Byline: Andrea Salzman, MS, PT
Not long ago, options for aquatic therapy equipment were nonexistent. As recently as the (mildly embarrassing) era of Cyndi Lauper and Boy George, clinicians relied on their own creativity to morph Clorox bottles and PVC piping into water-worthy fitness gadgets. But today’s aquatic providers have the best treatment tool of all available to them: Choice.
Aquatic equipment choices should grow organically from each patient’s needs. Kids don’t “do exercise”, so the tools of the trade of the pediatric aquatic therapist look a lot like every kid’s Christmas list: water guns, dive toys, hula hoops and beach balls. Adults in pain don’t need fancy resistance boots and bells to harness the beauty and serenity of aquatics. In fact, often the best equipment for the pain patient is no equipment at all. Athletes need to be challenged with resistance training, pregnant women need to increase blood flow to the fetus, and post-operative patients need to stay vertical for edema control -- all requiring different products.
Additionally, equipment is most helpful when it is used to advance specific goals. When selecting water gear, clinicians should ask themselves the focus of treatment: “Is it my intent to perform balance training? Core stabilization? Strength building? Respiratory development? Or good old-fashioned sensory stimulation?” These focus areas require very different products.
General Use
Pediatric clinics use several different products to rehabilitate children in an aquatic environment. For adults, therapy focuses more on exercise and less on play, but many core techniques are shared among generations. Equipment can work for both pediatric and adult patients if it accounts for the size differential.
• Toys. Toys are a must for pediatric clinics, but it’s easy to get carried away. A few floatable and sinkable toys usually suffice. Buoyant toys can be propelled across the water to encourage movement, while more advanced patients can retrieve sinkable objects from the pool floor. Diving to recover objects encourages hand/eye coordination and breath control.
Deb Theisen, formerly the adapted swim instructor at Regions Hospital in St. Paul, Minn., recommends basic sand pails and oversized sponges. Children who are reluctant to get into the pool are happy to sit poolside and get wet with water-laden sponges, she says. These toys can help ease the transition into the pool.
• Balls. Use inflatable balls to improve gross motor skills, arm strength and balance.
Caryl Sircus, MS, PT, who works with pediatric and orthopedic patients at Aquatic Therapy Associates in San Rafael, Calif., recommends using balls for dynamic exercises. They can also be used for beginner’s tasks, such as reaching, chasing, throwing, blowing and pushing, she says. A game of catch improves proprioception, participation and socialization. During these activities, crossing the midline and reaching behind the body become natural extensions of play and work the entire body.
For younger patients, consider smaller balls with textured surfaces because they’re easier to grip and provide sensory stimulation.
• Foam noodles. Foam noodles are used primarily to provide flotation support and position the body properly in the water, or create resistance to increase strength in upper or lower extremities. Patients can sit on a noodle, place it under the arms or push it down toward the bottom of the pool. It can be used as one long piece, or tied in a knot for variation.
“The noodle is the most frequently used item,” at the Desert Pain Institute in Mesa, Ariz., says Lynette Jamison, OT, who uses this piece of equipment with patients who are working on core stabilization.
“The noodle is the most versatile piece of equipment for my adult ortho population,” concurs Sircus. “It can be used in shallow water or deep water for balance training, resistive exercise, trunk stabilization and flotation.”
• Ramps & Lifts. Clinicians can make use of a ramp as a fun way for children to enter the pool. The ramp becomes another piece of treatment equipment”. Children can slither, slide and wiggle down the ramp, pretending to be safari or barnyard animals as a part of their session. Adults can use the same ramp to perform gradual entries. Letting patients enter the water at their own pace promotes safety and confidence.
Bess Maxwell, PT, PhD, of ShowMe Aquatics in St. Charles, Mo., trains children and adults with developmental disabilities in a community pool setting. Her greatest need is unfettered access to the pool. They make use of ramps when available, but often must rely on a lift instead.
“We can’t do our job without a quality lift,” says Maxwell. “It’s a must for people who can’t do transfers.”
A Balancing Act
Balance training is a basic part of many aquatic rehab routines. The following two pieces of equipment are standard in most facilities.
• Kickboards/balance boards. Kickboards are sturdy devices that improve flotation, and challenge balance and proprioception. Let patients hold onto the board for support while kicking, or train them to sit or stand on the board without falling
• Flotation mats. Flotation mats (also called flow-through mats) provide a greater challenge, since they’re less stable and sink under enough pressure. To practice functional stability, position patients on the mat in sitting, supine, prone or quadruped positions, and create movements that cause the surface to wobble.
Pain Control
With aquatic therapy, chronic pain sufferers can ease into movements that are too difficult to perform on dry land. Though water is a forgiving medium, it can also present positioning problems for clinicians working with this patient population. Adjustable equipment offers a solution.
Laura Diamond, PT, owner of Diamond Physical Therapy in Waltham, Mass., works with patients who have fibromyalgia, chronic pain, spine pain and neurological conditions such as multiple sclerosis. She considers buoyancy cuffs, belts and cervical collars essential for stretching and spinal stabilization work.
• Cuffs. Foam, air-filled or weighted cuffs can be strapped around arms or legs to facilitate exercises or create resistance.
To increase flotation, choose thin foam cuffs that attach with elastic straps. Air-filled cuffs provide adjustable buoyancy to position the body vertically for deep water work or horizontally for Bad Ragaz exercises. Weighted cuffs serve as grounding tools to push limbs down toward the bottom of the pool.
• Belts. Flotation belts provide the same benefits of cuffs, but they can be used around the waist during deep water work or around the pelvis for supine work. Belts can also be used during water jogging and stabilization exercises. And adjustable weighted belts can ground a person’s feet to the bottom of a pool in the shallow end.
• Cervical collars. Proper head and neck support in the pool is crucial for some patients. Clinicians can choose among three types of cervical collars. Foam and pellet-filled models are nonadjustable, while air-filled versions can be adapted by inflating or deflating the collar.
Resistance Training and Strength Building
Patients can benefit from aquatic resistance training to strengthen the core, and upper and lower extremities. To diversify workouts, consider adding the following devices to your facility.
• Dumbbells. Buoyant foam and plastic dumbbells can increase strength in the upper body and trunk. Train patients to create resistance by pushing the dumbbells down toward the pool bottom. Increase repetitions or dumbbell size as patients’ strength improves.
• Gloves. Encourage patients to don a pair of resistance gloves made of neoprene, latex or rubber. Exercises include opening and closing fists and moving the arms in various directions underwater. Gloves challenge the trunk and upper extremities, and increase proprioceptive input.
• Paddles. Paddles provide another way to work the core, chest and arms. Patients can use one or two hands to simulate rowing by rotating the paddles through water.
• Flippers/ fins. Wearing flippers creates a drag effect when moving the legs through water. Over time, the resistance increases strength in the lower extremities.
• Boots. Hard plastic boots are another alternative for lower limb strengthening. Patients can perform normal leg work routines and intensify the exercises with boots.
Breath Control
In addition to strength and balance exercises, you can also use aquatic therapy to improve respiratory function and expand lung capacity. For instance, a client can hold his breath and dive for sinkable objects.
Another option involves PVC piping. PVC piping can be elongated or shortened by adding or subtracting interlocking pieces. Help patients place one end of the pipe at the water’s surface and submerge the other end. The object is to blow bubbles through the end of the pipe, which helps increase expiratory muscle strength.
For an alternative use, manipulate multiple pieces of piping into a square that fits over a patient’s head and around his chest. The device provides light buoyancy and serves as a water walker for those who can’t take steps without support.
Whether your pool is in-house or community-driven, the right equipment can create an effective therapeutic environment for patients and clinicians. And you don’t even have to empty the Clorox bottle to do it.