For a patient in a wheelchair, escaping the limitations of gravity is a dream come true. Pool therapy helps these patients regain independence while fulfilling typical physical therapy goals of increasing upper body and core strength and promoting balance and flexibility.
"Water gives patients the ability to do more than they can on land so they can more quickly achieve their therapeutic goals," said Cindy Reese, DPT, ATRIC, CLT, physical therapist, Memorial Rehabilitation Institute at Memorial Hospital West in Pembroke Pines, Fla., part of Memorial Healthcare System.
Memorial Rehabilitation Institute began treating patients with spinal cord injury-and other wheelchair-bound patients -- in an aquatic environment more than 15 years ago. "The pool is an ideal place as an adjunct in the treatment of patients in wheelchairs," Reese said. "The water lessens pain for those who can't stand on land."
Aquatic therapy offers benefits to patients with varying levels of function, including, balance; strength; self-esteem; quality of life; endurance; range of motion and circulation.
Treating in the Pool
The buoyancy of water reduces the stress of gravity so even patients with partial weight-bearing status can exercise. The aquatic program specifically helps patients with spinal cord injuries increase strength and promotes flexibility, balance and range of motion.
The high specific heat of the water in a therapy pool -- typically 93 to 96 degrees -- reduces inflammation and stimulates circulation. Pain management and better circulation are attractive consequences of pool therapy. "The pressure of the water on the body helps move lymphatic fluid around," Reese said. "This helps to flush the lymphatic fluid to prevent cellulitis return blood to reduce swelling in injured areas."
For patients who are wheelchair bound, the aquatic program is based on personal goals. "For example, if the patient is interested in working on a car transfer, then we focus on strengthening the lower extremities."
Pool exercises for those in a wheelchair vary depending on the specific needs of the patient, according to Reese. The exercise may include some of the following:
Squat to stand: performed at the wall with a resistance cord to work on transfers
Walk: using the jets to provide resistance
Balance on one leg: using varying depths of water to work on weight shift
Sit or stand on float board or noodle: to gauge tolerance
Small box step: perform small movements forward and back with a resistance band
Ai Chi: movement and relaxation program for the pool
Watsu: gentle way to move in the water to stretch using the water to gain ROM in the whole body
"Each exercise involved multiple muscles at the same time which is my ultimate goal with these patients," Reese said.
Reese uses different parts of the pool for buoyancy. She may have a patient perform exercises in chest-deep water or waist-deep, as appropriate to the level of function. "Depending on the goals of the patient, I can use water to support, assist or challenge," she explained.
"There is so much creativity to be had in the pool and all aquatic therapists have different styles," Reese observed. "Some use the pool as an alternate gym and have the patient use resistive bands underwater. Others may use buoyancy as the tool to have the patient perform more standard exercises."
According to Reese, patients in wheelchairs have numerous issues and concerns that may affect them in the pool. First, these patients need to take extra precautions as they have a higher than normal balance and fall risk in the pool. Second, patients who are in a wheelchair are more likely to have osteoporosis and abnormal tone, both of which need to be taken into consideration in the water.
People in wheelchairs are more susceptible to sensory and skin issues and therefore, need to be aware of where their feet are and be sure they are not dragging them on the bottom or brushing up against the side.
"The pressure of the water affects how your heart and lungs work when exercising so I always need to consider the cardio exertion of my patients," Reese said. "Vertical exercises are safer than having the patient on his stomach which is stressful on the body."
Autonomic dysreflexia, a sudden onset of high blood pressure, is a syndrome that affects individuals with a neurologic level of spinal cord injury at or above the sixth thoracic vertebral level (T6). "It's important to be aware of the blood pressure issue and make sure the body is used to the water," Reese said. "Being in the water helps regulate a person's sympathetic nervous system which in turns helps the patient when he is out of the water."
Memorial Rehabilitation Institute's patients are particularly interested in regaining skills in the pool due to the warm-weather climate they live in. "Many of our patients have access to pools year round because we are located in southern Florida," Reese explained.
"It's important that family members and caregivers get in the pool to see their loved ones demonstrate exercises," Reese said. "We want to teach them appropriate techniques so they can continue the program in the community."
Reese is glad that so many of her patients are able to continue the benefits of aquatic therapy after their rehab sessions have ended. Because of Medicare and insurance, the therapists are unable to treat a patient on land and in the pool at same time and will only pay for a certain number of visits. "The patient has to be deemed intolerant of land exercises and then we spend about 4 to 8 sessions in the pool exclusively to build strength," Reese explained. "An individual bound to a wheelchair is thought to have a chronic condition by Medicare."
Aquatic therapy is beneficial to these patients in emotional and social ways as well, according to Reese. "Swimming is an activity that is fun to do with family members," she said. "The social component is so important to these patients."
Reese recently treated a man in his early 70s who suffered a bad fall while trimming trees in his yard. He was diagnosed with paraplegia with a T8 complete injury but according to Reese, he has more trunk control than the average complete injury.
After a hospital stay and extended time in a body jacket, the patient completed about 5 weeks of land therapy at Memorial Rehabilitation Institute. During land therapy, the patient worked on rolling, sitting and transferring from floor to chair. "He was very fit from a lifetime of activity," Reese recalled. "When we got him in the pool, his body remembered swimming when he was younger. The pool helped him deal with his low tone, participate in a cardio activity and work on standing exercises."
When therapy began, Reese had to work to locate the patient's balance point in the pool. "Finding the center of gravity on a patient with a spinal cord injury is a big challenge," Reese said. "How do you maintain vertical and how much equipment will the patient need?"
Safety is also a big issue. "The patient needs to learn to find ways to breathe and recover from a face down position," Reese explained. "They need to be prepared in case of a dangerous situation."
Reese had the patient use a noodle and floating bells in his hands to keep his face above water while floating on his front and back. Once his balance point was established, Reese slowly worked away from equipment so he could rely on his trunk control.
"We focused on strengthening his trunk to help with activities such as dressing and toileting," she said. "Then we incorporated upper extremity strengthening exercises such as pushing resistive bells down into water and using a kickboard."
After about 45 minutes in the pool, the warmth and exercise help the patient's range of motion and his ability to stretch for his tone. "At that point, his legs relax out straight which is so important for patients with spinal cord injury," Reese shared.
Reese encouraged the patient to practice transferring into the pool chair with the assistance of his wife, Laureen. "Now swimming is an activity that he and his wife do together," Reese said. "They joined the gym and come every day."
Relying solely on his arms, the patient is able to swim the length of the pool back and forth. He can transfer into the pool independently and efficiently. He was so pleased to return to an activity he could both enjoy and be challenged by, Reese told ADVANCE.
Rebecca Knutsen is on staff at ADVANCE. Contact: firstname.lastname@example.org