat because it's kind of like variable resistance and for this reason the patient can experience success they may not be able to experience against gravity on land.  We must however be cautious as they may not be able to control their arm or leg safely.  Maintain contact for safety until they've demonstrated control.  On land, weight lifters will use chains on barbells etc to create variable resistance.  We can further grade activity in water using floats or those water type dumbbells pictured earlier.  Check out videos.

Uncontrolled Usage of Moment of Force(Buoyancy)

So if you want to grade this exercise up or down, think about using versus not using a float or dumbbell.  Either way always think about safety.  Note how adding a float etc makes a ton of difference especially if you add a device more distal which would increase the force at a greater rate because it increases the "d" (distance) because the CB (Center of Buoyancy moves more laterally from the initial vertical starting line of the joint your are working.  In the videos above the joint is the shoulder.


Viscosity:  Viscosity is the property of friction in fluids or resistance to flowing movement.  So water actually has a low viscosity where as something like olive oil may have medium viscosity and honey would have high viscosity.

If  movement  is low then viscosity is low.  Different fluids are characterized by varying amounts of molecular attraction within the fluid.  When in motion this attraction creates resistance to movement.  I always think about this when it's about that time to change the car oil.  Too much oil viscosity creates engine heat and other issues etc.

Law of  Thermodynamics states, “Energy is never lost but instead transformed …” Some for example can be transformed into heat or even to increase surface tension acting like a membrane.
Try it using a straw. Stick a straw in a fluid.  Notice how it sticks at the end of the straw if you place your finger blocking the opposite end.


Turbulence is created with increase speed of movement because if the rise in internal friction in the fluid depending on fluid density and viscosity.

Note how turbulence acts on an object
Which direction did the object move?

How can we use this to help in treatment?

Turbulence to create resistance

Using Turbulence to Assist

Using Turbulence in Game Play

Red Light Green Light
Note how you can grade the activity with changing the effects of turbulence.  Change of speed, sudden stops, change in direction all create change in resistance.  Other properties of water are always in play too such as drag effect.

Hydrostatic Pressure

Hydrostatic Pressure: Fluid pressure is exerted equally on all surface areas of an immersed body at rest and the pressure is directly proportional to the depth of the body part below the surface.  Bottom line is we have to be aware of fluids in the body.

Imagine my daughter in water.  Fluid pressure is exerted all around her equally.

So what are some considerations in treatment?

Low Blood Pressure
Hydrostatic Pressure can actually lower blood pressure.  This can be good or bad.  Not rocket science here.  Be aware of what is normal ranges especially what is normal for the person you are working with including yourself.  In the Boy Scouts I learned something which may help you.  If the face is pale, raise the tail.  If the face is red, raise the head.  Take blood pressures, read charts, and do what it takes to be safe.  Do know harm folks and make sure your doctor approves!

If your fluids are being pushed through your system then you'll need to likely urinate and your client will too!  Use the bathroom before the workout.  You may need to do during and after as well.

Obviously, if you are losing fluids you could get dehydrated.  Make sure you and others are hydrated before and after the session.  If skin turgor is poor meaning your skin sticks together then not a good day for aquatics.  Check urine color and output volumes as well as capillary refill at your finger nails too.  Again with all factors, make sure your doctor approves!

Hey if you're in the Occupational Therapy profession, aquatics is a win-win.  You should bathe before and after, dress before and after, toilet before and after and during you've got great therapeutic activities!

Drag Force

Drag Force:  Drag is the force that resists the movement of a solid object through a fluid or gas.  

Watch his legs as I guide him through the water

How about some game play?

Drag Effect while performing the "TRAIN"

Notice the difference between the front versus the back

Note how the effects of drag are greater the faster you move and the force is even greater if the train of people is longer.  The ones in the front barely have to maintain balance yet the ones in the rear can't even hold on to the people in front of them or keep their legs on the ground.


The Halliwick method of teaching swimming was created by James McMillan at the Halliwick School for Girls in Southgate London.  Swimmers are taught 1:1 until they become independent.  Floats are typically not recommended in this technique.   So basically all of those properties of water previously discussed are used in the Halliwick Method.  Above were some of the many things one could do in this method.  The Train, Red Light Green Light and many other things.

Goals of Halliwick
4 Principles of Instruction

Mental Adaptation:  Recognizing how gravity and up thrust act on the body

Balance Restoration:  Large patterns of movements to restore or maintain balance

Inhibition:  Ability to create and hold a desired position or posture

Facilitation:  Able to perform purposeful and controlled movements without use of floats such as in swimming

Bad Ragaz

Bad Ragaz is an aquatic intervention that has been used since the 1930’s in the thermal spa waters of Bad Ragaz Switzerland.  The client is supported in supine with floatation rings to provide midline stability while the therapist guides the client in treatment.

Treatment Goals of Bad Ragaz

Increase ROM
Muscle Re-education
Spinal elongation/traction
Improving alignment and stability of trunk
Preparing body to perform ADL’s 

Warming up & Building Trust
There is a lot of touching which can be therapeutic yet intimate.  If the person has mental, emotional, or physical limitations and challenges, you can only imagine how important it is to build rapport and trust.  After a process of orienting to the pool and goals etc, I enjoy using "Snaking".


Isometric Treatment Technique
Of Bad Ragaz

The client holds one position while the therapist moves them in the water.  This is great for trunk stability as well as strengthening upper extremities. Isometric can be translated as "same measure".  On land, the plank is a good example of an isometric exercise.

Isokinetic Treatment Technique
Bad Ragaz

Therapist can provide a fixed stable point while the patient moves toward or away from the body.  The client is the one who determines the resistance by how fast they move in the water.  This is good for strengthening the extremities.  Note that the therapist positions their hand on only the side of the extremity that the person needs to push against.  The therapist provides proprioceptive feedback for the patient to help the patient motor plan the movement directed to do.  In the picture above, the person is performing shoulder abduction as he moves his arm away from his body toward me.  Typically, a fixed speed of the exercise is determined but can be changed by facilitation of the therapist and ultimately determined by the individual performing the exercise.  A good way to remember is to break down the term isokinetic to "same speed".  Obviously Aquatic therapy is a bit tricky to maintain the same speed.

In the picture above notice that now the hands are on the medial aspect of the extremity.  Now the patient is adducting their leg as he brings his leg toward his opposite leg.  Note that I am not moving.  I am a fixed point.  He is controlling the speed and therefore the resistance of the movement.

In this picture, I am placing my thumbs on his metatarsal heads of his foot to facilitate plantar flexion as he extends his leg.  To facilitate dorsiflexion with flexion of his knee and hip I change the position of my hands to his instep opposite of the balls of his feet.

When practicing keep in mind that you and your practice partner are much stronger than your patients will likely be.  Either way you may want to buy some aquatic type shoes to stay grounded.

Isotonic Treatment Technique
Of Bad Ragaz

In this technique, the therapist provides resistance by moving the client through the water.  The therapist can help or increase resistance depending on which direction they move the client.  This is good for core strengthening and flexibility.  Typically a constant resistance is applied as muscles are used to move one's joints.  Selecting weights to lift in a gym is a good example.

In the case of weight lifting, the individual uses muscles to move joints against resistance.  A good way to remember this is breaking the term down.  The word isotonic means "same tension".  In aquatic therapy this is a bit tricky as the resistance may change depending on speed etc.

In this video I am resisting against his attempts to grade the activity to a more difficult task.  Note that I am moving away from him.

In this video I am assisting his attempts to grade the activity to an easier task.  So in this case, I am moving toward him to help him.

Ai Chi

Ai-Chi is like Tai Chi except it is performed in the water.  It combines a series of gentle stretches and breathing exercises.  I would also recommend other martial arts but simply do them in the water. 

Primary Goals of Ai-Chi


Improve balance

Manage breathing

This video is above water for some exercises for demonstration purposes but ideally keeping your body in the water is better.

Arthritis Exercises

Primary Goals of Arthritis Exercises

Decrease Pain

Keep in mind the video is just a brief demonstration.  Each exercise may be performed for longer etc.


WATSU, which is also called water shiatsu, is a wellness or massage technique. People who perform WATSU believe that through stretching, the body’s meridians are believed to come closer to the body’s surface where the energy they carry can be released.  Check these videos out.

Therapeutic Activities

  This can be any activity you create using any combination of use of the properties of water or other techniques in achieving your goals.  Volleyball, Martial Arts, Basketball, Swimming, use of benches, use of floats, boats, and other tasks are acceptable.

I've often used towel assisted table top exercise to reduce resistance for upper body Range of Motion exercises.  This works well too!  In addition you can incorporate weight shifts and obviously core strength development.  All these exercises can do many things.  It simply depends on the needs of the person performing them.  You may need a therapist behind them for helping to facilitate movement/weight shifts etc and to maintain balance during weight shifts.  This can be much more difficult than it appears.  Remember the safe way is the best way!

I like this one for also promoting weight shifts for skin care management via pressure reliefs as well as improving core strength and fear reduction when performing functional transfers and lower body self care related tasks

Game play is the last level of advanced therapeutic benefit in Hallwick and simply therapeutic activities.  Basketball, swimming, water polo or any game play can really challenge someone physically while also promoting mental and emotional wellness.  Keep it fun but always remember to keep it client based as what is purposeful and meaningful to them may or may not be what is for you!