One of the greatest concerns many people have about living outside of their own home is the loss of independence. Too often, post-acute care facilities are so fearful for the safety of their residents that they don't allow any element of risk into life, resulting in an unfortunate "Catch-22." Sadly, all that results is a slowly narrowing funnel of independence that one day ends in fear.
The Wellness Concept
Charlotte Donaho, COTA, wants to change that. Donaho is the wellness coordinator at Epworth Villa Life Care Facility in Oklahoma City, Okla. She wields a secret weapon in her toolbox: a custom-designed therapy pool. Epworth Villa installed it about 11 years ago and it's proven to be one of their greatest assets.
"The best thing about having a pool right here is the independence it gives people," reports Donaho."
"Our (PT/OT) rehab staff use the pool for one-on-one therapy. But a lot of people would fall between the cracks without a wellness program. Many people are just 'too functional' for skilled therapy, and others are 'too plateaued' to continue in therapy. We think those people still need our attention and the pool is a great place to give it."
Epworth Villa is a five-level living community, which includes 240 independent living apartments and 8 to12 independent living duplexes, an assisted living floor, a nursing care floor (non-skilled) and a 48-bed Alzheimer's unit.
Epworth's 30,000-gallon rectangular pool has two sets of stairs with rails on either end of the pool. It is 3 feet deep at each end and 4 feet deep in the middle. The water temperature is kept at 86 degrees, except on arthritis exercise class days, when the temperature is raised to 89 degrees. The room air is kept at around 89-90 degrees in the winter, and in the summer, the roof is retracted and the pool essentially becomes an outdoor swimming pool.
The only problem is that there is no lift for adapted entry, something on Donaho's short wish list. There are chairs around the pool deck and two benches located at the bottom of the entry steps, to allow people to rest immediately after entering the water.
"I call them my 'therapy couches'," jokes Donaho. "People who can't tolerate standing exercise can get a jump-start by doing their exercises sitting down. For some people, it's a way to ease into water work. They feel safer, more grounded on the bench."
So who can use the pool?
"Our independent living residents have a key and have access 24 hours a day, seven days a week," Donaho reports. Otherwise, the pool is kept locked and is only accessible with staff. The rehab therapists use the pool as a modality for their one-on-one sessions with patients from assisted living or the nursing floor.
Donaho uses the pool primarily for wellness and arthritis classes. She even conducts a "men's only" water exercise class that includes three men from the Alzheimer's floor.
"The men would never come to the women's class -- we had to make it a guy thing," laughs Donaho.
The facility tries to maintain a 1:2 ratio of staff to volunteers for the assisted living classes.
"There's only so much bingo a resident can play, so we rotate water exercise classes into the schedule and the activities staff are nice enough to get into the water with the residents."
Group classes for independent living residents run 12 to15 people with one instructor. All in all, the pool has become quite a jewel in Epworth Villa's crown.
The Skilled Nursing Care Concept
If your resident population predominantly requires skilled nursing care, there are other factors to consider when putting in a therapy pool.
Gina Cutler, OTR/L, is a staff occupational therapist at Maplewood Nursing Home in Westmoreland, N.H., a 150-bed skilled nursing facility that also has an intermediate care and assisted living option.
Maplewood has a prefabricated pool available for use by their OT and PT staff. The pool is 6 feet by 12 feet and has depth options of 4 or 5 feet. The water temperature is maintained at 94 degrees, predominately for its beneficial effect on pain patients.
"There's a lot of arthritis pain in the geriatric population. The pool is a great medium for pain management," reports Cutler. "But in order for this to be effective, you have to consider the fear factor."
Cutler says that sometimes it is difficult to get residents to agree to try pool therapy. "There are a lot of people we would love to take into the water. Sometimes gravitational insecurity makes that impossible."
Cutler reports that they use a lift to take residents from the pool edge into the water. On occasion, the entire first two treatments are performed with the resident still sitting in the lift sling in the water.
"It all depends on the person's past history -did they grow up around water? If they did, the water is a wonderful thing. They are free from the pains of daily life while in the pool."
Cutler also suggests that facilities that are thinking of putting in a pool consider who will do all the prep work and pool maintenance.
"You don't want to have a situation where a half hour patient treatment takes two hours of your therapist's time."
Maplewood Nursing Home tries to offer its residents many extras. One of them comes in a 6 by 12 foot box and makes you feel good all over.
Resources
Charlotte Donaho can be reached at (405) 752-1200, ext. 252 or irelandgrl53@yahoo.com. Gina Cutler can be reached at (603) 399-4912 or rehab@co.cheshire.nh.us.
Sidebar
Want to Put a Pool in Your Facility? Here's a Checklist to Consider Before You Dive In
1. Type of Pool
Do you intend to have the pool custom-designed? If so, consult with an aquatic design specialist prior to hiring an architect. Do you intend to purchase a prefabricated pool? Request material from prefabricated pool manufacturers (use the search term "prefabricated therapy pool" in an online search).
2. Shape [1]
What will the basic shape of the pool be: rectangular, square, oval, circular or asymmetrical? Most common shapes such as the rectangle or square allow ample room for "lanes" for walking, jogging and (less likely for this population) swimming. Keep in mind that a circular or odd (kidney shaped, for example) design is nearly impossible to use with more than one patient/one therapist in the pool at a time. If you plan to purchase a prefabricated pool, this decision is largely out of your hands, as almost all prefabricated pools are rectangular in shape. · Will the intended shape impair user safety? Will it make it impossible to see or access a patient while working with another? · Will the intended shape allow complete, continuous circulation of pool water throughout all parts of the pool?
3. Dimensions [2]
Will you include areas for leisure activities such as sitting in front of water massage jets? If your population is able to sit unsupported on a bench (under your in-pool supervision), this may be an excellent addition to your pool. · Will you include lap lanes for unloaded water jogging? · Will you provide enough room for the anticipated occupancy, including room for future growth, given legal occupancy standards? Typically, one person is permitted for each 15 square foot of pool water surface in all areas of the pool 5 feet or less in water depth; one person is permitted for each 25 square feet of pool water surface in areas of the pool over 5 feet in water depth. For more specific details, see your State Code from Department of Health for occupancy rules.
4. Entry methods [1, 2, 3]
Will the pool have a zero-depth entry? This is very helpful if you wish to place a disabled person in a "pool wheelchair" (a standard stainless steel wheelchair that is used only for this purpose) on the platform and then immerse the chair with a movable pool floor. Negative to this: everyone in the pool goes "up and down" together, whether they want to get out of the pool or not. ·Will the pool have steps? Typically, either steps or ladders must be provided at the shallow end of the pool if the vertical distance from the bottom of the pool to the deck or walk is over 2 feet. Recessed steps or ladders must be provided at the deep end of the pool (even if your population would never use a ladder). If the pool is over 30 feet wide, steps or ladders must be installed on each side. If stepholes or ladders are provided in the pool, handrails must be provided that extend over the coping or edge of the deck. If the pool has steps, they should: be of a nonslip material; have a minimum tread of 12 inches; have a maximum rise or height of 10 inches; have on their leading tread an accent stripe of a dark, contrasting color between ½ to 2 inches in width; not have an abrupt drop-off or submerged projections into the pool, unless guarded by handrails; have at least 1 sturdy handrail, reachable from the pool bottom; have at least two rails if the steps are over 6 feet wide or if an additional railing is needed to define the location of the steps. · Will the pool have a ramp? This is essential if clients are to independently enter/exit pool via pool wheelchairs. · If a ramp is not present, will the pool have a self-operating hydraulic lift or deck-level overflow troughs to help clients enter and exit the pool? ·Will the width of each entry method accommodate large clients and oversized pool wheelchairs? ·Will the internal pool walls have handholds? All pools must have a continuous handhold along the pool edge.
5. Water temperature
Do you intend for the pool to neither heat nor chill the client while they are at rest (a temperature commonly known as thermoneutral, or approximately 93-94 degrees Fahrenheit) or will this be too warm for the intended clientele? This becomes an issue with high intensity aerobic exercise. · Do you intend the pool to be thermoneutral for the client while they are exercising? This temperature will depend on the intensity level of the client's exercise, but it is usually between 87-90 degrees Fahrenheit for vertical exercise. If you intend to perform passive relaxation techniques, such as Watsu, be aware that water temperatures below 93-94 degrees Fahrenheit will contribute to a chilling of the client during this passive work. · Resist the urge to try to bridge the gap between swimming pool temperatures (78-82 degrees Fahrenheit) and therapy pool temperatures (90-94 degrees Fahrenheit). You will only end up with everyone unhappy. · Will your system prevent the water temperature from rising above a set maximum? The absolute maximum for spas is 104 degrees, and the absolute maximum for pools used for exercise should not be much greater than thermoneutral.
6. Water depth [2, 3]
Will you have a zero-depth entry via a ramp? This is preferable, but if space constrains you, look at using a lift or purchasing a movable pool floor system. ·Will you offer a deep-water well? You will want at least a 6-foot well for water jogging. · Will you provide ample square footage at critical "working" depths? Most people prefer to walk and perform exercises between chest and neck-depth immersion. For most older adults, this translates to the 3 to 4 foot depth as the critical depth. By maximizing square footage at these depths, patrons will have more room in their preferred depths. · Will you provide ample square footage for water jogging/ lap swim lanes? It's preferable to provide at least two lap lane widths to permit passing. · Will you provide a gradually slanting bottom (no greater than 1 in 10 inches and preferably no greater than 1 in 12 inches) or will it transition between depths with steps? Step-offs must be marked visibly with colored line and depth markings. Rarely are step-offs in a therapy pool desirable unless available space prevents adequate sloping to a necessary depth.
7. Pool bottom and sides [2]
Will the pool have a tile bottom? One-inch non-slip tiles are preferred. · Will the chosen flooring be easy to clean? · Will the chosen flooring have the proper friction coefficient to prevent slip and falls? · Will the pool basin finish, including bottom and sides, have: a white or light-colored finish? nontoxic finish? smooth-finished surface? or crack-free finish?
8. Equipment in pool [1]
Will the pool have parallel bars? This is desirable with a gait-impaired population, however, only if pool is large enough to allow both parallel bars and adequate pool space at desirable walking/ exercising depths. · Will the pool have aerobic equipment? Some recently developed aquatic equipment includes cross-country ski machines, bicycles and treadmills. You must balance the benefit of such a device against the lost space. · Will the pool have workout stations? · Will the pool have benches or seats? This is desirable to provide clients a place to rest in the water and to allow relaxation next to water massage jets. · Will the pool have water jets for massage? This is desirable as it adds tremendous relaxation value to any pool. · Will the pool offer sufficient wall space for leaning against the wall and walking in critical depths when all equipment is in the pool?
9. Intended uses of pool [1]
Will the pool host group classes? Then the pool should have a depth of 3 to 4 feet unless deep-water work is included which will require 6 feet and water temperatures of 85 to 90 degrees Fahrenheit. · Will the pool offer one-on-one therapy? If so, the pool should have a depth range of 0 to 6 feet (although it is possible to work in the "critical depth range" of 3 to 4.5 feet) and water temperature of 90 to 94 degrees Fahrenheit. · Will the pool offer relaxation and leisure activities? Then the pool should have a water temperature between 90 and 94 degrees Fahrenheit. · Will the pool offer any of the above simultaneously? For example, if one-on-one clients will be seen at the same time as group classes, there needs to be adequate room at all depths used by both parties.
References
1. Clayton RD, Thomas DG. Professional Aquatic Management, 2nd ed. Human Kinetics: Champaign, IL; 1989.
2. Department of Health. Public Swimming Pool Rules. Print Communications Division of Minnesota Department of Health: St. Paul, MN; 1995.
3. Poteat Salzman A. Teacher' s Manual to Advanced Aquatic Therapy. Concepts in Physical Therapy Press: Oak Ridge, TN; 1998.
Disclaimer
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 asalzman@aquaticnet.com
