Water-based physical therapy can ease pain, movement

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

When physical therapy takes place in a pool or other body of water, it's called aquatic physical therapy.

Today we'll hear about the benefits of aquatic physical therapy from my two guests, Ryan Martin and Morgan Phillips. Both are physical therapists at Upstate. Welcome to "The Informed Patient," both of you.

Morgan Phillips, DPT: Thank you, Amber.

Ryan Martin, DPT: Thanks for having us.

Host Amber Smith: Let's talk about how aquatic therapy helps. Is it meant to improve mobility?

Morgan Phillips, DPT: Yeah, aquatic therapy is meant to help improve mobility. Our pool is a therapeutic pool, so it's kept between 86 to 90 degrees, so usually the warmth of the water helps people move a little bit better and improve range of motion. There's a lot of properties of water that also helps these patients get around easier and help them ambulate (walk or move) and function.

Host Amber Smith: So someone who's struggling to move on land has a better time in the water?

Morgan Phillips, DPT: Yeah. A lot of the patients we see are patients who might struggle exercising on land. They tolerate water therapy better because we have these properties of water such as buoyancy, which actually helps reduce weight bearing. So that's an upward force.

So for example, if you are in the water up to your belly button, you're about 50% unweighted. So depending on how deep the water is or how deep people are exercising in the water, they could be more and more unweighted. If you go all the way up to your neck, you're about 90% unweighted in the water, and it's definitely easier for people to move who have issues exercising or walking due to pain.

Host Amber Smith: What is hydrostatic pressure, and how does that help?

Morgan Phillips, DPT: Hydrostatic pressure is another property of water. Basically, it's the force that's put on patients while they're in the water. The deeper you are, the more that pressure will push on your body and help to promote blood flow. If the hydrostatic pressure is higher than diastolic pressure, that can help move fluid out of joints, too, so that can help with swelling, which can also help improve range of motion.

Host Amber Smith: Now, you mentioned the water temperature. Does that make a difference for people doing aquatic therapy?

Morgan Phillips, DPT: Yeah. Water temperature, I think, plays a big part in that because increased temperature helps increase patients' ability to move. That will increase the muscle temperature, reduces stiffness and helps with range of motion and mobility in general.

It also helps to relax muscles, so patients that are really tight usually feel a little bit looser in the water.

Host Amber Smith: What is viscosity, and what does that provide?

Morgan Phillips, DPT: Viscosity is basically the resistance that the flow of the water provides, so when a patient is moving faster through the water, that actually makes it more difficult to move through the water.

Also, if we increase surface areas, so we have special equipment that we use in the pool with these patients. The bigger the object or the bigger the surface area, the more resistance they will feel. So that's how we can kind of modify exercises, make them a little tougher. We can make things a little bit easier by controlling the surface area or how fast a patient is moving in the water.

Host Amber Smith: Well, let me ask Dr. Martin: Who can be helped by aquatic physical therapy?

Ryan Martin, DPT: There's a lot of diagnoses or patient populations that can benefit from aquatic therapy, and we can discuss some of the more common ones that we see in the pool, but we do see patients for both orthopedic and neurologic conditions in the pool here at Upstate.

Like Morgan said, we tend to try to utilize land therapy first, as that's the environment that we live in, and we would prefer to exercise and strengthen patients in that environment. However, if patients are having a difficult time tolerating land therapy due to high pain levels or decreased mobility, then that's where the aquatic therapy can come in and be really helpful.

We still tend to try to use the pool as a temporary measure and work our way back and progress back to land therapy, as tolerated. Sometimes patients will do a split treatment, alternating between land and pool visits. So we make those choices on kind of a case-to-case basis, and we reevaluate that throughout their course of care to see, again, when we can try to transition them back onto land, as able.

Host Amber Smith: Now, is this limited to adults, or do you have children that could potentially use the aquatic PT?

Ryan Martin, DPT: All would be candidates for the pool, however, we definitely primarily tend to see more adults in the pool, just based on the nature of the diagnoses that we typically get aquatic referrals for. Again, we can go through some of those, but a lot of the common ones, osteoarthritis or fibromyalgia, we tend to see more adults, but it definitely would be appropriate for children as well.

Host Amber Smith: Let's take one of the orthopedic issues, osteoarthritis. What can aquatic PT do for someone who has osteoarthritis, say, in their hips and knees?

Ryan Martin, DPT: Yeah, they're a great candidate for the aquatic therapy.

They're probably some of the most common patients that we see in the pool. As a result of the buoyancy, which Morgan explained earlier, it's essentially like being in a gravity-reduced environment. So that means there's less weight, there's less compression on your joints, so therefore those patients can typically tolerate more movement, more exercise.

They can get a better workout, more muscle strengthening, with less of the joint pain. And that buoyancy of the water can also assist with helping to move those stiff joints or assist with movement of weak muscles, so another benefit for those individuals with arthritis of the knees or the hips.

Host Amber Smith: Now, you mentioned fibromyalgia. That's someone with widespread musculoskeletal pain and maybe fatigue. Is aquatic therapy appropriate for that person?

Ryan Martin, DPT: Yeah, that's another one of the most common diagnoses we see in the pool. They'll have all those same benefits, again, of the buoyancy, like we've talked about, but again, that little bit of a warmer temperature to the water may actually help them, especially to kind of promote relaxation and a decrease of that muscle tone or muscle tension, so that can help alleviate some pain. That would probably be another benefit, especially for those patients with fibromyalgia.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Upstate physical therapists Ryan Martin and Morgan Phillips about aquatic physical therapy.

Now, you mentioned neurological conditions. What sorts of things might you see?

Ryan Martin, DPT: Perhaps stroke would probably be a common one that comes to mind. Morgan and I are both part of the orthopedic PT team here, so we don't handle those patients ourselves, but we do have our specialized neurotherapists who work with more of those patient populations that have the neurologic diagnoses. So stroke would probably be one of the big ones that would come to mind, maybe multiple sclerosis.

Morgan Phillips, DPT: Yeah. And I know some of our neurotherapists have been seeing patients who have had spinal cord injuries in the pool. We have a lot of equipment, which we'll go over too, that helps with mobility. And even if these patients aren't able to walk independently, these therapists do have tools where they are able to participate in aquatic therapy.

Host Amber Smith: Are there any precautions to aquatic therapy? I'm wondering about people who aren't great swimmers.

Morgan Phillips, DPT: For patients who aren't great swimmers, that is definitely a precaution for therapy, but that doesn't mean that they can't participate. For the most part, we keep the pool at around 5 feet, so people really aren't swimming, they're moreso just moving and exercising in the water, so they definitely still can participate in therapy.

Going back to precautions or contraindications:

If people have any DVTs, (they're) not permitted to be in the water.

Any (patients with) severe cardiovascular, cardiopulmonary compromise shouldn't be in the water.

HIV -- chemicals in the pool may exacerbate symptoms.

Some other precautions that we would have to look at, for these patients: Epilepsy is a precaution for getting in the water, certain kidney disorders, any UTIs (urinary tract infections) or bladder incontinence are all big things that we look at. And we screen these patients at a land appointment before we send them to the pool to make sure that they are appropriate, and they don't have any of these precautions to getting in the water or to make sure they're safe when doing so.

Host Amber Smith: And you said "DVT," what is that?

Morgan Phillips, DPT: Yes, that's a blood clot. A deep venous thrombosis.

Host Amber Smith: Gotcha. Well, what can you tell us about the Upstate pool?

Morgan Phillips, DPT: Our pool is unique in the fact that it raises both up and down. Like I said, we typically keep it around 5 feet, but we can modify that, depending on the patients we have in the water. But the pool is the same depth the entire way around. And, like I said, we can modify that to kind of play around with that buoyancy and the hydrostatic pressure a little bit.

Also, we do have a ramp for patients to enter and exit the pool. So if stairs are an issue, they can use the ramp with a railing. And then we do have your typical stairs that you can use.

Host Amber Smith: So you raise and lower it. The floor of the pool moves?

Morgan Phillips, DPT: Correct.

Host Amber Smith: OK. Does the physical therapist get in the water with the patient?

Morgan Phillips, DPT: We can get in the water with the patient, if that's something that they would benefit from. Like Ryan was saying earlier, him and I mostly treat patients with orthopedic conditions, and for the most part, we are on the pool deck, in a group session.

So we might have a couple patients at once, but they're going through their own exercises, and we're giving them the instruction from outside the pool. But if a patient is not safe, or they might need more hands-on help, we definitely can put them in a one-on-one session and enter the pool with them.

Host Amber Smith: So you do individual and group?

Morgan Phillips, DPT: Correct.

Host Amber Smith: OK. How do you know that aquatic therapy is helping an individual?

Morgan Phillips, DPT: We make sure that at least every 10 visits, we see the patient again on land, just for a typical PT session. And like I was saying earlier, the first day, we screen them for contraindications, make sure that they're appropriate to enter the pool, they do their pool sessions and then we'll see them back there to remeasure some stuff. So we might look at range of motion, strength, walking, balance and then having a conversation with the patient. And we want to know, subjectively and objectively, are they getting better with aquatic therapy?

Like Ryan was saying earlier, our ultimate goal is to get them out of the pool and functioning on land, because that's where they typically have to function, so that's kind of how we measure progress and make sure that they are getting better.

Host Amber Smith: Is aquatic therapy covered by insurance, like regular PT?

Ryan Martin, DPT: So aquatic therapy can be covered by insurance, just like typical land-based physical therapy. You would still need a referral for regular physical therapy, but to do aquatic PT, you have to have a referral from a physician specifically requesting aquatic therapy, is the only difference there. So yeah, typically it is covered by insurance, so yes, absolutely.

Host Amber Smith: Do most of your patients when they complete the aquatic PT, do they stay with you doing land-based PT for some time, or do they ever just graduate back to home?

Ryan Martin, DPT: Again, often the goal is to get these patients in the pool initially, maybe again when they're not tolerating land therapy so well, and try to improve their strength and their mobility and then transition them back to land as needed.

With any sort of physical therapy, whether it's land-based or aquatic-based, it's not a perpetual thing, right? It's only ever a temporary measure, coming to physical therapy. So we're always trying to educate patients on what they can do at home, establish them with a home exercise program to kind of prepare them for discharge and to set them up to be able to continue to manage independently outside of here.

So if patients are discharging from aquatic therapy, we'll often just kind of point them in the direction if they want to continue with doing some aquatic exercise. We'll give them options of local community pools that they can take advantage of, whether that's free public pools, through like the City of Syracuse Parks and Rec Department, or YMCAs, getting a paid membership or doing group classes sort of thing. So yeah, some patients may transition to land therapy prior to discharging. Others may continue on with aquatic exercise or aquatic group classes on their own once we've discharged them from the pool here at Upstate.

Host Amber Smith: What about lakes in the area? Do you ever have patients who are planning to go to a lake?

Ryan Martin, DPT: Yeah, anything that we teach them and that they learn, as far as exercises and activities that they're doing with us in the pool, that can be carried over.

It can be done if they have a pool at home or if they have a neighbor or a friend with a pool, or if, like you say, they have a lake, any other body of water they can swim in. Definitely, again, we want to educate them, give them the tools to where they're able to continue working on that stuff on their own independently.

For a lot of exercises in the pool, you don't need a lot of equipment or just a few simple things. In our pool here at Upstate, obviously we have different equipment that we can utilize, so they may not be able to replicate all of those things without some of those pieces of equipment. But there again, there's a lot they could do at home in a pool or in a lake that they can carry over and continue doing.

Host Amber Smith: Now, how would someone who's listening to this be able to connect with you to see if they could come and have their physical therapy done in the pool?

Morgan Phillips, DPT: I think the first step would be, they'd have to be evaluated by their doctor. And their doctor would have to write a script specifically saying aquatic therapy.

And then they'd call us and get set up for that evaluation, and we would meet them, get to know them on land, figure out what their goals are for therapy. And then we can talk about that schedule. Maybe we send them completely to the pool, or maybe we do a little bit of pool therapy and a little bit of traditional, land-based PT.

But the first step would be contacting your primary care or a doctor to write a script for physical therapy.

Host Amber Smith: For Upstate physical therapy.

Morgan Phillips, DPT: Yep. And it just has to say aquatic therapy on it.

Host Amber Smith: Good to know. Well, thank you both for telling us about this.

Morgan Phillips, DPT: No problem.

Ryan Martin, DPT: Yeah. Thanks for having us.

Host Amber Smith: My guests have been Dr. Ryan Martin and Dr. Morgan Phillips, both of whom are physical therapists at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe, with sound engineering by Bill Broeckel and graphic design by Dan Cameron.

Find our archive of previous episodes at upstate.edu/informed.

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This is your host, Amber Smith, thanking you for listening.