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Hot Trends in Warm Water
Aquatic Therapy for the Pediatric Patient


December is the time even we Wisconsinites give in and put on our bathing suits. The winter-induced blubber makes even the bravest among us quiver.

But for those of us who are fortunate enough to work in the water year-round, we don those suits with pride.

Why? We are aquatic therapy providers. We have the ability to offer our patient air and water, an integration of effort and ease. We see the possibilities inherent in gravity, but we delight in the possibilities intrinsic to buoyancy, viscosity, turbulence and pressure. Our universe expands, and our patient's universe expands in tandem.

Most of us treat a bit of everything under the sun. We treat patients by applying a unique body of knowledge and clinical skills that make us competent and capable of capitalizing on the effects of water.

However, the realm of pediatrics is perhaps more esoteric than most, and often requires the attention of a skilled pediatric therapist.

"Children are not little adults," remarked Dori Maxon, PT, PCS, MEd. And they cannot be treated as such.

Having just come from the womb, babies seem the perfect candidates for aquatic intervention. Gravity rules the earth, and infants with neuromuscular and orthopedic dysfunction often find this cruelly apparent. Water offers these children a reprieve. Warm water offers a soothing reprieve.

As a child grows, the mass of the body doubles, then again, and so on. Gravity converts mass into "weight," and weight makes things like walking, running and jumping difficult.

The following article offers an overview of how some clinicians are overcoming these limitations by offering children a world of possibilities -- as close as the neighborhood therapy pool.

Neonatal Aquatic Intervention
Helen gave birth to a 2 lb. 13 oz. boy. It was too early for Robert to be in the world, and it was evident by just looking at him. Since Robert had not grown fat in the womb (and subsequently cramped in the womb), he wasn't forced into the traditional fetal position. He laid in the incubator splayed out in an abnormal extension posture.

It was difficult to position him into a simulation of the in utero environment without affecting his lines and monitors; he looked fragile and intimidating to his parents. Subsequently, Robert was at risk for not being touched. What should be done to help him?

In 1983, Sweeney published a fascinating paper on a pilot study whose purpose was to examine the use of immersion alone versus immersion plus exercise (hydrotherapy) with premature infants.1

She wanted to know two things:

1) if either immersion or hydrotherapy would change the arousal state of the infants; and

2) if either would be dangerous for this population. The infant's exercise regime was based on neurodevelopmental technique principles of gentle graded spinal flexion and rotatory shoulder and pelvic movements.

The infants' responses were different with immersion only compared with hydrotherapy (what we would now describe as aquatic therapy). Blood pressure and heart rate went up in both conditions, but less dramatically during hydrotherapy than immersion alone. The "drowsy" state of arousal was maintained with immersion, whereas a "quiet alert" state was elicited after the infant was exercised in water.

Early Intervention Adapted Aquatics
Travis was born in Texas. He could not move. The doctors advised his mom not to pick him up or nurse him as he was to die within the week, and it would be uncomfortable if mother had formed an attachment. Mom was a former Marine Corps Sergeant. She had her own ideas about Travis and made the hospital care for him. As the state wished to institutionalize him, she eventually had to fight to keep her own son.

By two months, Travis had been diagnosed with Spinal Muscular Atrophy, a form of muscular dystrophy. He was given another two years to live. Four months later, at the request of his physical therapist, Travis entered the Paso Robles (CA) Early Intervention Adapted Aquatics Program (E.I.A.A.) under the direction of Dick Smith.

By two years old, Travis could walk in shoulder deep water and scoot about on his buttocks on land.

By age four, Travis competed in his first Special Olympic Area Swim Meet by swimming both freestyle and backstroke.

At age five, he took his first steps on land, using lower leg braces.

By six, he was walking all over the place. Today, he is self-caring.

Take Smith's advice about Travis. "If you get the chance, don't play cards with him. He's good."

If Travis had been institutionalized, the costs would have been phenomenal. First, Travis would have been a dependent, not independent, person. That cost is immeasurable. Second, the state of Texas would have foot the bill for the care of Travis. At an estimated $80,000 per year, Texas would be out about $960,000 for the 12 years of care (so far) for Travis; this cost would obviously escalate for each additional year of care.2

So what made the difference in Travis' story? Dick Smith believes it was early intervention adapted aquatics and a committed family. Smith is an Adapted Aquatics Faculty instructor and a member of the Aquatic Council of the American Alliance for Health, Physical Education, Recreation and Dance (AAHPERD). Although Smith is not a therapist, his years of working with children in the pool have given him an experience base from which PTs and OTs may learn.

Smith currently runs his early intervention program with five to eight month old children with either cerebral palsy or muscular dystrophy. The children are referred from a physician, and Smith seeks the input of the child's physical or occupational therapist.

His goals are to improve muscular strength, reduce atrophy, gain use and control of limbs, and maintain activity for as long as possible. His work integrates play with stimuli. Approximately 90% of children have in-water parent participation.

Neither his goals nor games would raise an eyebrow in the therapy world. They are common. The catch? Smith adds water. And it makes a difference.

"The past twenty-four years of teaching special populations has supported my original beliefs on how important warm water and a controlled environment can be," stated Smith. "I've observed results that far exceeded my expectations."

In order to assess if these observations are valid, programs like Paso Robles need to be subjected to scientific perusal. Smith would like to obtain funding to conduct a two-year pilot study on E.I.A.A.

In such a study, physical therapists would perform evaluation and reassessment of the subjects to document change. The results from this study could alert health care providers to the benefits of aquatic intervention early in a child's development. This information could then be disseminated to the public at large.

Smith agreed. "The best legacy that I can hope to leave is to have been instrumental in helping hundreds of special children to lead happier, healthier and (more) productive lives."

Watsu® and Other Touch-Oriented Treatment
The Special Needs Aquatic Program (Richmond, CA) is one of many pediatric programs that take manual therapy techniques into the water.

"I love working with children in the pool," remarked owner, Dori Maxon. "The water is inviting and accepting. I feel that the bond between the child and therapist is stronger as the child has to trust for his safety."

Maxon's day at the pool begins at 4:30 p.m. with a team meeting consisting of staff and volunteers who work together within the program. By 4:45, an aquatic class begins that focuses on the physical disabilities and social skills of teenagers.

Between 5:30 and 7:00, the pool is used for classes for three - to seven-year- olds with neuromuscular or developmental disabilities. Maxon also spends time teaching others (including parents) what to do with the children; she sees it as a force multiplier."More teachers mean more children can be served."

Of special interest, Maxon believes the aquatic environment not only promotes healthy touch for the patient, but for the therapist as well.

"My touch and handling skills are better in the water," reported Maxon. "I can feel and see the results of my handling and the child's efforts. It is intellectually stimulating for me to problem-solve in a 3D, ever-changing medium."

Maxon integrates 1:1 techniques like water shiatsu (Watsu) with her pediatric clientele, but she also encourages 1:1 therapy in a small group setting to encourage socialization and imitation. She feels passive techniques like Watsu play an important role in the spectrum of treatment, but should only be one component of any program.

Lori McCoy, PT, of Capernaum Pediatric Physical Therapy, Inc. (Minnetonka, MN), performs approximately six 1:1 aquatic treatments with pediatric patients daily, while regularly incorporating education of PT students and parents of patients into these sessions.

She agrees that water provides a sensory environment that is unlike any that therapists may obtain on land.

"The child is surrounded by increased sensory input," stated McCoy. "Resistance and buoyancy allow increased reaction time, and can be used to facilitate appropriate or desired movement reactions without having to use specific touch of handling points."

"This allows more natural or normal input into the child's sensory system. Every touch elicits a reaction of some sort. Less facilitation (by the therapist) more closely approximates the eventual motor pattern the child will use," said McCoy.

Aquatic Integration of Age, Disability and Providers
At the State University of New York (SUNY) at Stony Brook, an MD and a PhD join hands to bring children together in the pool. Charles Stewart, MD, and Peter Angelo, PhD, offer a one time a week aquatic session at the university pool.

While the session meets for two and a half hours, one hour is devoted to discussions, lectures and demonstrations for those involved in the adapted aquatics training program.

"We have not so far separated persons with different types of disabilities of different ages. All are in the water at the same time," reported Stewart.

"While it is perhaps somewhat more manpower-intensive this way, the interaction between children (and adults) with different abilities (and, of course, disabilities) is a powerful incentive for the vast majority of our young clients to return on an ongoing basis."

Like Dick Smith, Stewart believes the future of aquatics for children lies in the ability of professionals to work together. "Hopefully, a hot trend for the future is the ongoing interaction between the aquatic educational experts and the health care professions," said Stewart.

"It is essential that each professional respect the strengths of the other, thus working together for the good of the child." Sounds about right to me.

1. Sweeney, J.K. (1983). Neonatal hydrotherapy: an adjunct to developmental intervention in an intensive care nursery setting. Physical and Occupational Therapy in Pediatrics. 3(1), 39-52.

2. Financial estimates provided courtesy of Dick Smith, Paso Robles Adapted Aquatics Program, PO Box 1485, Paso Robles, CA, 93447.

The information presented in this article is meant to be a summary and educational in nature. It is not meant to serve as a substitute for legal advice.

Author Bio
Andrea Poteat Salzman, MS, PT is the owner of two businesses, the Aquatic Resources Network and Concepts in Physical Therapy. She has received both the prestiguous Aquatic Therapy Professional of the Year Award (Aquatic Therapy and Rehabilitation Institute) and the Tsunami Aquatic Therapy Award.

Salzman is well-regarded within the industry as:

  • Editor-in-Chief of an aquatic therapy trade journal and newsletter;
  • Author of over a dozen publications, including the soon-to-be-released Evidence-Based Aquatic Therapy textbook;
  • Freelance author and columnist;
  • Aquatic therapy seminar instructor;
  • Adjunct faculty and research advisor, St. Catherine Physical Therapy Program, Minneapolis, MN;
  • Immediate past manager of therapeutic aquatics, St. Paul Ramsey Medical Center, St. Paul, MN;
  • Researcher and grant recipient examining aquatic exercise vs. land-based exercise.

She may be reached via e-mail at


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