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 look at the pool and may think of synchronized swimming, of water aerobics, of learn-to-swim lessons, of just about everything but skilled intervention. Consequently, they want therapists to make a strong case for taking a patient into the water.
Definition of Terms
First, describe cardiopulmonary compromised language in lay terms to increase patient
understanding.
• Cardiac failure: Condition resulting from the inability of the heart to pump sufficient blood to meet the needs of the body.
• Chronic obstructive lung disease (alternately called chronic obstructive pulmonary disease): Disease process that causes decreased ability of the lungs to perform their function of ventilation. Diseases that cause this are chronic bronchitis, pulmonary emphysema, chronic asthma, and chronic bronchiolitis.
• Coronary artery disease: Narrowing of the coronary arteries sufficiently enough to prevent
adequate blood supply to the myocardium.
• Coronary heart disease: Decreased flow of blood to the heart muscle to the extent that either the basal needs for oxygen are unmet, or the oxygen supply is insufficient when an increased demand for oxygen is made, as in for work or exercise.
• Myocardial infarction: Condition caused by occlusion in one or more of the coronary arteries.
• Myocardial insufficiency: Inability of the heart to perform its usual function. Eventually, this
results in cardiac failure.
Precautions and Contraindications
The next step is to identify precautions and contraindications to exercise in a therapy pool for patients with compromised cardiopulmonary systems.
The traditional method for determining exercise intensity (via the Karvonen formula) is
inadequate for use in the pool, especially for the cardiopulmonary compromised patient. Target heart rate zones should be established at 12 to 17 beats per minute (bpm) lower than the Karvonen formula indicates.
If the patient takes medications that artificially elevate or decrease the heart rate, or if he has a pacemaker, 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 poor swimming skills, he should not attempt to swim for cardiac rehabilitation, as the oxygen demand is too high.
If the patient has low vital capacity (<1.5 liters), 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).
Specifics for Designing Programs
Next, therapists should identify techniques and specific treatment parameters for designing an aquatic therapy program for the cardiopulmonary compromised patient. Follow these important steps:
• 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;
• Insist that the patient bring necessary equipment (e.g., an inhaler, nitroglycerin, glucose tablets) or do not allow the patient to exercise;
• Do not leave the patient unattended, even if state code does not require lifeguards present;
• Have CPR and an emergency plan posted for both staff and patients.
Establishing Goals
Therapists should be open when discussing the goals for aquatic therapy for cardiopulmonary compromised patients. These could include:
• Improvement in diuresis and edema control;
• 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;
• Improvement in work tolerance or duration;
• Decrease in complaints of pain or of anxiety about poor respiration;
• Compliance with attendance and willingness to learn and execute an aquatic program.
Benefits of Aquatic Therapy
The next objective involves identifying the benefits of aquatic therapy for the cardiopulmonary compromised patient. These will likely include:
• Increase in cardiac efficiency and myocardial perfusion;
• Improvement in cardiac preload, stroke volume, and cardiac output during exercise;
• Decrease in risk of heart arrhythmias during exercise;
• Strengthening of expiratory muscles (must push against hydrostatic pressure);
• Promotion of stretch of scarred skin (s/p open heart surgery);
• Promotion of clearing of excretions;
• Promotion of complete exhalation and larger inhalation;
• Reduction in lower extremity edema;
• Earlier return to activity after cardiopulmonary event;
• Encouragement of socialization in a "normal" recreational environment.
Phases of Cardiac Rehab
Therapists should be sure to describe, for their patients, a safe and appropriate aquatic Phase III cardiac rehab program.
Phase I–the inpatient phase–includes the stay in the coronary care unit (CCU) until discharged from the hospital. Treatment includes initiation of bed mobility, then progression to 10 to 15 minutes of ambulation per day by discharge.
Phase II—the outpatient phase—follows two to four weeks post discharge until three to 12
months outpatient. Treatment includes education, counseling and 3x/week supervised exercise.
Phase III—also an outpatient phase—follows three months to one year of outpatient status and beyond. Treatment includes health maintenance, smoking cessation, weight control, stress management, and potential for follow-up sessions. Prerequisites for entering a cardiac aquatic rehab program should include prior participation in at least eight weeks of land-based cardiac rehab; established "norms" for blood pressure, heart rate and angina, and an established arrhythmia history and medication effects.
Parameters for Cardiac Aquatic Rehab
Exercise is generally of low intensity and short duration, and has frequent rest periods. Angina response should be respected, and any progression of exercise intensity and duration should be conservative. (Note: initial angina may be from fear, not immersion or exercise.) Water temperature should be maintained between 88 degrees to 92 degrees Fahrenheit, as colder water may result in arrhythmias. Water that is too warm may result in an inability to dissipate heat. The depth of the water should be altered if immersion results in an increased difficulty in respiration, due to difficulty with chest expansion (due to hydrostatic pressure). Target heart rate training zones should be between 12 to 17 beats per minute lower than an equivalent exercise on land. Horizontal movement in water (true swimming) is a skilled activity and can be aerobically demanding. The poor swimmer may reach VO2s of more than 90 percent max.
Conclusion:
Swimming should not be attempted as cardiac rehabilitation unless the patient already has strong swimming skills. All participants should have a medical release, regardless of remoteness of heart difficulties. Providing PT in an aquatic environment becomes logical when you can break it down into component parts.
This population is often forgotten!