For the Children: Taking your pediatric patient into the therapy pool

Payers look at a child in the pool and see swim lessons. Your job is to show them skilled therapy. Here are the precautions, techniques and goals that make the case.

Want to go deeper? Explore the Pediatric Aquatic Therapy bundle →

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 may look at the pool and 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.

Objectives

First, describe pediatric language in lay terms to increase patient understanding. The pediatric population is usually defined as children and teenagers under 18 years.

Second, identify precautions and contraindications to exercise in a therapy pool for the pediatric patient. Note that precautions and contraindications that are general to the public at large are not listed here.

1. Children are not able to perspire and dissipate heat as well as adults, so keep the pace down. Also, they are usually deficient in anaerobic capacity, so modify the workout.
2. Children with high tone, spasticity or rigidity may show an increase in these tone problems because of the lack of a stable base and normal gravity-based environment in the water.
3. Identify techniques and specific treatment parameters for designing an aquatic therapy program for the pediatric patient.

Techniques and Specifics

The key is to encourage fun and not just exercise. Music and games should be used promote goals (relaxation vs. facilitation). Programming should include both mind and body (e.g., sensory integration), including:

• Sensation (rhythm, balance);
• Emotions (e.g., through body movement);
• Creativity (i.e., conceiving images, thoughts, situations);
• Imagery (i.e., storytelling in workout movement patterns);
• Relaxation training.

Activities should be varied constantly, and ideally should be discontinued in the middle of the fun, so the patient will want to continue. Make use of equipment, from inner tubes to kickboards, frisbees to balls, basketball hoops to sinkable toys, as well as traditional aquatic equipment. Other tips include keeping the shallow end of the pool shallower than 3 feet, and keeping the pool full of relatively warm water to promote increased attention.

What are the goals of aquatic therapy?

Your goals for the pediatric patient in aquatic therapy should include most or all of the following:

• Improvement in flexibility;
• Improvement in strength;
• Improvement in balance, reaction time and safety during ambulation;
• Improvement in gait parameters;
• Improvement in ability to perform ADLs;
• Improvement in exercise tolerance;
• Decrease in abnormal tone and synergistic patterns;

• Improvement in head and trunk control;
• Improvement in perceptual and spatial relations (e.g., body awareness, midline concept, distance/depth perception, eye-hand coordination);
• Improvement in oral/facial control;
• Reduction in tactile defensiveness/hypersensitivity;
• Decrease in fatiguability;
• Decrease in complaints of pain;
• Improvement in cardiopulmonary fitness;
• Improvement in skill and coordination through sports;
• Compliance with attendance and willingness to learn and execute an aquatic program.

What are the benefits of aquatic therapy?

• Application of weight bearing in a graded or progressive manner;
• Increase in proprioceptive awareness during exercise and functional task simulation;
• Application of resistance in a graded or progressive manner;
• Assistance in limb movements against gravity (assisted by buoyancy);
• Encouragement of socialization in a "normal" recreational environment that offers noncompetitive fun and socialization;
• Provision of a safe environment;
• Retardation of muscle atrophy and contractures, which may occur in the absence of exercise;
• Decrease in muscle tone and spacticity (if water is thermoneutral or warmer);
• Provision of an environment that can eventually be barrier free and free of assistive devices;
• Provision of an environment in which it is possible to treat multiple problems at once without seeming like "work" to the child;
• Provision of safety education in water to promote follow-through as adults.

For education only; not a substitute for individual clinical judgment.