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Rough Waters: Patients with systemic or metabolic challenges

Updated: 18 hours ago

Byline: Andrea Salzman, MS, PT

Aquatic therapy isn't always smooth sailing. In fact, therapists who treat patients in the pool may face rough waters.

Along with understanding the nuances of patient diagnoses, you should also know the technical distinctions of treating people in water. This rings true when caring for patients with systemic or metabolically challenged conditions, such as high risk pregnancy, obesity, diabetes mellitus and immunosuppressive disorders.

When assessing these patients you should also remember to discuss therapy goals. In all cases, general goals include improving vital capacities, respiratory rates, inhalation/exhalation patterns, and sputum clearances and

functional coughs. You should also focus on cardiopulmonary fitness, abilities with activities of daily living, work tolerance, flexibility, strength and endurance. Aquatic therapy can also alter body composition, decrease shortness of

breath or dyspnea with moderate levels of activity, and increase therapy compliance.

General Considerations

Before taking patients with systemic or metabolically challenged conditions in the water, you need to identify precautions and contraindications. You should obtain a medical release and check vital statistics prior to sessions and during aquatic therapy. And before starting, make sure these patients have any necessary interventions handy, such as glucose tablets.

Start therapy slowly and keep in mind that these patient populations are more difficult and may not be able to exercise as intensely as uncompromised clients. If patients take medications that artificially elevate or decrease heart rates, don't use the Karvonen formula or any modified formula to establish heart rate parameters.

Instead, teach patients to use a rating of perceived exertion (RPE), such as the Borg scale. An RPE scale is based on the physical sensations, such as muscle fatigue, heightened respiration and breathing, sweating and increased heart rate, people experience during activities. This rating can be subjective, but it's a good way to estimate heart rate during activity. 1  With the Borg scale, patients can rate exertion levels on a scale between six (no exertion) and 20 (maximal exertion).

Keep in mind that if patients have a low vital capacity (less than 1.5L), the hydrostatic pressure of water against the chest wall may make respiration difficult. Exercising in shallow water or in a supine float may help the situation. If the pool is too warm, encourage breaks. Don't leave patients unattended and have a CPR and emergency plan in place and posted for staff and patients. Also, keep patients' heads uncovered and the pool humidity low to allow for radiation and evaporation.

Focus on Specifics

Aquatic therapy can offer an array of benefits, such as decreasing weight-bearing during exercise and reducing muscle atrophy and contractures that accompany immobility. Patients can also benefit from the gravitational pull on posture. An aquatic environment increases proprioceptive awareness during exercise and functional task simulation, and it

strengthens expiratory muscles. It also encourages patients to clear excretions, and build greater capacity for exhaling and inhaling. If patients are part of group therapy sessions, it gives them the opportunity to socialize in a recreational environment that's barrier and assistive-device free.

More individualized benefits depend on specific systemic and metabolic conditions, such as the following patient populations.

• Women with a high-risk pregnancy.

Aquatic therapy can increase blood flow to the fetus, decrease swelling in a mother's legs and improve central circulation. As inpatients, women can visit a pool twice a day for hourly sessions. Encourage Kegel exercises. And patients should attempt to maintain exercise levels that they've achieved prior to pregnancy. However, be cautious and don't permit them to exceed those fitness levels. Allow patients to continue exercising in a supine position, unless they feel dizzy, nauseous or lightheaded for more than two minutes. Encourage modification and avoid high impacts, rapid cutting and excessive resistive movements.

Demonstrate first, second and third trimester alternatives if necessary. During sessions, watch for dramatic heart rate increases and overheating, since pregnant women can have trouble with heat dissipation. After workouts, monitor vitals and don't allow over stretching.

• Bariatric patients.

By providing a non weight bearing environment, bariatric patients can avoid more difficult land exercise and reduce stress on their joints. In addition, the floating capability in water allows them to exercise easier. When treating these patients, you need to remember to monitor vital signs because even low intensity weight-bearing exercises can create higher heart and respiratory rates. Also keep in mind that the water's warmth may make it

difficult to sustain aerobic exercise. However, you might have difficulty convincing bariatric patients to try aquatic therapy. Patients may also have problems with socialization in a pool, because they may be unwilling to put on a bathing suit or shorts. In these cases, you should try to promote the fitness benefits of aquatic exercise and convince them that it's a less physically demanding environment.

• Diabetes and diabetic neuropathy.

A pool's hydrostatic pressure helps patients maintain edema control and

circulation. Water's buoyancy also permits clients with diabetes and diabetic neuropathies to exercise pain-free in a closed kinetic chain. But make sure patients ease into exercise because the activities may vastly alter their blood sugar levels. Diabetic neuropathies can affect the feet. As such, patients must protect their feet during sessions by wearing aqua socks. Be sure to check for open wounds. Also, monitor for hyperglycemia and hypoglycemia, which is more likely. Incorrectly treating hypoglycemia could complicate the onset of a seizure or hyperthermia. If patients have two serious episodes, discontinue therapy until a diabetic condition is under control. And make sure patients with diabetes stay in contact with their physician to make any necessary medication changes.

• Immunosuppressive disorders.

Water's buoyancy permits patients with immunosuppressive disorders, which include AIDS, to exercise pain free. Progressive resistive and aerobic exercises in a pool can also retard muscle wasting that's often associated with these conditions. But don't allow these patients to overwork the body during therapy, even if they feel great. Continue monitoring vital

signs. Check for open wounds because these patients are prone to air- and water-borne infections. The AIDS virus is fragile and can't live in chlorinated pools, but patients risk infections in locker rooms, showers and on pool decks.


Patients with systemic and metabolic conditions sustain a plethora of painful, debilitating symptoms that can make routine, land-based therapy difficult. But the properties of water can temporarily alleviate these symptoms and allow people to exercise in a pain-free, non weight bearing environment. It won't take long before they realize the wonders of water.


1. Centers for Disease Control and Prevention. Accessed

Andrea Salzman, MS, PT, is founder of the Aquatic Resources Network, an international aquatic therapy

clearinghouse of information. She can be reached at or

Heating Up with Warm Water Massage

By Joel Posner, MD

For centuries people have turned to healing waters to alleviate health ailments. The Greeks and Romans used

therapeutic baths to cure disease, and former President Franklin Roosevelt established the Warm Springs White

House in Georgia to relieve muscle cramps and neuralgias associated with his post polio syndrome. And the French

government currently certifies more than 100 water sources to treat a variety of disease symptoms.

The reason is clear: Warm water massage provides numerous physiological benefits. This therapy causes dilatation

in muscles close to the skin, which lowers blood pressure, and relaxes tense and spastic muscles to alleviate

headaches and muscle pain. It also slows the heart rate to relieve situational anxiety and help sore muscles heal

faster by increasing blood flow. These effects can treat a variety of conditions including:

• Arthritis. Soaking in a warm tub with jet massagers keeps muscles and tendons loose and flexible so people with

arthritis can exercise and maintain mobility longer. In turn, this slows joint deterioration.

• Diabetes and obesity. In a small study, researchers prescribed hot tub massages to diabetic patients for three

weeks. People who soaked regularly reduced blood sugar by 13 percent, slept better and lost an average of 3.75

pounds. 1

• Heart disease. Soaking in a hot tub can cause blood pressure to drop significantly. Many patients may experience a

slow, steady decrease.

Elderly patient populations can also benefit. Hot tubs with massage jets relax muscles and joints, which keeps elderly

patients flexibility and active, and helps muscle injuries heal faster.

The evidence behind these benefits is culled from personal experience and small, short-term studies. Although

there's a need to examine the effects of warm water therapy more systematically, you shouldn't wait to offer it to

clients. The benefits appear to be too great.


1. Hooper, P.L. (1999, September 16). Hot-tub therapy for type 2 diabetes mellitus. New England Journal of

Medicine, 341(12), 924-925.

Joel Posner, MD, is professor of medicine at Drexel University College of Medicine in Philadelphia, Pa.

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