Byline: Andrea Salzman, MS, PT
I’m not going to lie to you. Patients with compromised cardiopulmonary systems, such as those with Chronic Obstructive Pulmonary Disease (COPD), may not tolerate full-body immersion. However, this is by no means a universal contraindication. In fact, clinicians who blindly create
an arbitrary cut-off for aquatic participation (for instance, an ejection fraction <25% or vital
capacity <1.5 Liters) are neglecting one of the most powerful pulmonary exercise programs on the planet: immersion.
For many years, the pool was considered verboten for the cardiopulmonary client. Why? Most of the research investigated the risks involved when a patient took to the pool in order to… wait for it…. swim.
Swimming is a highly complex task, often requiring dangerous VO2 and heart rate levels,
especially in the poor swimmer. 1 These conditions can create cardiac arrhythmias in cardiac compromised patients and significant dyspnea and air hunger for those with COPD. However, vertical (read: upright) exercise in water has been shown to be as safe -- or even safer -- than its land-based counterparts under many conditions. 1-5
Not only is COPD no longer considered a contraindication, therapists are intentionally plopping their respiratory patients in the pool. Why… ? Because immersion in graded pressurized environment (i.e. the pool) can provide a progressive pulmonary challenge unlike any other. It’s amazing to think of how the human body deals with pressure — even out of water. At sea level, there are 14.7 pounds of air (1 Atmosphere) pressing against every square inch of the human body. This means that before a person immerses even one toe, each inch on his body is pounded by 14.7 pounds of molecules. As divers put it, we should be crushed to death!
However, inside our bodies are molecules that push back with an equal — or even greater —
force. For instance, every time your heart pumps, it creates a pressure on your arterial vessels of approximately 120 mm. Even when the heart rests, there remains an intrinsic outward pressure of approximately 80 mm. You may know this more commonly as blood pressure (the normative 120/80 used as the example).
So what happens when we enter the pool? The pressure pushing inward on our bodies increases as depth increases. Even the casual swimmer instinctively recognizes the power of pressure as ear pain whenever diving down to the bottom of the pool. Scuba divers experience this to a much greater extent, doubling the amount of pressure from 1 Atmosphere to 2 Atmospheres of pressure within the first 34 feet of a dive.
This hydrostatic pressure drives fluid to the large vessels of the lungs (creating a 60% increase in the work of breathing) and creates a mechanical barrier to ribcage expansion. All before the first exercise is performed. With the proper instruction, the resulting pressure gradient can be used to create an amazing therapeutic training effect. How? Listen in on a recent interview of two clinicians who make the daily effort to treat their COPD clients in the water.
Why is your practice "better" for the COPD client with aquatics than without it?
Wendy Morine, PTA, ATRIC, CCI is the Aquatics Coordinator at Spooner Physical Therapy in
Scottsdale, Arizona - Our facility, a private practice outpatient clinic, has a 12’x14’, 5,000 gallon California Pool that was built 12 years ago. Because we have the pool, we do not have to turn away patients who are unable to do land-based exercises. Because the act of immersion itself creates work, we can do exercises that would be impossible on land. For example, I often create a simple, fun respiratory challenge by positioning my patient in chest-deep water next to anything that is small and floats like a ping pong ball or rubber duck. I cue the patient to blow the object across the pool and time it or measure the distance for some objective outcomes for documentation.
Nancy Martinez, BA, PTA in an aquatic therapist at Celebration Health, part of the Florida
Hospital System in Orlanda, Florida – Our pool is an in-ground 50’x35’ (or so!) pool that is used by the outpatient clinic within the hospital as well as by our fitness and health programs. The aquatics program is a terrific start as an alternative to those patients whose pain level would not permit them to exercise on land. Plus, the warmth of a pool like ours (90-92 degrees Fahrenheit) is palliative and encourages movement from our "fearful" patients.
The first thing most patients do is ambulate the length of the pool - approx 35' - closest to the shallow section, using a hand on the wall or a foam rolling pin (better than a dense white noodle most times) or nothing. Sometimes, all they do is walk the first 2 visits. We even take patients using oxygen into the pool. Those with nasal cannulas simply bring a long (40') hose and we stabilize their oxygen tank on the side of the pool. Those individuals cannot go the full length and are asked to rest and breathe deeply more often, but we don’t see it as a barrier at all. If the patient is compliant with aquatic therapy 2 days per week, by the end of 2 weeks (4 sessions), he or she starts to see improvement in stamina and mobility, which is very exciting.
What would you say to a clinician who wanted to hear "a truly valuable piece of advice" related to pulmonary training in the pool?
Wendy - COPD is an indication for aquatic therapy. The hydrostatic pressure present during immersion produces approximately a 60% increase in central blood volume. In short, immersion makes the lungs work harder, ultimately increasing the strength and endurance of the respiratory muscles. Do keep in mind that when working with COPD, you must be very careful to watch for any chemical sensitivity. Check that your patient does not have any reactions to the chemicals or you might trigger an onset of respiratory abnormalities.
Nancy - Go slowly and constantly monitor, observe, and engage the patient in conversation to assess the physical/mental/ emotional stress. Rest as needed. Be aware at all times of perceived breathing difficulties and react accordingly. Any rest periods can be used as a quantitative measure indicating progress in the chart if it is done consistently. For example, have the patient sit on a step or a built-in bench or lean on the pool wall when shortness of breath becomes a problem. Time the amount of rest needed before the patient can continue and keep track of this from session to session.
Finish this thought "If our pool closed down today, our COPD patients would…"
Wendy - …need to continue to do aquatic therapy independently in a community pool or get some personal classes one-on-one.
Nancy - ...be more sedentary or not attend therapy at all due to the perception of overly "strenuous exercise" on land. With co-morbidities like stenosis or kyphosis, just ambulating is tiring muscularly.
Finish this thought "The biggest pain in the gluts about having a pool is..."
Wendy - …definitely the maintenance and upkeep. I am the Lone Ranger in my setting and I do all of the patient treatments, maintenance and light repairs as well as purchasing supplies and keeping the quality of the water within code.
Nancy - ...the time it takes for patients to arrive, change and get into the water. Once they discover they like it, I have a hard time getting them out.
Do you agree with this statement? "Staff members require supplemental training in order to work in the water."
Wendy – Each one of our Aquatic staff employees are at the very least Water Safety and Rescue as well as CPR/AED trained and certified. We then go one step further and have them attend the Arthritis Foundation Aquatic Exercise Certification course so that they will feel comfortable in assisting clients in our Aqua Motion Wellness classes.
Nancy - I agree 100%. Everybody at our facility must be trained in CPR/AED. We train our Tech Assistants in the “what, why, and how” of exercise. More importantly, it’s important to realize that most PTs and PTAs have had minimal training in aquatic therapy and tend to do land-based exercises in the water without considering the properties of water and how it affects ROM, overall effort, etc. That’s why it is important to have aquatic-specific training in order to be a competent aquatic therapy provider, especially when working with patients with compromised systems, such as the COPD client.
Conclusion
There are as many different lists of precautions and contraindications as there are therapy pools. The important point to remember is this: labeling a condition a “precaution” allows the therapist the discretion to treat or not treat the patient. Labeling a condition a “contraindication”, on the other hand, takes the discretion out of the aquatic therapy provider’s hands. The pool is a unique tool in your arsenal. Don’t disarm: Take the time to investigate the power of the pool.
Updated References
Angelo Deus F, Castro CLFE, Oliveira VC, et al. Aquatic Exercise for People With Asthma: A Systematic Review With Meta-Analysis of Randomized Controlled Trials. The Journal of Asthma : Official Journal of the Association for the Care of Asthma. 2024;61(8):780-792. doi:10.1080/02770903.2024.2303776.
Benzo-Iglesias MJ, Rocamora-Pérez P, Valverde-Martínez MÁ, García-Luengo AV, López-Liria R. Effectiveness of Water-Based Exercise in Patients With Chronic Obstructive Pulmonary Disease: Systematic Review and Meta-Analysis. Sensors (Basel, Switzerland). 2023;23(20):8557. doi:10.3390/s23208557.
Maccarone MC, Masiero S. Spa Therapy Interventions for Post Respiratory Rehabilitation in COVID-19 Subjects: Does the Review of Recent Evidence Suggest a Role?. Environmental Science and Pollution Research International. 2021;28(33):46063-46066. doi:10.1007/s11356-021-15443-8.
Güeita-Rodríguez J, Gil-Montoro N, Cabo-Ríos B, et al. Impressions of Aquatic Therapy Treatment in Children With Prolonged Mechanical Ventilation - Clinician and Family Perspectives: A Qualitative Case Study. Disability and Rehabilitation. 2022;44(8):1284-1293. doi:10.1080/09638288.2020.1800832.
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Love the information about why the pool is not forbidden to CP Compromise patients.