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Using Aquatic Therapy to Enhance Body Awareness and Kinesthesia

Byline: Andrea Salzman, MS, PT

*Not her real name

Leah’s* first reaction to entering the water was so bad that her therapist had to stop the treatment. Later, when occupational therapist Yael Yoshei worked with this 8 year-old with Rett Syndrome, she cried throughout the entire session. Leah was afraid of movement, afraid of the water splashing her face, and her apraxia prevented her from using equilibrium reactions in an effective way.

It’s true that children like Leah can make gains in the water that are not easily achieved on land. However, there is a real risk with these children that the natural unloading which occurs in the water will disrupt their already atypical feedback loops. Additionally, refraction can limit a child’s ability to self-monitor limb placement and visual cues are untrustworthy. So, does it even make sense to work on body awareness and kinesthesia in the pool?

Enhancing Body Awareness and Kinesthesia

Yoshei thinks the answer is an unequivocal “yes”. When working with Leah, Yoshei decided to make use of the innovative Snoezelen Hydrotherapy pool. This unique pool built at the Williams Island Therapeutic Swimming and Recreation Center, Beit Issie Shapiro, Raanana in Israel incorporates elements from the Snoezelen room (soft lights, background and underwater music) and then combines these environmental elements with the so-called “enabling therapist” approach. In this approach, the client leads the treatment and chooses the activities and stimulations given to him/her during the treatment.

Yoshei remembers, “Leah entered the water, carried in my arms, showing clear signs of anxiety and fear -- crying and screaming. I used very soft lighting and quiet songs in order to calm her down. Very slowly, she started making eye contact with me and her muscle tone relaxed.”

By the end of Leah’s first session, she was ready to float on her stomach with support in her arms, put her mouth in the water and try to blow bubbles. She had even started to smile. These activities led to Leah’s increased willingness to move her body in space.

Often it takes a creative therapist to get a child with kinesthetic problems to be willing to work in the water. Shay Vanderloo, COTA (Wholistic Therapy Services, Hastings, Nebraska) suggests role-playing as a viable option. She has created a whole make-believe Egyptian adventure for her kids, an adventure which includes a game called the Mummy Wrap.

“I wrap my patients in different textured wet towels,” reports Vanderloo. “They have to break through the towels to get free to save the ruby -- a toy jewel floating on a mat -- by jumping into the pool.” The goal? To increase kinesthetic input and diminish hypersensitivity.

Kari Valentine, OTR/L, works in the same clinic as Vanderloo and also believes in the power of creative play.

“We have many flow-through mats shaped like animals and we will line the animals up to make a train.”

Depending on the goals, her patients will crawl, walk, or slide on their belly with a weight on their backs (like a pack-horse or camel). Valentine believes the weight on a child’s back gives deep pressure to calm the nervous system while simultaneously challenging the shoulder complex.

“After navigating the animal train, my patients will be sent to the water-gun area. I will squirt hands, feet, legs and arms with water from the gun to help with desensitization and body awareness.”

Therapists who want to jack-up the mental intensity during water-gun time can have their patients call out the names of the body part hit by the stream of water. Or, better yet, both therapist can take turns. The therapist begins the game by “hitting” the child’s right hand with a stream of water. The child then tries to replicate this effort by using his gun to return the favor.

Following the shooting gallery, Valentine will send her kids to the miniature plastic slide on the side of the pool. Each child must fill-up a bucket or laundry detergent jug with water, lift up the bucket, and pour the water down the slide before being allowed to slide down him or herself.

One as-yet-untried idea? The Kid Wash. For this activity, the therapist would place window clings all over a flow-through mat. The child would roll over the mat with his wet body. Hopefully, the clings would stick and the child would jump into the water to free him or herself from the wraps.

One thought. Window clings with larger dimensions might be easier to find and retrieve from the pool before migrating to the gutters or clogging the drains.

Karen Reckamp, OTR/L has worked with many children with autism in the Wolfson Children’s Rehabilitation therapy pool in Jacksonville, Florida.

“We achieve proprioceptive input by having our kids push-off the side of the pool with their arms,” reports Reckamp. Her patients get feedback for their upper extremities and trunk while playing games such as Shark Attack, Motor Boat, and Flying Fish.

Melissa Moos, DPT (Wholistic Therapy Services) uses the pool wall as well to get lower extremity loading and weight bearing in a very controllable situation. “I will have my kids scrunch their bodies into a ball while hanging onto the wall and then push backwards shooting into the middle of the pool.”

The American game Simon Says can be used to both assess and encourage proprioceptive awareness. Yoshei makes use of this kid’s game to teach better body control, for instance to control facial motor skills. She has her patient stand in the shallow water, at a depth in which the child feels comfortable.

“I play a game of blowing bubbles with my kids. I tell them to blow strong bubbles, soft bubbles, a lot of bubbles -- or just one bubble at a time.” This modulation of breath and facial control requires the children to notice the effects of their efforts and then to modify their efforts. Yoshei then morphs this game into a session of Simon Says where the therapist is Simon and the child must perform the full-body motions requested.

Although it is true that quiet, full-body immersion can dampen proprioceptive input, the wise therapist knows how harness the effects of turbulence and momentum for enhancing body awareness and kinesthesia. Simple childhood games like whirlpool (running in one direction in a circle and then quickly reversing direction to move against the “current”) can create opportunities for feedback loops which are unachievable on land.

And wet, clingy items such as towels, fabric shower-curtains and even plain old discarded clothing can be used to morph a dress-up game into a therapeutic session designed to enhance proprioception.


Water activities can provide disabled children with the opportunity to improve their understanding of their own bodies. It helps that pool-time seems less like “therapy” and more like fun for the children. For additional, practical ways to integrate kinesthetic drills into your pool work, check-out the “How to Enhance Body Awareness” sidebar.


How to Enhance Body Awareness during Your Aquatic Treatment

Facing body awareness issues with your pediatric patients? Try some of these well-tested methods for working kinesthetic tasks into your pool time.

Your 7-year old patient has difficulty with showering independently and has trouble with identifying which parts of the body have been washed and which parts need attention.

It is possible to embed self-help moments into the entire pool session, not just the time of actual immersion. Start your therapy treatment in the shower by requiring the child to make choices about the sequencing of showering including deciding which part of the shower should take place first, second, third and so on. Ask her: Do you need to check the temperature before getting under the water? Should you take your towel into the shower stall or would it be better to leave it out of the water’s reach? Which parts of your body have you finished washing? Use a 10-second count for each sequence of the washing/drying to create a predictable start and stop to the activity. [Karen B. McPhee, MSEd, CAS, CTRS, The Center for Therapeutic Recreation, Portland, Maine]

Your 6-year old patient has trouble donning his clothing correctly in the mornings. He oftentimes comes to breakfast with his pant legs tucked into his socks and his t-shirt worn outside his shirt.

Practice the “Get Dressed Relay” in the pool. Put various articles of clothing in two opposing corners of the deck. Have your patient either swim or gutter crawl (hand-cruise along the edge of the pool) from the first location to the second and then climb up onto the side of the pool. He will pick a clothing item from the pile, put it on, swim (or crawl) to the second location (usually 14-20’ away), climb out of the pool and put on another piece of clothing. He will repeat this until fully dressed. To make it even more challenging, require your patient to put on the clothes in an appropriate order (for instance, boxer shorts and tshirt first, socks second, pants and shirt third, belt and shoes last). This drill provides extensive amounts of proprioceptive input and problem-solving and kids love it. [Karen Reckamp, OTR/L, ATP, Wolfson Children’s Rehabilitation, Jacksonville, FL]

Your high functioning patient demonstrates difficulty with bilateral coordination, balance, visual-motor control and using his body-powered upper extremity hook prosthesis.

Start with the child lying on a flow-through mat in order to play “Subway Sandwich Shop.” It’s time to make lunch! Use the mat as a piece of bread. Place your patient (who is now the sandwich meat) on top of a wet beach towel (the cheese) and roll him up tight. Ask what other things should go on the sandwich? Mayo? Take a kickboard and use it as a knife to spread the invisible mayo. Add a pickle (the noodle). Season with salt and pepper by sprinkling from a watering can. Finished? Fold the mat over to form the top half of the sandwich. The grand finale? Have a rubber shark swimming nearby to take a bite out of this irresistible treat. [Karen B. McPhee, MSEd, CAS, CTRS, The Center for Therapeutic Recreation, Portland, Maine]

Your high functioning autistic patient demonstrates difficulty with bilateral coordination, balance, visual-motor control and using his body-powered upper extremity hook prosthesis.

Start with your patient standing on the flow-through mat with different colored fabric hair ties around forearms and ankles. Throw a beach ball to him, calling out a color, and have him kick or hit the ball back to you with the color-matched limb. Combine colors so that the patient must use both hands simultaneously or – a more difficult task – kick and punch with opposite arm-leg combinations. Have him don and doff the hair ties on arms and legs and have him figure out (on his own) how to use both arms in coordination. If possible, have the patient use the prosthesis to place the hair ties on his other limbs. [Kari Valentine, OTR/L, Wholistic Therapy Services, Hastings, Nebraska]

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Read more research on pediatric aquatic therapy here: Shariat, Ardalan, et al. "The effectiveness of aquatic therapy on motor and social skill as well as executive function in children with neurodevelopmental disorder: A systematic review and meta-analysis." Archives of Physical Medicine and Rehabilitation (2023).

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