In the summer of 2000, I started my career as a physical therapist at Oxford Physical Therapy, Inc. located in the small town of Oxford, Ohio. I was excited to find my niche and explore the opportunities Oxford Physical Therapy provided. This small, three-therapist practice was growing and the clinic was on the verge of expansion.

During my exploration of Oxford, I discovered the Miami University Aquatic Center and took a certification course allowing me to teach pregnant moms how to safely exercise in the pool (Moms in Motion™). I was amazed at the benefits water had on this population – especially, with swelling reduction, joint and spine unloading, and pain reduction while exercising. I began to consider the advantages of using water as a tool to help both my patients and other populations in the Oxford community.

Lara Freidline, PT, MPT, instructs a patient to perform a posterior pelvic tilt against the wall facilitated by pushing down on a dumbbell.

The first time I mentioned treating patients in the pool to my supervisor, Peter Zulia, he gave me a familiar smile, yet questioned the need for a pool given our clinic’s success in outpatient orthopedics. Over time, the idea grew on him and we started developing our aquatic physical therapy program. I immersed myself in various aquatic courses with authorities in aquatic physical therapy – including Lori Thein-Brody, PT, PhD, SCS, ATC – completed my Arthritis Foundation Certification, became a certified pool operator (CPO), and reviewed many aquatic exercise resources. Our next challenge was to define the role aquatic physical therapy would play in our company.

The terms “aquatic therapy,” “aquatic physical therapy,” “water fitness,” and “water exercise” overlapped in the literature. What made aquatic physical therapy unique among these terms and reimbursable by insurance was that water exercises and rehabilitation were done with a physical therapist (PT) or a physical therapist assistant (PTA). That distinction was clear, but whether the therapist had to be in the water with the patient or just on the pool deck directing care was not as clear.

As a former water fitness instructor, being out of the water felt more like I was teaching another water fitness class and not giving my patients the manual hands-on treatment they needed and deserved. Being in the water with my patients was how I wanted to practice aquatic physical therapy. Now we just had to find a pool.

Our first pool site in Oxford came through a relationship with the Miami University Aquatic Center. We rented pool time four hours/week split between two different days. The facility was impressive and encouraged both creative and diverse treatment plans and satisfied patients. However, with the outstanding facilities came high cost, difficult access, and a lack of schedule flexibility. As our practice grew and expanded to suburban Cincinnati, we looked for other locations to house our aquatic physical therapy program.

In our second clinic in Fairfield, Ohio, we installed our own private Endless™ current pool. My CPO course laid the foundation for getting this pool up and running, demanding many hours of testing the water and learning the quirks of maintaining a pool. Though there was increased cost and labor associated with operating our own aquatic facility, principal benefits included complete control of the pool schedule, temperature, and accessibility. As certain patient populations respond well to warm water, we are able to provide this unique medium of warmth and relaxation in our Endless pool to facilitate better mobility and less pain. This has been a successful niche practice for many arthritis and back patients.

Our next aquatic physical therapy pool site came with a contract to lease space inside a local gym with an on-site lap pool. This arrangement eliminated the clinic-to-pool drive time and maintenance responsibilities, but has also limited temperature and scheduling control. In a lap pool, the water is typically cooler which increases the exercise speed and intensity needed for patients to keep warm. Specific patient populations tend to experience more effective therapy in a cooler pool, including patients with multiple sclerosis, pregnant women, and patients with significant swelling or those who need more intense workouts.

In several of our clinics without on-site pools, we have been successful in utilizing local hotel pools for our aquatic physical therapy programs. Getting to know the hotel manager and pool operator is essential for developing these relationships, and these arrangements have worked well in terms of accessibility and schedule flexibility. Diminishing levels of reimbursement for services require greater efficiency in managing treatment expenses. The lower cost of hotel pool rental has aided our efforts toward cost effectiveness.
   
Why Aquatic Physical Therapy?

Regardless of location, from on-site private clinic pools to off-site hotel pools, water is water and your patients can still benefit from Archimedes’ principle of buoyancy, hydrostatic pressure, turbulence, drag, bow, and surface tension. Unless you are on the moon, these properties and benefits are not possible on land.
   
When we started our program, we did not know how aquatic physical therapy would impact Oxford Physical Therapy Centers. Now after 10 years, we have gained a reputation in aquatic physical therapy. Not only do our patients benefit, but our services has also benefited. We offer more than just physical therapy; aquatic physical therapy programs give additional opportunities for many patients struggling with exclusively land-based therapy. The pool is a powerfully uplifting exercise option.

Using a noodle for suspended bicycling to unload the spine and legs while progressing cardiovascular conditioning.

I always say, “Exercising in the pool is like giving your joints the day off, but still working your muscles.” Once patients can see and feel the effects of water unloading, it becomes self-motivating. Once doctors can see and hear about the effects of water unloading, they become a great referral source. However, because we do not live in the water, a balance of land and water therapy sessions has provided our patients with the best outcomes. Through our aquatic journey so far, we have brought five of our nine centers aquatic physical therapy.

Is aquatic physical therapy worth it?

I asked several of my patients this question; here are some of their responses:

“The pool is definitely better for stretching – it just loosens up the muscles.”
– (22-year-old patient with a recent ACL reconstruction)

“I wouldn’t be able to do anything without the water exercise. I get in the pool as often as I can – it is my solace.”
– (73-year-old patient with weight and shoulder problems)

“I have a lot less apprehension in the pool since the water will catch me if I fall. So, I can push myself more in the water than on land.”

– (20-year-old patient with second revision of an ACL reconstruction)

“I hate to say this but, working out in the pool does make me look more handsome.”
– (70-year-old patient with bilateral total hip replacements)

Resources

Research continues to grow in aquatic therapy. However, obtaining it, reading it, and applying it is difficult. As our aquatic physical therapy program grew, we established an aquatic committee with representatives from each pool site to meet every other month. During these meetings, each clinic gives a pool report including insights into referrals, challenges, and successes. To keep up on the literature, we review a current aquatic article at each meeting. We often rely on The Journal of Aquatic Physical Therapy published by the APTA Aquatic Physical Therapy Section. The Journal of APTA contains articles applicable to daily practice and helpful case studies. Many more sites provide quality information once you start looking.

It only takes one interested therapist to get an aquatic physical therapy program started and the benefits can last for years for your clinic and your patients. Could your patients benefit from the water? How could you join the aquatic journey? What pool options do you have in your community? What will you do?

— Lara L. Freidline, PT, MPT, founded the aquatic physical therapy program at Oxford Physical Therapy Centers in 1999 in Oxford, Ohio – Oxford Physical Therapy Centers now has nine centers located in Cincinnati and Northern Kentucky. Further questions and comments can be directed to editorial@therapytimes.com.