I moved to Minnesota in the month of July. This was a grievous tactical error, for it was not until December that we exchanged gifts with our Secret Santas at work. By the time I unwrapped my Christmas gift (a Midwestern-themed calendar that reported fun facts, e.g. "the temperature at which flesh freezes"), all the roads back home were frozen shut.

I was here for the duration.

Since that time I have endeavored to discover what the native people do to keep limber in the winter months (read: Oct-April).

The first winter, I decided to put my hand to snowmobiling. My hand did fine. It was my ischium that had issues.

The next year, I re-enacted the more understated fishing scenes from "Grumpy Old Men". The ones where the ice makes horrid cracking sounds and Jack Lemmon and Walter Matthau drop to their knees whimpering "She's going to blow".

I sold Christmas trees sitting in a portapotty with casement windows (known in Wisconsin, for some hysterical reason, as a warming hut).

After 4 years in Minnesota and 6 in Wisconsin, I'm pleased to say I have finally found my winter calling. Warm water immersion.

Now some may not be willing to give immersion its due as a true winter sport. These people obviously live south of the Mason Dixon line and know not of what they speak.

Be logical. A pool junkie must wear a swim suit (at least, a pool junkie must wear a swim suit at the pools I attend). In my book, any activity that requires an article of clothing which includes a verb in its title is automatically granted status as a sport.

Plus, there is nothing like immersion in warm water for release of stress and promotion of relaxation. In many therapeutic pool settings, you can schedule a session with a therapist who will stretch and massage your muscles while you are supported by a plinth made exclusively of the property of buoyancy.

In other settings, you can bob in a "sea" of mineral water in a world of diminished sensory input. Both sound just about perfect to me.

Aquatic therapy versus spa therapy
It is important to understanding that water can be used both for passive immersion and active tasks or exercise. There are two main categories of aquatic passive modalities: spa therapy (known most commonly as "balneology") and hydrotherapy.

According to the National Library of Medicine, balneology refers to bathing in -- or even drinking -- mineral waters. Any passive immersion in hot or warm baths in natural mineral waters, spas, or "cures" could be labelled as spa therapy or balneology. [1]

In contrast, hydrotherapy refers to the external application of natural (not mineral) water, with an emphasis on water temperature and the motion of water. [2] In the U.S., the term hydrotherapy is typically used as a synonym of the term "whirlpool bath" and is used predominantly to describe wound care.

Americans tend to feel that the power of immersion is in the activity that occurs once immersed (e.g. gait training, therapeutic exercise, functional task simulation). In fact, the American Medical Association takes pains to describe aquatic therapy as an attempt by a therapist to improve function through the application of aquatic therapeutic exercises [3]

But, there is still a case to be made for the joys of inactivity, of lounging, of stillness. So, open your mind to a marriage of the Old World concept of spa therapy and the New World concept of aquatic therapy, and learn what wonders creative pool programming can offer your patients.

Aquatic specialty techniques (passive and active)
Ai Chi
The technique Ai Chi refers to a form of active aquatic therapy modeled after the principles of T'ai Chi and yogic breathing techniques. [4] Ai Chi is typically provided in a hands-off manner (the provider stands on the pool deck to allow visual imaging of complex patterns by the client). The client stands in chest-deep water and is verbally and visually instructed by the provider to perform a slow, rhythmic combination of therapeutic movements and deep breathing.

Aquatic Proprioceptive Neuromuscular Facilitation
A form of active aquatic therapy modeled after the principles and movement patterns of Proprioceptive Neuromuscular Facilitation (PNF). [5] Aquatic PNF can be provided in either a hands-on or hands-off manner by the provider. The client is verbally, visually and/or tactilely instructed in a series of functional, spiral and diagonal, mass movement patterns while standing, sitting, kneeling or lying in the water. The patterns may be performed actively, or with assistance or resistance provided by specialized aquatic equipment or the provider.

Aquatic Task-Type Training Approach
A set of guiding principles which help practitioners create functional therapeutic activities for patients to perform in water. [6] It is important to note that Aquatic Task-Type Training Approach (TTTA) is not a classic specialty-technique with specific movement patterns and components; rather it is a "school of thought" or a set of suggested parameters for optimizing treatment, especially treatment of the neurologically-compromised client. Aquatic TTTA may be provided in either a hands-on or hands-off manner by the provider. The client is positioned in a functional task position and is verbally, visually and/or tactilely instructed to simulate tasks which are currently poorly executed or unachievable on land. The tasks may be performed actively or with assistance or resistance provided by specialized aquatic equipment or the provider.

Bad Ragaz Ring Method
A form of active or passive aquatic therapy modeled after the principles and movement patterns of Knupfer exercises and Proprioceptive Neuromuscular Facilitation (PNF). Bad Ragaz is always performed in a hands-on manner by the provider. [7] The client is verbally, visually and/or tactilely instructed in a series of movement or relaxation patterns while positioned horizontally and supported by rings or floats in the water. The patterns may be performed passively (for flexibility and relaxation), actively or with assistance or resistance provided by a provider.

Fluid Moves® (Aquatic Feldenkrais)
A form of active or passive aquatic therapy modeled after the Feldenkrais Method®. Fluid Moves may be provided in either a hands-on or hands-off manner by the provider. [8] During active Fluid Moves, the student is guided in an exploratory process, following a sequence of movements based on the early developmental stages of the infant. The client stands in chest-deep water, typically with his back to the pool wall, and is verbally and visually instructed by the provider to perform a slow, rhythmic combination of therapeutic movements and deep breathing. The passive, hands-on component to Fluid Moves is modeled after the "Functional Integration" component of the Feldenkrais Method.

Halliwick Method
A form of adapted aquatics which can also be modified into active, aquatic therapy. [9] Halliwick is almost always performed in a hands-on manner by the provider and is typically done through the use of games within groups of client-provider pairs. The client is usually held or cradled in the water while the provider systematically and progressively destabilizes him in order to teach balance and postural control. The provider progresses the client through a series of activities which require more sophisticated rotational control in an attempt to teach the client to swim (for adapted aquatics clients) or in an attempt to teach control over movement (for aquatic therapy clients). The client is continuously required to react to, and eventually to predict, the demands of an unstable environment. The Halliwick Method combines the unique qualities of the water with rotational control patterns in an attempt to facilitate improvements in the body's neurologic, musculoskeletal, and psychosocial systems.

Watsu®
A form of passive aquatic therapy modeled after the principles of Zen Shiatsu. [10] Watsu is always performed in a hands-on manner by the provider. The client is usually held or cradled in warm water while the provider stabilizes or moves one segment of the body, resulting in a stretch of another segment due to the drag effect. The client remains completely passive while the provider combines the unique qualities of the water with rhythmic flow patterns which attempt to facilitate improvements in the body's neurologic, musculoskeletal, cardiorespiratory, metabolic and psychosocial systems.

Bringing it All Together: The Aquatic Relaxation Chamber
In Danville Illinois, Mick and Sue Nelson have married the luxury and indulgence of spa therapy with the functional benefits of aquatic therapy, and dubbed it the Aquatic Relaxation Chamber (ARC). [11]

The Aquatic Relaxation Chamber is a warm water specialty pool designed for use by a wide variety of populations. Kept at spa-like 95°degrees Fahrenheit year-round, this 10 x 15 ft pool offers easy entrance and access. But the ARC is not just a pool. The Chamber incorporates water flow control for soothing water massage, mood lighting, and aroma therapy.

One of the most relaxing features of the ARC is the sound and visualization control produced by an under- and above-water speaker system coupled with the ability to project life size full-motion video images on the surrounding walls.

Patients can soak or receive therapy while surrounded by the calm relaxing sounds of the ocean's surf, the soothing visual image of the beach at sunset, and while smelling the slight scent of Morning Rain Mist in the air. It's all brought together in the ARC.

Hmmm. I'll meet you in Danville next February...

References
1. National Library of Medicine. Metathesaurus Medical Subject Headings and Annotation Note.National Library of Medicine; Washington, D.C., USA; MeSH Number E2.780.108. Revised 1993.

2. National Library of Medicine. Metathesaurus Medical Subject Headings and Annotation Note.National Library of Medicine; Washington, D.C., USA; MeSH Number E2.780.450. Revised 1991.

3. American Medical Association. Current Procedural Terminology (CPT), 4th ed. American Medical Association; Chicago, IL; 1999: 415-416. CPT Information Services. Personal communication clarifying CPT definition of aquatic therapy.American Medical Association: Chicago, IL; April 8, 1999.

4. Kunno J (creator of Ai Chi), Sova R. Personal communication clarifying definition of Ai Chi. Aqua Dynamics Institute: Tsunashima, Kouhoku-ku, Yokohama, Japan; March 6, 1999.

5. Ogden D, Jamison L (authors of Aquatic Therapy Using PNF Patterns. San Antonio, TX: Therapy Skill Builders; 1994). Personal communication clarifying definition of Aquatic Proprioceptive Neuromuscular Facilitation. Thunderbird Samaritan Medical Center: Glendale, Arizona, USA; February 21, 1999.

6. Morris D (coined term "aquatic task-type training approach". Author of "Aquatic rehabilitation of the neurologically impaired client". In: Ruoti RW, Morris DM, Cole AJ (eds). Aquatic Rehabilitation for Health Professionals. Philadelphia, PA: Lippincott-Raven; 1997). Personal communication clarifying definition of Aquatic Task-Type Training Approach. University of Alabama at Birmingham, Division of Physical Therapy: Birmingham, Alabama, USA: October 20, 1999.

7. Garrett G. (Author of "Bad Ragaz Ring Method". In: Ruoti RW, Morris DM, Cole AJ (eds). Aquatic Rehabilitation for Health Professionals. Philadelphia, PA: Lippincott-Raven; 1997). Personal communication clarifying definition of the Bad Ragaz Ring Method. Newport News, VA; April 8, 1999.

8. Ashton D (creator of Fluid Moves). Personal communication clarifying definition of Fluid Moves. The Well Being: Knoxville, Tennessee; October 27, 1999.

9. Lambeck J (spokesman for the International Halliwick Association). Personal communication clarifying definition of the Halliwick Method. International Halliwick Association: Bad Ragaz, Switzerland; February 10, 1999.

10. Dull H (creator of Watsu). Personal communication clarifying definition of Watsu. Worldwide Aquatic Bodywork Association: Middletown, California, USA; April 3, 1999.

11. Mick and Sue Nelson. Personal communication about the Aquatic Relaxation Chamber.Poolside Health and Wellness Center: Danville, Illinois; October 20, 2003.

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