Careful Planning: Taking the systemic or metabolically challenged patient into the water

Byline: Andrea Salzman, MS, PT

Therapists who work in the water have a difficult task. Not only must they understand the nuances of their patients'; diagnoses, but they must understand all the technical distinctions that come from working in a unique environment: the pool.

In addition, there is more of a call for "justification" for aquatic therapy than for garden-variety physical therapy. Payers want therapists to make a strong case for taking a patient into the water.

Know Your Terms

Always describe systemic or metabolically challenged language in lay terms to increase patient understanding. A high-risk pregnancy, for example, can refer to a condition known as placenta previa, or placenta that is implanted in the lower uterine segment, or multiparous, which refers to producing more than one child at birth.

In addition to pregnancy, other patients with systemic or metabolical disorders might include those who are obese (people with 20 percent to 30 percent over normal fat percentage); or those with diabetes mellitus, or immunosuppresive disorders (including AIDS), which refers to any disorder which acts to prevent the formation of an immune response. In addition, these patients could also have general debilitation, or widespread weakness and poor functional ability.

Precautions and Contraindications

Always identify precautions and contraindications to exercise in a therapy pool for patients with systemic and metabolic disorders. Monitor vitals aggressively, start slowly and work into more vigorous activities. Insist that the patient has his necessary equipment (e.g., glucose tablets) or do not allow him to get into the pool.

Assess for open portals in the patient's skin (e.g., wounds, menstruation) for microbes to enter or exit. If the patient takes medications that artificially elevate or decrease the heart rate, neither the Karvonen formula nor any of the "modified" formulas are appropriate to establish heart rate parameters for exercise. Instead, the patient should be taught to use a rating of perceived exertion (RPE) such as that described by Borg. If the patient has low vital capacity (<1.5L), the hydrostatic pressure of the water against the chest wall may make respiration difficult; thus he may need to exercise in shallower water or in a supine (horizontal) float. If the patient has difficulty "throwing off" the heat built up during exercise in water that is warmer than skin temperature, care should be taken to allow radiation and evaporation to occur (e.g., keep the head uncovered, keep humidity relatively low).

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Techniques and Specifics for Designing Programs

Therapists should identify techniques and specific treatment parameters for designing an aquatic therapy program for patients with systemic and metabolic diseases.

Always obtain a medical release. Check vital statistics prior to initiation of any session and

several times during the session. Encourage breaks—even breaks out of water—if the water is warm. Do not leave patients unattended even if state code does not require lifeguards to be present. Have a CPR and emergency plan posted for both staff and patients. View the patient holistically, even more so than normal. Use the pool as a medium that addresses multiple needs at once (e.g., diabetes, obesity). Keep in mind that the patient may not achieve as high an intensity as an uncompromised individual, but his duration of exercise may be longer.

Goals for Aquatic Therapy

Discuss the goals for aquatic therapy for your patients with systemic and metabolic diseases.

Goals overall should or could include:

• Improvement in vital capacity;

• Improvement in respiratory rate, depth and inhalation/exhalation patterns;

• Improvement in sputum clearance and functional cough;

• Decrease in shortness of breath or dyspnea with moderate levels of activity;

• Improvement in cardiopulmonary fitness;

• Improvement in ability to perform ADLs or ambulation without difficulty;

• Improvement in exercise tolerance and in work tolerance or duration;

• Improvement in flexibility, strength and endurance;

• Altered body composition;

• Compliance with attendance and willingness to learn and execute aquatic program.

Benefits of Aquatic Therapy

Identify the benefits of aquatic therapy for patients with systemic and metabolic diseases, such as:

• Reduction in weight-bearing during exercise;

• Reduction in gravitational pull on posture;

• Retardation of the muscle atrophy and contractures that often accompany immobility;

• Increase in proprioceptive awareness during exercise and functional task simulation;

• Increase in amount of time to recover from loss-of-balance episodes;

• Provision of an environment that is barrier free and free of assistive devices;

• Increase in proprioceptive awareness during exercise and functional task simulation;

• Strengthening of expiratory muscles (must push against hydrostatic pressure);

• Promotion of clearing of excretions;

• Promotion of greater exhalation and inhalation;

• Encouragement of socialization in a "normal" recreational environment.

Characteristics of Treatment

High-risk pregnancy patients may be involved in an aquatic therapy program as inpatients or outpatients. For example, inpatients could come to the pool up to two times per day. Their IVs are kept dry on kickboards on the side of the pool while the patient hangs in an inner tube (partially deflated) in the water for up to one hour each time. This is not 1:1 treatment. The rationale for such a program is to increase blood flow to the fetus, decrease swelling in the mother's legs, increase mother's central circulation, and increase mother's comfort. There are no current studies that address whether this truly helps delay birth and increase birth weight.

For pregnant patients who do not fall into the high risk category, obtain a medical release and informed consent from the patient. The patient should try to maintain levels of exercise achieved prior to pregnancy, but should not exceed them. The exercise class should serve as a network for nutritional and exercise information as well as social time.

Watch for dramatic heart rate increases and overheating, as heat dissipation is harder for these women. Encourage modification, and give the patient permission to rest or stretch at any time. Encourage the patient to work according to how she feels at the time, not how she has felt before. Avoid high-impact moves and rapid cutting movements, and excessive resistive exercises or complex choreography. Demonstrate first, second and third trimester alternatives if necessary. Monitor vitals, especially after cardiovascular work. Don't allow over-stretching (ligamentous laxity). Allow the patient to continue to exercise in a supine position in the water unless she begins to feel dizzy, nauseous or light-headed (maximum of two minutes). Have the patient bring water poolside, and encourage Kegel exercises.

For patients who are obese, monitor for vitals often. Keep in mind that even lower intensity weight-bearing exercise can create higher heart and respiratory rates than in a non-obese counterpart. If the patient is nonweight-bearing, it takes very little work to sustain floating. The patient should be able to get a more difficult workout than on land with less stress to the joints. Keep in mind that the warmth of the water may make it difficult to allow sustained aerobic exercise. Also keep in mind that the patient may be unwilling to put on a bathing suit or shorts, and that socialization may work both for or against you with this population.

For patients with diabetes or diabetic neuropathy, monitor for open wounds often. Have patients wear aquasocks; they should not be barefoot. The hydrostatic pressure will aid the patient in edema control and in circulation. Buoyancy will permit the patient to work in a pain free closed kinetic chain even for affected lower extremities.

Monitor for signs of hypoglycemia (more likely) and hyperglycemia. If you are going to err, err on the side of hypoglycemia, as there is little margin for error for treating hyperglycemia. This can complicate onset of seizures or hyperthermia. Make sure the patient eases into exercise because it will vastly alter his blood sugar levels. Make sure patients with diabetes remain in contact with their physician in order to make any changes in medication. If patients have two episodes of serious hypoglycemia, they should be discontinued from aquatic exercise until this is controlled.

For patients with immunosuppressive disorders (including AIDS), monitor vitals and for open wounds often; make sure menstruating females use internal protection. Use progressive resistive exercise to retard muscle wasting. Don't allow these patients to overwork, even though they may feel great. Buoyancy will permit these patients to work in a pain-free closed kinetic chain. Aerobic exercise is just as important for this patient as it is for patients with fibromyalgia. The AIDS virus is very fragile and cannot live in a chlorinated pool. Instead, the biggest concern for infection should be the locker room, showers, and on deck with open wounds. These patients can be at high risk for obtaining air- or waterborne infection from others.

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