Depth-Specific Aquatic Therapy

Byline: Andrea Salzman, MS, PT

At a seminar (now many years ago) in Iowa, I provided training to approximately 30 therapists. The therapeutic pool used for the seminar had three depths available for use: 3', 4.5' and a deep water well. It was a fabulous group which worked hard to fit all thirty people into the 4.5' depth for some hands-on work. 

It soon became obvious how critical depth is for aquatic therapy! 

4.5 feet was too deep for most therapists to work in.

At the end of the day, the therapists asked for me to come up with a prompter list of activities and exercises that could be done in different depths of water. A cheat-sheet, if you will. The resulting list is provided below. 

Use this list to start using your whole pool and not just that chest-deep water.

And for those of you looking to build, know what activities you want to do before you settle on a pool 6" too deep. 

Once your pool is built, it is nearly impossible to make adjustments in depth. 

 On Ramp                  

1. Crawling entry/exit (e.g. children pretending to be different kinds of animals) 

2. Crab-walk entry/exit 

3. Seated hip hiking (e.g. scooting up and down ramp on gluteals) 

4. Searching for underwater items on hands and knees               

5. Wheelchair mobility (up and down ramp)                    

On Steps   

1. Crab-walk entry/exit 

2. Seated hip hiking (e.g. lifting up and lowering down steps using triceps, latissimus dorsi, etc.) 

3. Seated stretches of lower extremities on lowest step (shallow enough for head-out immersion, but deep enough for body part to be unloaded) 

4. Seated exercises that encourage crossing of midline, use of neglected side, etc. 

Any exercise that is too difficult to perform seated in deeper water (e.g. child's play) 

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 2' —2'6" Depth (Approximate) 

1. Quadruped exercises (e.g. single arm raises, single leg raises, opposite arm/leg raises, abdominal crunches by bringing both knees to chest) 

2. Tall kneel exercises —single knee (e.g. initiation of standing from tall kneel, weight shift in the AP plane, maintaining positioning against outside turbulence) 

3. Tall kneel exercises —bilateral knees 

4. Plantar grade exercises (arms weight bearing on bottom of pool, legs floating) 

5. Transitional exercise (e.g. moving from quadruped to tall kneel, moving from tall kneel with a single knee to both knees, moving from quadruped to plantar grade) 

6. Inverted quadruped exercises ("Inverted" position) 

7. Floating (for fearful or small clients)
   

 2'6"— 3'6" Depth (Approximate)                     

1. Squatwalking 

2. Resisted walking and running (e.g. charging rapidly across the width of the pool) 

3. Resisted calisthenics (e.g. jumping jacks, cross-country skiing) 

4. Side saddle position in Watsu® (back to wall, squatted with leg in a Figure-4 position to hold client in "saddle" 

5. Calf strengthening and stretching (e.g. toe and heel rocking, heel cord stretch) 

6. Prone exercises with mask and snorkel (e.g., cervical, spinal, shoulder, and hip ROM, resisted PNF patterns) 

7. Bad Ragaz Ring Method (depth varies as provider is immersed to ~ T11 while standing) 

8. Some Task-Type Training Approach work simulation activities 
   

3'6"—4'2" Depth (Approximate)  This is the "critical working depth" for most patients and providers. If your pool doesn't have this depth -- and a lot of it -- you're in trouble.

1. Reduced weight-bearing walking and running 

2. Reduced weight-bearing calisthenics 

3. Reduced weight-bearing spinal and lower extremity stretches 

4. Upper extremity PNF (proprioceptive neuromuscular facilitation)/ PRE (progressive resistive exercise) patterns 

5. Lower extremity PNF/PRE patterns 

6. Watsu sessions 

7. Wassertanzen sessions 

8. Halliwick games and instruction 

9. Ai Chi patterns 

10. Aquatic Feldenkrais® patterns 

11. Bad Ragaz Ring Method (depth varies as provider is immersed to ~ T11 while standing) 

12. Swim stroke training and modification (if instructor is standing in water) 

13. Manual therapy and massage Relaxation training and imagery

14. Some Task-Type Training Approach work simulation activities 

 5'6" Depth & Deeper (Approximate)                                                                    

1. Unloaded distraction of spine and lower extremities 

2. Unloaded aerobic exercise 

3. Unloaded relaxation and imagery (including "hanging") 

4. Swim stroke training and modification (if instructor is standing on deck) 

5. Treading water and diving 

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For more information about all the aquatic specialty techniques mentioned, the reader is directed to the resources provided below.

 Additional Resources 

Ai Chi Kunno J, Sova R. Ai Chi. (Book and Video). Port Publications, Inc.: Port Washington, WI; 1996. To order: DSL, Ltd, 1218 Noridge Trail, Port Washington, WI 53074. Phone (414) 284-7039. 

Aquatic Feldenkrais Ashton D. Feldenkrais on Land and Water (video or audiotape). The Well Being; Knoxville, TN; 1996. To order: 9113 Cedar Park Lane #C, Knoxville, TN 37923. Phone (888) 935-6287. Fax (865) 693-6235. 

Feldenkrais Guild, PO Box 489, Albany, OR 97321-0143. Phone (800) 775-2118. Fax (541) 926-0572. 

Aquatic PNF Jamison L, Ogden D. Aquatic Therapy Using PNF Patterns. Therapy Skill Builders: San Antonio, TX; 1994. To order: Out of print and may no longer be ordered through publisher. Limited copies may be obtained c/o: Sprint Rothhammer International, Inc., PO Box 3840 , San Luis Obispo, CA 93403-3840 USA. Phone (800) 235-2156, (805) 541-5330. Fax (805) 541-5339. 

Bad Ragaz Ring Method Cunningham J. "Applying the Bad Ragaz Ring method to the orthopaedic client." In: Orthop Phys Ther Clin of North Am. 1994; 3(2): 251-260. To order: WB Saunders Company, The Curtis Center, Independence Square West, Philadelphia, Pennsylvania 19106-3399 USA. Phone (800) 654-2452. 

Garrett G. "Bad Ragaz Ring Method." In: Ruoti RG, Morris DM, Cole AJ (eds). Aquatic Rehabilitation. Lippincott-Raven Publishers: Philadelphia, PA; 1997:289-304. To order: Lippincott-Raven Publishers, 227 East Washington Square, Philadelphia, PA 19106. Phone (800) 777-2295. 

Halliwick Method Cunningham J. "The Halliwick Method." In: Ruoti RG, Morris DM, Cole AJ (eds). Aquatic Rehabilitation. Lippincott-Raven Publishers: Philadelphia, PA; 1997:305-332. To order: Lippincott-Raven Publishers, 227 East Washington Square, Philadelphia, PA 19106. Phone (800) 777-2295. 

Campion MR. "The Halliwick Method and Conductive Education." In: Campion MR (ed). Hydrotherapy: Principles and Practice. Butterworth-Heinemann: Oxford, England; 1997:169-174. To order: Butterworth-Heinemann, Linacre House, Jordan Hill, Oxford OX2 8DP or 313 Washington Street, Newton, MA 02158-2500. Phone (617) 928-2500. 

Cunningham J. " Halliwick method." In: Ruoti RG, Morris DM, Cole AJ (eds). Aquatic Rehabilitation for Health Professionals. JB Lippincott Co: Philadelphia, PA; 1997: 305-331. To order: Lippincott-Raven Publishers, 227 East Washington Square, Philadelphia, PA 19106. Phone (800) 777-2295. 

International Halliwick Association, Hermitage, 7310 Bad Ragaz, Switzerland. Email: hermitage@spin.ch. Website: www.hermitage.ch. 

Swim Stroke Training and Modification Dunlap E. "Swim stroke training and modification for rehabilitation." In: Ruoti RG, Morris DM, Cole AJ (eds). Aquatic Rehabilitation for Health Professionals. JB Lippincott Co: Philadelphia, PA; 1997: To order: Lippincott-Raven Publishers, 227 East Washington Square, Philadelphia, PA 19106. Phone (800) 777-2295. 

Task-Type Training Approach Morris DM. "Aquatic rehabilitation of the neurologically impaired client" (Task-type training approach). In: Ruoti RG, Morris DM, Cole AJ (eds). Aquatic Rehabilitation. Lippincott Publishing: Philadelphia, PA; 1997: 105-125. To order: Lippincott-Raven Publishers, 227 East Washington Square, Philadelphia, PA 19106. Phone (800) 777-2295. 

Morris DM. "Aquatic rehabilitation for the treatment of neurologic disorders" (Task-type training approach). In: Becker BE, Cole AJ (eds). Comprehensive Aquatic Therapy. Butterworth-Heinemann: Boston, MA; 1997: 49-71. To order: Butterworth-Heinemann, Linacre House, Jordan Hill, Oxford OX2 8DP or 313 Washington Street, Newton, MA 02158-2500. Phone (617) 928-2500. 

Watsu Dull H. "Watsu" In: Ruoti RG, Morris DM, Cole AJ (eds). Aquatic Rehabilitation. Lippincott-Raven Publishers: Philadelphia, PA; 1997:305-332. To order: Lippincott-Raven Publishers, 227 East Washington Square, Philadelphia, PA 19106. Phone (800) 777-2295. 

Dull H. Watsu: Freeing the Body in Water. Harbin Springs Publishing: Harbin Springs, CA; 1993. To order: Worldwide Aquatic Bodywork Association, PO Box 570, Middletown, CA 95461. Phone (707) 987-3801. Worldwide Aquatic Bodywork Association (WABA), PO Box 889, Middletown, CA 95461. Phone (707) 987-3801. Fax (707) 987-9638.