Slide 1. Slide 3 Course Objectives Upon completion of this course, participants will:

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1 Slide 1 Fundamentals of Aquatic Intervention for the Pediatric Population Combined Section Meeting 2017 San Antonio, Texas February Christine Taylor, PT, DPT PCS Theraplay Pediatric Rehab & Wellness Slide 2 Disclosure The speaker has no financial interest in or conflict of interest related to this presentation. The speaker will not receive compensation from any company and is not paid to represent specific products or services. Slide 3 Course Objectives Upon completion of this course, participants will: understand the benefits for choosing aquatic physical therapy as a primary or adjunct method of intervention; identify functional limitations best-suited for aquatic-based intervention; learn effective handling techniques in four major treatment positions; choose the type of equipment best suited for use during therapy; Link application of aquatic techniques to functional land-based outcomes.

2 Slide 4 Why Aquatics? Slide 5 The Challenge Slide 6

3 Slide 7 Why it Matters Slide 8 Aquatic Physical Therapy Changes Lives Slide 9 Then I met Jesus

4 Slide 10 Jesus at 22 months Slide 11 Aquatic Physical Therapy Pearl #1 Is a Life- Changing Form of Intervention Slide 12 Our Mission Transforming society by optimizing movement to improve the human experience.

outcomes and are consistent with current professional knowledge Skilled Intervention by a physical therapist,

5 Slide 13 The Therapist s Tool Box Slide 14 CREATE A NEW PARADIGM Slide 15 The Health Care Relationship The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge Skilled Intervention by a physical therapist, performed in water using clinically relevant, evidence-based techniques to remediate or reduce functional impairments.

Slide 17 Terminology Aquatic Physical Therapy is NOT: Water Exercise Hydrotherapy Water aerobics Swim Therapy/Lessons Aquatics

6 Slide 16 Pearl #2 Aquatic Physical Therapy is a valuable component to health care and plays an integral part in helping individuals improve function. Slide 17 Terminology Aquatic Physical Therapy is NOT: Water Exercise Hydrotherapy Water aerobics Swim Therapy/Lessons Aquatics Slide 18 Aquatic Physical Therapy integrates: the unique knowledge, skills, and training of a physical therapist or assistant and cannot be performed by an unlicensed individual, a personal trainer, caregiver, or aquatic instructor.

Slide 19 Aquatic Physical Therapy Is a Specialty Practice Specific handling techniques Manual skills to influence or restrict movement Tactile,

7 Slide 19 Aquatic Physical Therapy Is a Specialty Practice Specific handling techniques Manual skills to influence or restrict movement Tactile, verbal, and visual cues to guide movement Integrates functional skills training Little to no floatation support Slide 20 Aquatic PT or Not? Slide 21

8 Slide 22 Slide 23 Slide 24

9 Slide 25 Slide 26 The What, Why, and How of Aquatic PT Slide 27 Aquatic Physical Therapy Uses the properties of water to affect movement and cause physiologic change. The properties are referred to as Hydrodynamics

uniform support and resistance Therapist: Lessens work required for

10 Slide 28 Hydrodynamics Buoyancy Density Viscosity Thermodynamics Hydrostatic pressure Slide 29 Stability Patient: Water provides uniform support and resistance Therapist: Lessens work required for handling Slide 30 Mobility Near zero gravity + buoyancy supports movement

and digest) for inhibition Slide 33 The Benefits: For Therapists The Goal of PT: to maximize movement Aquatic therapy enables the therapist to see what movements the

11 Slide 31 Proprioception Uniform pressure supports body awareness to improve brain-body connection. Slide 32 Alertness or Calming The multi-sensory environment stimulates sympathetic nervous system (alerting) for facilitation or Parasympathetic nervous system (rest and digest) for inhibition Slide 33 The Benefits: For Therapists The Goal of PT: to maximize movement Aquatic therapy enables the therapist to see what movements the patient can perform without the constraint of gravity. Helps focus land-based intervention in the areas where the patient has the ability to make the most gains. Efficiency: Allows for training of multiple systems during a single session.

12 Slide 34 The Benefits for Patients: Maximize movement with opportunity and options for participation. Aquatic PT provides opportunities for movement the patient may otherwise be unable to perform. Aquatic PT introduces the patient to an activity that allows for life-long participation. Enables/promotes caregiver participation. Slide 35 Some clinical impairments treated with aquatic physical therapy: Weakness Rom deficits Dyspraxia Dyspnea Proprioception Coordination/agility Pain Balance deficits Slide 36 #3 Aquatic Physical Therapy is beneficial for treating any type of clinical impairment. Aquatic Physical Therapy can either inhibit or facilitate movement in one or more body segments. Aquatic Physical Therapy is the only treatment that offers continuous, fluid, velocity-dependent, uniform resistance. Aquatic Physical Therapy is the only treatment that enables therapists to use controlled pressure to support all or a portion of the patient s body weight. Aquatic physical therapy allows therapists to affect degrees of movement simultaneously.

For each patient, provide written precautions and contraindications and discuss with

13 Slide 37 Getting Started The Basics Slide 38 Slide 39 Think Safety First Develop or Review safety policies prior to commencing aquatic treatment. For each patient, provide written precautions and contraindications and discuss with caregivers. Provide written pool guidelines and review with caregivers (hygiene, dress, jewelry, food, drink, outside toys, etc.)

14 Slide 40 Consider Logistics Is the environment suitable for treating children? How will the client enter/exit the facility? What plans are in place to address an emergency? Are there two forms of communication in the event of an emergency? What are the evacuation procedures? Who is responsible for water quality and maintenance? Slide 41 The How to: Slide 42 First Steps Land-based Evaluation Determine the clinical impairments suited for treatment in water. Discuss the option of aquatic PT with caregivers Review checklist for participation with caregiver Review logistics, provide handouts on policies, precautions, safety, etc. Take patient/caregiver on tour of pool site

15 Slide 43 Ready to Dive In Slide 44 Entry: Vertical with support at upper trunk, facing child. Slide 45 Supported Entry Child walks or transfers into pool feet first with therapist for stand by assist Pool lift Two-person transfer from wheelchair to edge and two person lift from inside pool to water.

16 Slide 46 Exiting the pool Slide 47 Movement The Four Basic Positions: Vertical,. Prone, Sidelying and Supine Slide 48 Vertical movement face to face

17 Slide 49 Vertical+Lateral Movement face-to-face Slide 50 Vertical facing away (passive) Slide 51 Vertical facing away (active)

18 Slide 52 Prone Slide 53 Sidelying Slide 54 Supine

19 Slide 55 Combination Movements Toes Up, Toes Down The Dolphin Snaking Turning and Rolling Slide 56 The Wango Slide 57 Position 1: Dance pose

20 Slide 58 Side Dip Slide 59 Dance Pose 2 Slide 60 Up and Rotate to facing away

21 Slide 61 Dip Back Toward Supine Slide 62 Sidelying to Prone Slide 63 Supported Prone

Slide 64 Prone with Movement Slide 65 Body Segment Training: Legs Pushing off edge Push/pull patient s feet (patient supine with or without floatation) Water walking (all directions with or without

22 Slide 64 Prone with Movement Slide 65 Body Segment Training: Legs Pushing off edge Push/pull patient s feet (patient supine with or without floatation) Water walking (all directions with or without fins or leg weights) Frog kicking with fins Straight leg raises (patient supine, holding barbell and feet stabilized on mat, edge of pool, or by therapist. Plyometrics using step bench, pool steps or platform Slide 66 Core Curl ups with barbell Alternating leg raises (patient supine holding barbell or noodle) Knees to chest (with or without ankle weights) Supine with patient on airex mat

23 Slide 67 Upper Extremities Walk the wall Pull ups at edge, feet dangling Big arms (patient standing or prone; breast stroke movement with or without body movement) Use barbell or dumbells to push against water Push/pull/static holds with therapist creating movement Slide 68 Use equipment only: Using Equipment To stabilize a body part while manipulating or working another segment; To promote independent movement when the patient is otherwise unable to move; To provide additional resistance. Slide 69 Use equipment to: To support head or trunk while therapist controls other movements To support independent movements To challenge movement (stability, balance, offer resistance ) To support participation when patient is unable to control their body position or move independently.

24 Slide 70 When you give a child the gift of mobility, you change their life forever. Slide 71 Appendices Resources to make life easier Slide 72 Checklist for participation Patient has a stable medical status The patient has no precautions or contraindications against participation. The patient has caregivers committed to support participation. The family/caregiver has the financial resources to attend regular sessions. The therapist has the skills required to provide effective intervention. The aquatic environment is accessible for the patient. The aquatic environment is compatible with the patient s needs. Patient has had no negative experience with water. Safety issues have been addressed and plans put in place before participation. Policies and procedures are developed to address all aspects of aquatic PT.

Slide 73 Professional Components Do I have the experience needed to work with this patient? To handle emergencies? Do I have the insurance coverage needed to cover treatment in a pool (on or offsite)?

25 Slide 73 Professional Components Do I have the experience needed to work with this patient? To handle emergencies? Do I have the insurance coverage needed to cover treatment in a pool (on or offsite)? Does the patient s insurance cover aquatic physical therapy? For leased pools, is there a binding contract? Slide 74 Pools Good accessibility: external and internal Adequate changing facilities to accommodate children of all sizes and levels of mobility. Good, consistent water quality: Chlorine (1-3) ppm; ph ( ); alkalinity ( ppm); calcium hardness ( ppm) Water Temperature degrees; Air temp 80+ degrees+ Slide 75

26 Slide 76 Targeted Body Action Position/ Activity Techniques Contact Points: Initial (I) and Progression (P) Associated Land-based activity Head Control: frontal plane Head Control: Sagital plane Head Control global Supine position; I: occiput/lumbar Pull to sit on wedge, ball, or floor; a/p toes up/toes movements in sitting; Head down on down; P: thoracic; lumbar; no decline, ball, peanut bolster. contact Prone position: I: facing patient with Prone carry, Prone prop on flat surface floatation and chin touching with/without upper chest support; water, progress same w/out prone on ball/peanut/bolster; prone floatation with linear movement. P: sternum at varied depths, upper trunk, mid trunk beside patient. Front facing carry I: Upper chest/axillae Side to side movement on bolster or w/ sidestepping, P: upper chest bilateral; ball; rocker board; lateral reach outside Side lying; Lateral lateral chest on bottom side BOS. sway, tick-tock combined with proximal ASIS on top side. Rolling, tick tock Chest wall top side and Upright with movement (passive and lumbar or unilateral PSIS active) Slide 77 Techniques Targeted Position/Activity Contact Points: Initial (I) and Associated Land-Based Activity Body Progression (P) Action Chest Vertical, supine, side I: Generally, one hand at anterior Prone flying on ball, bolster, or Wall lying, prone. Passive chest wall, contralateral arm swing; supine or sit and reach Expansion or guided ai chi guides movement into horiz abd overhead (hyper flexion of accepting,wango, of shoulder. humerus) stand and reach P: CGA with active movement. behind body. Trunk Supine supported I: head to upper thoracic spine, Supine to sit trunk flexion on flexion trunk curls on increase lever arm to increase incline, progress to flat surface floatation mat, trunk intensity; with or without contact on hands curls holding noodle P: contact guard at lumbar to or allowing patient to use hands to or barbell, trunk sacral level, support at legs for help pull upward; passive forward curls with lower legs advanced participants. acceleration on scooter board or on pool deck or edge jettmobile. of pool. Standing unilat or bilateral hip and knee flexion with or without resistance. Trunk Prone position, I: Upper chest support facing Prone scooter board, prone flying i d b id i i i h f d h Slide 78 Targeted Body Action Position/Activity Techniques Contact Points: Initial (I) and Progression (P) Associated Land-Based Activity Trunk rotation Supine (rock the boat), I: supine/recumbent the patient s head stand or sit and rotate with rests on your shoulder to free up both barbell or small ball; hands for stabilizing and moving. supine or recumbent unilateral kick across P: increase distance moved, place and midline. hold strategies against turbulence or resistance created by therapist moving. Rolling, reaching across midline with upper or lower body, bilateral reach to end ranges right and left with lower body static, Russian twist. Lower extremity separation: frontal and sagital Dorsiflexion Plantar flexion Vertical, supine or prone. I: supine behind patient with bilat arms Walking, Cycling, kicking, Passive guided LE beneath axilla or one arm beneath axilla straddle sitting, unilateral separation, reciprocal, and other guides leg separation. standing with contralateral leg kicking, scissoring, walking, movements. P: sba to cga for stabilization. sidestepping, step ups. Vertical in standing: static I: Bilateral ASIS for standing and walking; Long sit forward drags with squat holds, heel rocks, P: use noodle, barbell or kick board to patient on scooter board or walk with flippers; supine stabilize body in supine and drag patient magic carpet, rocker board, drags with and without forward with toes/fins up. tricycling, walking decline flippers. Toe walking, forward jumping, hopping, supine push offs from wall, walking into Straddle sitting on peanut progressive depths. with legs dangling and rocking Vertical, supine, prone side to side, walking inclines (wedges, slides), pushing weighted sled etc forward.

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28 Slide 82 Slide 83 Slide 84

29 Slide 85 Resources Swimwear/Floatation Supports/Gear: Kiefer, Swim Outlet, Theraquatics Disposable Swim diapers: Little Swimmer, Pampers Splashers, Dollar General Swim Diapers. Reusuable diapers: Swimmates/Up360 for larger children and adults. Therapy Pools: SwimEx, Hydroworx, Endless Pools APTA Section on Aquatics: Aquatic Therapy and Research Institute (ATRIC): Aquatic Physical Therapy International: Aquaticnet.com American Red Cross: safety Centers for Disease Control: safety, chemical, printable posters CMS Manual System Publication transmittal 88, May 7, WOTA: Water Orientation Test: Slide 86 References American Red Cross Scientific Advisory Council Guidelines for Group Aquatic Outings. International Journal of Aquatic Research and Education, 8, American Red Cross Scientific Advisory Council Appropriate Water Temperatures in Which to Conduct American Red Cross Aquatic Instructional Programs. Review. Downloaded 08/01/2016. Becker B Aquatic Therapy: Scientific Foundations and Clinical Rehabilitation Applications. Physical Rehabilitation and Medicine, 1 (9), Becker B, Hildenbrand K, Whitcomb R, Sanders J Biophysiologic Effects of Warm Water Immersion. International Journal of Aquatic Research and Education, 3, Blum. N The Effectiveness of Aquatic Physiotherapy in Patients with Haemophilia: A Review of the Literature. Aqualines, 27(2): Booth S Aquatic Exercise Rehabilitation for the Paediatric Cerebral Palsied Client Group-Specifically Children Aged yrs, Presenting with Spastic Diplegia as Classified as GMFCS-E&R Level III (Palisano, Rosenbaum, Bartlett & Livingston, 2008). Aqualines,26(2): Bradford W What Bathers Put Into a Pool: A Critical Review of Body Fluids and A Body Fluid Analog. International Journal of Aquatic Research and Education, 8, Slide 87 References Chan RC, Chen CL, Lai CJ, et al. (2015). Pediatric Aquatic Therapy on Motor Function and Enjoyment in Children Diagnosed with Cerebral Palsy of Various Motor Severities. Journal of Child Neurology, 30(2): Cross D Examining the Evidence for Interventions with Children with Developmental Coordination Disorder. British Journal of Occupational Therapy, 75(12), Cross A, Rosenbaum P, Gorter J. (2013).Exploring the Aquatic Environment for Disabled Children: How We Can Conceptualize and Advance Interventions With the ICF? Critical Reviews in Physical and Rehabilitation Medicine, 25(1-2), Dimitrijević, L., Aleksandrović, M., Madić, D., Okičić, T., Radovanović, D., & Daly, D. (2012). The effect of aquatic intervention on the gross motor function and aquatic skills in children with cerebral palsy. Journal of human kinetics, 32, Fragala-Pinkham M, Haley S, O Neil (2011). Group swimming and aquatic exercise programme for children with autism spectrum disorders: a pilot study. Developmental Neurorehabilitation, 14(4), Fragala-Pinkham M, Smith H, Lombard K, et al Aquatic Aerobic Exercise for Children with Cerebral Palsy: A Pilot Intervention Study. Physiotherapy Theory and Practice,30(2): Getz M Hutzler Y, Vermeer A, et al The Effect of Aquatic and Land-Based Training on the Metabolic Cost of Walking and Motor Performance in Children with Cerebral Palsy: A Pilot Study. ISRN Rehabilitation, Vol 2012, 1-8.

30 Slide 88 References Getz M, Hutzler Y, Vermeer A The Relationship Between Aquatic independence and Gross Motor Function in Children with Neuro- Muscular Impairments. Adapted Physical Activity Quarterly, 23, Hildebrand K, Nordio S, Freson T, Becker B Development of an Aquatic Exercise Training Protocol for the Asthmatic Population. International Journal of Aquatic Research and Education, 4, Hillier S, McIntyre A, Plummer L Aquatic Physical Therapy for Children with Developmental Coordination Disorder: A Pilot Randomized Controlled Trial. Physical and Occupational Therapy in Pediatrics, May, 30(2): Marinho-Buzelli AR, Bonnyman AM, Verrier MC.(2015). The Effects of Aquatic Therapy on Mobility of Individuals with Neurological Diseases: A Systematic Review. Clinical Rehabilitation, Aug;29(8): Murphy N, Carbone P, and Council on Children with Disabilities Promoting the Participation of Children with Disabilities in Sports, Recreation, and Physical Activities. American Academy of Pediatrics, 121(5): Oliveira LC, Trócoli TO, Kanashiro MS, Braga D, Cyrillo FN. (2014). Electromyographic Analysis of Retus Femoris Activity During Seated to Standing Position and Walking in Water and on Dry Land in Healthy Children and Children with Cerebral Palsy. J Electromyogr Kinesiol. Dec:24(6): Slide 89 References Pharr J, Irwin C, Irwin R Parental Factors That Influence Swimming in Children and Adolescents. International Journal of Aquatic Research and Education, 8, Porter R, Blackwell S, Smith G, et al Metabolic Cost Comparison of Running on an Aquatic Treadmill with Water Jets and Land Treadmill with Incline. International Journal of Aquatic Research and Education, 8, Rice S, Council on Sports Medicine and Fitness Medical Factors Affecting Sports Participation. American Academy of Pediatrics, Vol 121(4):

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