Beyond the Basics - Putting Aquatic Therapy into Practice

Kathleen: Good morning and thanks for joining us today. I am so excited to continue our series on aquatic therapy. In our last presentation, we discussed the principles of water and how they impact our treatments. We discussed the contraindications, precautions, and also talked about how the major systems of the body are impacted by the principles of water. We looked at a case study of how our pool was used in a plan of care to really make changes in the daily routine and function of a patient. In this presentation, we are going to take it one step further. Let's get into the details of aquatic therapy and gather some new tools for the old tool box. Beyond the Basics will give you resources to put aquatic therapy into practice today. We will get into the details of how using aquatic therapy in your treatment plans, and how to document aquatic therapy so that the insurance companies continue to reimburse for these services.

Overview of the History of Aquatic Therapy

Why Aquatic Therapy?

This approach to healing is not new. Records indicate that in 2400 B.C., early Egyptians and Muslims were using water for therapeutic purposes. Historical records of early Japanese and Chinese civilizations respected water and worshipped running water. They would use submersion in baths for long periods of time for healing. Waters in Bath, England were used as early as 800 B.C. for healing purposes. Throughout history and across cultures, individuals have used the thermal effects of water to soothe body tissues and reduce pain.

"Hydrotherapy"

In the 1800s, Winterwitz, an Austrian professor founded a school of hydrotherapy in Vienna. He studied the reaction of tissues to water against various temperatures. He established acceptable physiological basis for hydrotherapy for that time. Treatments at that time were for conditions like typhoid fever, influenza, TB, gout, and neuritis.

Development of Spas

Spas can be traced back to 500 B.C. in Greece where natural hot springs and baths of mineral and thermal water served as precursors of the modern spas of Europe. Initial spas in Europe were used to treat disease and documentation shows that it came over to the U.S. as early as 1792 by European physicians. It was documented that many people suffering from rheumatism visited the Sweet Springs in Hot Springs, Virginia. Later on in the 19th century, spas were developed for the middle class and wealthy society.

Aquatic Rehabilitation in USA

In Warm Springs, Georgia, it was discovered by chance that a young man with polio, after falling from his wheelchair into a pool, could move part of his paralyzed legs. He eventually progressed himself from his wheelchair to walking with just a cane. In 1924, President Roosevelt popularized the use of pool exercise to treat his polio. Treatment of orthopedic conditions after both World Wars continued to support the use of water as a medium in rehabilitation.

20th Century

In 1957, the president of the American Congress of Physical Therapy established a committee for data collection on the spas and health resorts in the U.S. They looked at the therapeutic agents that they were using in the facility. This committee established a list of approved health resorts and standards. Later, this committee became the advisory committee to the Council on Physical Medicine and Rehabilitation of the American Medical Association. Post-Vietnam war, clinics throughout the U.S. were using water for rehab for injured soldiers. Water aerobics became very popular in the 1980s. For those who were not able to tolerate high impact aerobic classes, they also had exercise for people with arthritis became popular at this time. The National Arthritis Foundation YMCA aquatic program was established in 1983. During this era, there was a marked increase in the research related to the physiological responses to immersion and to exercise in a water medium. And in 1992, the Aquatic Physical Therapy Section of the APTA was founded.

Principles of Water

For today's presentation, we will do a quick recap of some of the principles of water.

• Buoyancy
• Hydrostatic Pressure
• Viscosity
• Specific Heat
• Refraction

We went into these in detail in our first series. These are the five principles we will overview today.

Buoyancy

Buoyancy is the force exerted on an object under water which aids our bodies by giving us the feeling of weightlessness. It allows for flotation and reduces the effects of gravity on our injured or aching joints and muscles.

Hydrostatic Pressure

Hydrostatic pressure is the pressure exerted by a fluid at equilibrium at any given point within the fluid. It plays a key role in how our circulatory and pulmonary systems are impacted by immersion. Hydrostatic pressure supports and stabilizes the patient allowing those with balance deficits to perform exercises without a fear of falling and decreasing their pain.

Viscosity

Water has a low viscosity, or resistance. Yet, we can change the resistance of water if we use jets or other methods to propel the water and create increased resistance for exercise. The greater the drag, the greater the muscle recruitment needed. Water's natural viscosity can be used to increase the rehabilitation process.

Specific Heat

Water has a high specific heat, meaning it takes a lot of heat to raise its temperature. The ideal therapeutic range is 91 to 95 degrees Fahrenheit and warm water provides a relaxing and soothing environment for aching joints and muscles.

Refraction

Refraction in where objects under water appear skewed as we look down into the water at them.

System Impact

Let's review our systems and how they are impacted by immersion up to chest level. I think Amelia Elena Stan, faculty of Physical Education and Sport, summarizes the effect of immersion best in the Journal of Romanian Sports Medicine Society.

Immersion in warm water:

• Transfer of heat
• Pain relief
• Promotes relaxation
• Feeling of weightlessness
• Supports body at the same time provides resistance

She says, "The biological effects of immersion in water include the effective transfer of heat to the body, which in essence relieves pain and promotes relaxation due to the thermal energy transfer. The weightlessness effects, produced by the interaction between buoyancy, pressure hydrostatic, viscosity and cohesion properties of water, support the body and at the same time provide resistance." She continues, "Other biological benefits of immersing the body in water up to chest include lymphatic compression, venous compression, increased central blood volume, increased cardiac volume, increased atrial pressure, increased stroke volume, increased cardiac output, increased work of breathing, increased oxygen delivery, improved dependent edema, increased muscle blood flow, offloading of body weight, decreased joint compression with movement, increased flow to the kidneys, higher pain threshold, suppression of sympathetic nervous system activity, and promotion of metabolic waste." There are so many systems that are impacted, especially our circulatory and pulmonary systems. These are the ones that we need to pay the most attention to in my opinion. As our patients come through the doors with impairments of these systems, we must be sure to review how the systems are impacted and ask questions if you do not understand the effect of immersion on any body system. Again, we went into detail with precautions and contraindications in our first series, but let's do a quick review.

Precautions and Contraindications

According to Mosby's Medical Dictionary, a contraindication is a factor that prohibits the performance of an act or procedure in the care of specific patients; whereas, a precaution is a method or a procedure intended to prevent or avoid adverse outcomes.

Contraindications

• Cardiac failure
• Unstable angina
• Severely compromised cardiovascular system
• Unstable abnormal blood pressure
• Severely limited vital capacity
• Tracheotomy

In our first presentation, we reviewed in detail that anyone with cardiac failure, unstable angina, or a severely compromised cardiovascular system should not be treated in the water. We also added that anyone with an unstable blood pressure, severely limited vital capacity, or someone with a trach are not appropriate for treatment in the water.

• Cerebral hemorrhage within three weeks of bleed
• Uncontrolled epilepsy
• Temperature sensitive conditions
• Supra pubic catheter or any ostomy
• Absence of cough reflex /mouth closure deficits
• Severe Cognitive Deficits
• Unpredictable bowel incontinence

Furthermore, people who have suffered a CBA, we need to wait at least three weeks after the hemorrhage to begin aquatic therapy. The list of contraindications for patients continues with uncontrolled epilepsy, temperature sensitive conditions, supra pubic catheter or absence of cough reflex, severe cognitive deficits or with unpredictable bowel incontinence are not appropriate for aquatic therapy.

• Significant open wounds or skin infections
• Scabies or lice
• Deep x-ray therapy or renal disease
• Contagious water or air-borne infection/disease
• Fever or Vomiting
• Severe hydrophobia
• Later stages of pregnancy

Other contraindications are significant open wounds or skin infections, scabies or lice, deep x-ray therapy or a renal disease where the patient cannot adjust to fluid loss, contagious water or air-borne infection or disease, fever or vomiting, severe hydrophobia, or later stages of pregnancy unless approved by a physician.

Precautions

Moving onto precautions, you will need to use your best clinical judgment when you have patients with these conditions.

• Abnormal blood pressure
• Angina or other cardiac considerations
• Limited vital capacity

For abnormal blood pressure, you will need to monitor the response to immersion and exercise. If your patient has angina or other cardiac considerations or a limited pulmonary vital capacity, you should carefully consider aquatic therapy with any of these limitations. You also may consider asking their referring physicians for their approval for aquatic therapy prior to initiating it.

For patients with neurological dysfunction, the following precautions must be considered.

• Multiple sclerosis
• Controlled seizures
• Bladder or bowel incontinence
• Diabetes, Neuropathy

Patients with multiple sclerosis may not tolerate water temperatures over 88 degrees due to the increased fatigue that can be caused due to the warmth of the water. I recommend you first obtain written physician's approval before writing a plan of care including aquatic therapy for someone with MS. If there is a history of controlled seizures, I recommend, if you elect to treat the patient in the pool, that they wear a flotation device at all times. If your patient has bladder or bowel incontinence, you need to outweigh the risks versus benefits, and be sure you know what to do if there is an episode of incontinence in the pool. If your patient has vertigo, nausea, diabetes or neuropathy, all these should be considered carefully before incorporating aquatic therapy into the treatment plan.

• Prosthetic limbs
• Ear Infection
• Menstruation
• Hearing aids  
• Contact lens  

Only prosthetic limbs designed for swimming are appropriate to be worn in the pool. Take precaution if your patient has an ear infection or is menstruating. And before the patient enters the pool, be sure to remove hearing aids or contact lenses especially if their head will be near the water.

• Small open wounds
• Uncontrolled diabetes
• Chemical sensitivity
• Behavior problems
• Fear of water 

Be sure to take caution if your patient has any open sores or wounds, making sure that you cover those appropriately. Be sure to monitor your diabetic patients very closely. For those with chemical sensitivity, make sure you are cautioning them of their risks. For the patients who have had any behavioral deficits, be sure aquatics is a safe environment or maybe go in the pool with them for their sessions. Finally, for any patient who has a fear of water, it is best to progress them slowly.

Plan of Care

Let's talk about a plan of care that includes aquatic therapy. I would like to think that everyone agrees that getting into a body of any warm water is nice, and that most people, unless there is a fear of water, would likely prefer to be in an environment that is soothing, especially after an injury. Picture yourself as the patient. Would you rather lie on a cold therapy mat table and perform exercises? Or would you rather get into a nice warm tub, say around 92 degrees, and move around with ease while you perform exercises? I know I would much rather be in the water, but unfortunately Medicare and other insurance companies are not necessarily concerned about what feels better. They need to know how we are getting our patients back to their baseline. As a therapist, you must create a plan of care that supports the reasoning behind this modality.

Aquatic Therapy-Functional Approach

This plan of care, as it incorporates the intervention of aquatic therapy, CPT code 97113 needs to be all about how this patient will improve in their day-to-day life. Even though Medicare is the federal program, they leave it up to local contractors to deny or appeal the coverage of therapy. Today, I will speak about our local coverage determination or LCD in Northeast Ohio. You should be familiar with your local coverage. I have noted the definition here of LCD from the CMS website. Please read this if this is something new to you.

From Referral To Pool

Once a referral is made, whether it was for traditional physical therapy or occupational therapy on land, or if it is a specific referral for aquatic therapy, we must first perform an evaluation on land. This is where it is critical that you gather all of the past medical history and current medical issues so that you have a clear understanding of any potential precautions or contraindications for a plan of care. During your evaluation, you will need to determine if the CPT code 97113 for aquatic therapy will benefit the patient and indeed help make progress towards your established goals. If you do choose to add this code into the plan of care, then be sure to have goals that will be progressed with the help of the use of this modality. You do not necessarily have to write goals that specifically say aquatic therapy, but you need to have goals that will support the use of water just as you would do with any other CPT code.

Take for instance if you choose the CPT code for neuro reeducation, do you typically have a balance goal to support the use of this treatment code? Consider aquatic therapy code the same. And later on today, I will be specifically talking about documentation and giving some helpful hints so that you are appropriately documenting for aquatic therapy.

• 1-2 times per week in water
• Typically patients are in both land (traditional) and aquatic therapy
• Treat in water up to 8 times and need to determine if patient is making measureable functional gains to continue aquatic based therapy
• Where are you, the therapist?  In the water too?

Once your eval is complete, and you have decided that you would like to schedule the patient for their first pool session, you should consider how many times a week you want them to be in the pool. This will vary from patient to patient, but typically I start with aquatic therapy one to two times per week, and most of the time, I am combining that with some traditional OT sessions on land to be sure that I am getting the carryover to function that I need.