Abstract
Context/Objective: Aquatic therapy (AT) has been used to enhance balance and mobility in people with disabilities; however, AT is reported to be underused among people with spinal cord injury or disorder (SCI/D). We aimed to understand the perceptions of AT use by physical therapists (PT), PT assistants (PTA) and kinesiologists (KIN) across Canada for clients with SCI/D.
Design/Methods: Individual semi-structured interviews were completed with PT, PTA and KIN (phone or in-person). PT, PTA and KIN who had used AT with at least one client with SCI/D in the past year were eligible. Interview questions queried each participant’s AT setting, AT approaches, and perceived facilitators and barriers to AT implementation for clients with SCI/D. Interviews were audio recorded and transcribed verbatim. Thematic analysis was used to identify themes and subthemes.
Results: Six PT (2 male, 4 female), three PTA (female) and 1 KIN (female) participated. The following four themes were identified: (1) multi-system benefits from AT (e.g. from impairment to function, confidence and enjoyment); (2) application of AT (e.g. based on principles of the water); (3) perceived barriers to implementing AT (e.g. pool accessibility, client comorbidities); and (4) water as an enabler to function on land.
Conclusions: The participants reported AT was a unique and versatile approach that benefits the multi-dimensional aspects of the health of individuals with SCI/D. They successfully integrated AT into their clinical practice despite the barriers faced by professionals and clients.
Keywords: Aquatic therapy, Spinal cord injury, Thematic analysis
Introduction
Aquatic therapy (AT) is an intervention with the potential to address the rehabilitative needs of individuals with a spinal cord injury or disorder (SCI/D).1,2 The physical properties of the water, such as hydrostatic pressure, buoyancy, thermal conductivity and drag force, enable exercises that facilitate and gradually challenge movement that would be difficult for a patient to perform on land.2,3
AT can be used safely by individuals with SCI/D taking into consideration the individual’s skin and bowel care, cardiorespiratory status and pool accessibility.4 While there are few randomized controlled trials of AT for SCI/D,5,6 there is evidence to suggest that AT can improve spasticity,7 cardiorespiratory function,8 balance and walking functions,9 and functional independence10 in individuals with SCI/D.
Despite the feasibility and potential benefits of AT, most of the aquatic interventions used post-SCI/D have focused on aquatic treadmill training9 and swimming.8,10 Yet the aquatic environment allows for a range of therapeutic interventions (e.g. balance and gait training, range of motion, sensory stimulation).2,11 Furthermore, AT has been reported to be underutilized among individuals with SCI/D mainly due to the presence of comorbidities.12 The underutilization of AT among individuals with SCI/D likely results from a multitude of factors, not only the presence of comorbidities. For example, limited access to therapy pools and trained professionals, limited time for AT in rehabilitation centers, and a lack of knowledge of the benefits of AT may be potential barriers to AT utilization post-SCI/D.
Therefore, this study aims to explore the perceived use, benefits and barriers of the application of AT in the SCI/D population from the perspectives of common administrators of AT – physiotherapists (PT), physiotherapy assistants (PTA) and kinesiologists (KIN) – to direct future research in this area.
Methods
Design and participants
A qualitative research design using inductive thematic analysis, as described by Braun and Clarke in 2006,13 was used. Perspectives were sought from participants who were PT, PTA and KIN who had used AT with clients with SCI/D within the year prior to the interview. All participants were assigned pseudonyms. Participants were recruited from the Canadian Aquatic Rehab Instructors, the Canadian SCI Standing and Walking Measures Group and through the Ontario Kinesiology Association over a period of six months.
Data collection
After approval was obtained from the Research Ethics Board of the University Health Network, eleven practicing health professionals from across Canada consented to participate in the semi-structured interviews, from November 2018 to March 2019. The interviews, which were conducted jointly by two research team members (AMB, AZ), occurred either in person or over the phone and followed a semi-structured interview guide consisting of open-ended questions about past experience and perceptions of AT use with individuals with SCI/D (Supplemental online material). Due to the exploratory nature of the study, we did not restrict the discussion to a particular group of individuals with SCI/D or type of AT intervention. Interviews were audio recorded and transcribed. Participants were given the option to review copies of the transcripts and make changes, additions or deletions as desired (i.e. member-checking).
Data analysis
Two members of the research team (AMB, AZ) independently familiarized themselves with the data by reading and re-reading the transcripts for persistent observation and engagement with the research dataset. Then, they generated initial codes independently. In order to help ascertain a deeper understanding of the respondent’s opinion, two levels of analysis were performed: the first level involved reviewing at the level of the coded data extracts and the second level looked for themes in relation to the entire data set.13 After analyses at both the first and second levels were completed, the two research team members met in person to review the themes identified in the entire dataset and generate new themes. An in-person peer debriefing session with a third researcher (KEM) followed to further enhance the credibility of analysis. Themes were finalized with KEM who had also read the transcripts. The content from the entire dataset was transferred to Nvivo 12 (QSR International Pty Ltd., Burlington, MA) for coding, organization of the coded data and analysis. Finally, data extracts that appropriately and accurately represented each theme were selected from the dataset.
Results
One of the 11 participants who provided informed consent did not complete the interview. Hence, 10 professionals (eight female) participated: six PT, three PTA and one KIN. Participants’ profession and work setting are displayed in Table 1. The participants’ time of practice in their current work setting varied from five months to 20 years. Six participants worked in Ontario, three worked in British Columbia and one worked in Saskatchewan.
Table 1. Participants’ sex, profession and work setting.
| Participants | Sex | Profession | Work setting |
|---|---|---|---|
| Frank | M | PT | Rehabilitation hospital |
| Lisa | F | PT | Acute care children's hospital |
| Susy | F | PTA | Private aquatic therapist |
| Rob | M | PT | Private clinic |
| Ann | F | PTA | Rehabilitation hospital |
| Mei | F | PT | Rehabilitation hospital |
| Cathy | F | PT | Rehabilitation hospital |
| Betty | F | KIN | Private clinic |
| Alex | F | PTA | Neurorehabilitation outpatient center |
| Cindy | F | PT | Rehabilitation hospital |
PT: physiotherapist. PTA: physiotherapy assistant. KIN: kinesiologist. M: male. F: female.
Four main themes were identified from inductive analysis of the dataset: (1) multi-systems benefits from AT; (2) application of AT; (3) perceived barriers to implementing AT; and (4) water as an enabler to function on land. The four themes with respective subthemes and supporting quotes are listed in Table 2.
Table 2. Theme, subthemes and supporting quotes.
| Theme 1: Multi-system benefits from aquatic therapy |
| Subtheme: From impairment to function |
| “ … all the ones that pertained to their therapeutic goals. They are more comfortable in the water. They improve their physical fitness. They improve their body awareness. They improve some of their swelling, and then … that helps achieve their goals in the community, whether it is walking over ground or improving their flexibility or make them stronger to be able to propel their manual wheelchair.” (Rob) |
| “ … the pool is often an environment where they have less pain, more movement, more independence … ” (Cindy) |
| “ … there’s benefits … you can do a lot of strengthening work, whole body movements with very weak muscle.” (Mei) |
| “So, they definitely are working on not only strength, but they are working on endurance too, and fitness.” (Cathy) |
| “When you have someone who [has] pain which is spasticity or tone related, then the warm water environment can also be a place where there is less of that, and therefore their pain is less, so they are freer to move … ” (Cindy) |
| “They can sleep much better when they have aquatic therapy. So, by sleeping better the whole body is better in the next day.” (Suzy) |
| Subtheme: Confidence |
| “Ah I think that’s the biggest thing; it gives them a sense of confidence too. Then ‘Ok I can do this, or maybe I can do it out of the water’.” (Lisa) |
| “Then I have found that for patients who lack confidence, so their balance isn’t that bad, but they lack a lot of confidence, that can be a great place because you can really, it’s not unlike putting a harness on someone. Go ahead and fall, nothing is going to happen.” (Cindy) |
| Subtheme: Clients’ enjoyment |
| “Sometimes clients are hesitant to get in, but the biggest challenge in the class is getting them out. Haha. Everyone wants to stay in.” (Ann) |
| “They always tell me ‘this is the best therapy yet’ and ‘oh I’m seeing my land therapy three times a week … do you think I can see you the three times and cut them down to two times? Cause I benefit a lot more than with land physio’.” (Suzy) |
| “So I think that’s a big benefit because they don’t see it as exercise they see it as a pleasurable, enjoyable activity.” (Mei) |
| Theme 2: Application of aquatic therapy |
| Subtheme: Based on properties of the water |
| “You know it’s easier to do some motion, so to do against gravity it’s harder. Where we have the buoyancy in the water helping lift and when they see what they can do in the water with reduced weight bear, it helps their mental aspect of it as well.” (Suzy) |
| “What I also love about the pool is the extra resistance coming from the water. So they have to really work. And also the blood pressure is not an issue. It is not an issue as much because of all the hydrostatic pressure. So they don’t faint on me, right?” (Cathy) |
| “ … the metacentric effect and what not … so, that’s a great way to work on the core and the balance as well.” (Suzy) |
| “ … if they are tight in some muscle groups, do some stretches, because out pool is warm, it’s a good place, and it helps the muscles decrease the spasms for a lot of them.” (Cathy) |
| “I think the water was a nice option to not only distract him, but I think the warmth and the hydrostatic pressure … just gave him much more relief from his pain.” (Lisa) |
| Subtheme: Role of aquatic therapy education |
| “ … since my course that I took in European Country on aquatic therapy and I’ve done the five modules that they had to offer at European Facility … and there were also a lot of techniques that can be used with spinal cord injury.” (Suzy) |
| “ … our training at our center is more safety based, like it's not what you do in the water therapeutically, it's more or less left to the therapist to figure it out. And I haven’t found a course yet, like I know in the questionnaire there was a [question] ‘have you taken a professional education course in aquatic therapy?’, and I was like oh, I wish! … I think I did mention, that at least in our corner of the country we have no continuous education course in [aquatic] therapy and it’s not taught in school either. So that was something like, oh I’ll get in the water and figure out what I think would be good for them. What are we doing … is there something else that we don’t know, right? So it would be helpful to have that, and have more guidance as therapists … So, that it’s more maximized”. (Cathy) |
| Subtheme: Use of clinical judgement to guide decision |
| “I am choosing when and where to bring my patient based on my clinical judgement, what I find on land, and then I said, ok maybe we want to achieve the single leg stance balance, ok let’s try to go in the water if you're struggling on land. So, I change the goal based on what the patient needs at the moment to achieve.” (Frank) |
| “I don’t follow any guidelines … it’s kind of case by case … They’re all different. Like a [person with a C6 injury] will show up differently than another [person with a C6 injury] … it goes with the personality of the client and how far they’ve gone and you know you kinda have to readapt and move on to work with the client, and not just say ‘ok, this is an incomplete C6, this is how is going’. I don’t think this is how it works or how it should work.” (Suzy) |
| “I just use my good old physiotherapy background and I just watch them move. So, it’s kind of functional-based. It’s very functional based and very yes, movement-based, my own analysis of movement. I see what they don’t have and pick out how to work with that.” (Cathy) |
| Theme 3: Perceived barrier to implementing aquatic therapy |
| Subtheme: Accessibility |
| “ … that’s why I mentioned we are attached to the rehab center … so the pool is actually the pool of the adult rehab center. We don’t have our own pool. But, we have an hour each day where we can use that pool.” (Lisa) |
| “so, bear an opportunity to get in the pool barrier-free so, you know, lower the barriers to accessibility, that would be much better! … [individuals with spinal cord injury] should have access to pools … you know, regular people have access, and can go to pools whenever they want … ” (Rob) |
| “Forty-five minutes is as long as we can manage because it’s a one hour program and then we, our clients change every hour, so then, it’s a big struggle to get them out and showered and changed, in their chair, because we all have clients at the top of the next hour … Certainly the more staff we have the more clients we can bring in the pool, so we have two because that is what we require by law for safety … if we had a bigger pool or more staff we could. We are often limited by how many people we can bring in by the number of the staff resourced at, available to do the pool.” (Ann) |
| “ … we recognize that the pool is underused, the cause of that is staffing, lack of staffing available to use the pool.” (Mei) |
| “ … so offering an adult swim that early in the morning is not doable for them. They cannot attend that time. So I found that sometimes I have to rent the pool which is really costly. I don’t want anybody to be in there and we’re talking 100 dollars an hour because … plus the life guard because, the facility’s police is to have the life guard on deck when there is someone in the water. So, like I said, yes, schedule, environment financial … it’s all something that can be a barrier for some of my clients.” (Suzy) |
| Subtheme: Clients’ function and health |
| “But they really shouldn’t have had bowel incontinence recently, like in the past 2 days. Or, if a patient doesn’t have an established bowel program or bladder management program. It needs to have been established, and fairly consistent … No surprises kind of thing.” (Cindy) |
| “Obviously open wounds, infections. Both of those are the two other big barriers.” (Mei) |
| “Patients who have very very poor proprioception on land are likely going to be worse in the water, because there is less mechanoreception and less information coming into their joints about where their body is in space. And even just the visual optics of the water can be extra confusing. So patients with poor proprioception, if they still want to try it, I am willing to do that, but I give them a lot of education and warning that this could be a worse environment for you, so not to get defeated.” (Cindy) |
| “Sometimes patients have also other comorbidities right? So, we need to make sure that it is appropriate also for the patient to go in the water. Ah … I am thinking about skin. I am thinking about also respiratory condition, because … if you go in the water, there is more pressure … the lung expansion is less in the water.” (Frank) |
| Theme 4: Water as an enabler to function on land |
| Subtheme: Safe environment to initiate functional movement |
| “I try to include aquatic therapy when I feel that it can be something useful for the patient, to achieve some functional task that on land they’re [finding] difficult because of different reasons.” (Frank) |
| “I am usually using it for patients who are lower functioning from a strength perspective or have less independence from the functional perspective in terms of … maybe they can’t, they are early in learning to move from sit to stand or they can walk but they have balance, a lot of balance challenges, and they are dependent on a fairly dependent gait aid. For those individuals, water can be really good.” (Cindy) |
| Subtheme: Motivating for clients |
| “Because if they can do it in the water, they feel then why should I not be able to eventually do it on dry land?” (Suzy) |
| “I’m not sure if sometimes they want to stay around because it’s 94 degrees, you know, and it’s really wonderful. But, it’s more so because they are inspired and they can achieve their goals of mobility and increasing their strength and independence and movement more in the water, faster in the water than on land.” (Ann) |
Theme 1: Multi-systems benefits from AT
All participants reported that AT was beneficial to several aspects, from impairment to function (subtheme 1). In addition, exercising in water improved their clients’ sense of confidence (subtheme 2) and enjoyment (subtheme 3).
From impairment to function
The participants reported that AT improved balance and mobility, increased muscle strength, reduced muscle tone and pain, and enhanced the endurance and fitness of their clients with SCI/D (Table 2). A few participants also reported that AT improved sleep and reduced swelling, and one participant (Suzy) reported that some of her clients gained increases in bone density.
Confidence
Participants highlighted that the aquatic environment is a medium to improve their clients’ sense of confidence. Cindy (PT) reported that if her client had good balance control, but lacked confidence in balance skills, the pool was a great place to take the client. She further explained, “I think the confidence thing is definitely something that is useful … [the water] provides an opportunity for problem solving. And sometimes that’s all a person needs … lots of opportunities to practice their problem solving skills, and then they are able to use them out there in the real world”.
Clients’ enjoyment
The participants mentioned that their clients with SCI/D, both adults and children, appeared to enjoy AT. As Mei (PT) explained, “ … there are very few clients who don’t like coming in the water, and even the ones who are terrified of the water at the start will very quickly change to the reverse, to actually loving it.”
The clients’ enjoyment seems to impact their adherence to AT. When Betty (KIN) was asked if her clients adhered well to the AT program, she said, “ … the clients are very keen to get in the water, so there is no problem with buy-in from the client perspective”.
Participants who treated their clients in group sessions explained the benefit of social interactions for their clients. As Cindy (PT), who led a group class in a rehabilitation hospital, shared,
… peer support is massive. And the pool, it looks like it’s a good environment for that sort of social interaction … they in most cases are like, okay, well I’m doing better than that person, or that person is struggling with the same thing that I am. So I think there are lots of psychological opportunities.
Some clients even keep their social connections beyond the AT sessions as Cindy added, “I had one class that wanted to start a Facebook group afterwards … they really enjoyed each other.”
Theme 2: Application of AT
Most participants used AT once or twice a week for approximately 45min per in-water session. Three participants (Susy, Betty and Rob) used community pools with their clients while all other participants had a pool in their clinic or hospital setting. Only three participants (Frank, Susy and Alex) reported being educated in specific AT methodologies and used these methods in their current practice. The majority of participants used their clinical judgement aligned with knowledge of hydrodynamics to guide decisions once with their clients in the pool. Therefore, three subthemes were identified when analyzing the professional’s use of AT: (1) based on properties of the water, (2) role of AT education, and (3) use of clinical judgement to guide decisions.
Based on the properties of water
Although the majority of participants lacked formal education in AT, they seemed knowledgeable in the principles of hydro- and thermal-dynamics. The participants mentioned the effects of buoyancy, drag force, hydrostatic pressure, metacentric effect (i.e. when buoyancy counteracts the force of gravity and creates a rotational torque) and thermal properties of the water on to their clients with SCI/D. The buoyancy was used to offload the body weight and assist upward movement that was difficult for the client to execute on land. The water resistance was often mentioned to promote muscle strength and endurance. The hydrostatic pressure was associated with reduced swelling in the limbs and with preventing low blood pressure. The metacentric effect was used to stimulate core muscles and balance in the water, and the warm water was reported to have a positive effect on pain and muscle tone. The supporting quotes for the water properties are provided in Table 2.
Role of AT education
Most participants lacked a formal education in AT. Only three participants, two PTA and one PT, mentioned having taken formal courses in AT methodologies. Frank, an internationally-educated PT, had completed formal education in AT in Europe and contrasted the differences between Canadian and European approaches. He explained,
… and then I came here in Canada, I had a course with “Canadian Instructor”, so to develop also some knowledge about the Canadian methods … and I found similarities and I found also some differences … here in Canada we tend to use more functional stuff. So, more functional approach … In “European Country” I found … too much passive stuff than active functional stuff.
Susy (PTA) also reported to have completed five modules of AT courses in a European clinic facility. She used the Bad Ragaz Ring method and the Halliwick method with her clients in the pool. Suzy thought that AT was underdeveloped in Canada. She added, “But, we are so little and not enough in Canada to speak up about that great modality [aquatic therapy] and we don’t do enough research. I think maybe funding has a lot to do with that”. A third participant, Alex (PTA), referred to herself as a “Watsu practitioner” and explained that she used the Watsu AT methodology in most of her practice.
The participants reported different views on formal AT education. Rob (PT) explained that formal training in AT is not crucial to be a good AT practitioner. He explained,
And I always say … my therapists, I say to them. I don’t care what sort of courses you have taken. Unless you can apply those to your practice, so, it doesn’t matter if you’re a manipulative therapist or you’re this or that. If you can’t work well with clients, and you know, work well in a team, then it just doesn’t really matter.
In contrast, Cathy (PT) perceived formal AT education as helpful, “ … one of my colleagues was trained in Great Britain, and she is just very good in the pool, ‘cause she has had training. So, we certainly learn from her”.
Use of clinical judgement to guide decisions
The participants expressed a preference to use their clinical judgement in their AT practice, rather than a prescriptive approach. A few factors seemed to contribute to this preference, namely the heterogeneity of individuals with SCI/D (Table 2) and the uncertainty about the state of the AT evidence, making AT guidelines, if they were to exist, likely not applicable to their clients.
Uncertainty about the state of scientific evidence was reported by a few participants. Mei (PT) explained, “ … the question I always have difficulty with, the only question I have, is there evidence for it? It’s not so much I don’t agree or disagree, it’s I don’t know”. Frank (PT) wished for an objective way to measure AT effectiveness, “Sometimes we say to the patient ‘oh, see, wow, now you can move the leg faster in the water’ or ‘you can control better in the water’, but it’s only kind of eyes or feeling … so there is nothing measurable”.
Theme 3: Perceived barriers to implementing AT
Common barriers to the implementation of AT were: (1) accessibility (e.g. pool environment, scheduling, staffing, and costs), and (2) the clients’ function and health (e.g. comorbidity, physical and mental statuses).
Accessibility
The main barriers regarding accessibility to therapeutic pools for clients with SCI/D were related to the pool environment, scheduling, staffing and costs (see Table 2). Rehabilitation hospitals were reported to have accessible pools for their clients; meaning these pools had one or more ways for clients to enter (e.g. lifts and/or ramps) besides offering a warm and therapeutic temperature. In contrast, therapeutic pools were less accessible in the community. Susy (PTA), who has used community pools to assist her clients for more than 10 years, explained the challenge for clients with SCI/D to access the pool: “ … there’s a couple of pools that I would like to use … but, because there is no ramp to get the clients in or a transfer chair, or the facility itself – the change rooms are not accessible”. She added,
… and then, like I said, the time frame … they offer adult swims at six o’clock in the morning until eight o’ clock. Well, we all know that those with spinal cord injury, they have a morning routine and it takes time to achieve. And then they need to regain some energy before they can do anything else because it is a work-out on its own to do the ADLs in the morning.
Staffing limitation was another barrier, especially in rehabilitation hospitals where at least one staff is required to be in the pool and another one on deck during therapy sessions. Cathy (PT) explained “it’s a bit staff intense at times, because you have to have a rehab assistant available to take someone into the pool. So that assistant has to be pulled from the gym to come in the water with us”. Group therapy appeared to be one solution to staffing limitation in the rehabilitation hospitals, as Cathy (PT) explained, “ … the pool class is a good solution because again, we group people, so the staff is working with 4 or 5 clients and we can optimize that ratio of staff to client”.
Clients’ function and health
Comorbidities play an important role in the use of AT, sometimes preventing pool access in the early phases of recovery. Clients with uncontrolled bowel and/or bladder functions, an unstable cardiovascular condition or open wounds are not allowed to enter the pool (Table 2). Cathy (PT) explained,
What’s challenging, well there are a couple of things. The bowel routine has to be established. If it is not established they cannot get in the water … well, one of my clients right now, he would be ready to get in the water, but unfortunately his bowel is not routine yet, so that delays things. So I have to use other modalities with him.
She added,
… and then another client … their surgical wound is not quite closed yet, or there is still a little bit of drainage, then we can’t take him in the water because the risk of infection. So again he would be an ideal candidate ‘cause he is totally in that early phase.
Other reported conditions/clinical presentations that may prevent clients with SCI/D from using the therapy pool were metastatic cancer (i.e. if client is receiving radiation), associated multiple sclerosis (i.e. the warm temperature could be deleterious), and individuals with very severe proprioceptive impairments (i.e. client may feel uncomfortable in the water).
Theme 4: Water as an enabler to function on land
Overall, the aquatic environment was reported to be a safe environment to initiate functional movement (e.g. sit-to-stand and walking). The participants reported that individuals with SCI/D who were unable to perform a specific function on land were able to execute these tasks in water. Two subthemes were then identified when analyzing the aquatic environment as an enabler to function on land: (1) safe environment to initiate functional movement, and (2) motivating for clients.
Safe environment to initiate functional movement
Overall, the participants reported taking their clients in the water when they are unable to perform a function against gravity (Table 2). The lower gravity environment of water, both in the shallow and deep ends of the pool, was reported to be a good way to engage in standing and walking training. Usually, the clients progress from the deep to the shallow end and then to land, as Susy (PTA) reported, “and so we start in a little bit deeper and eventually make [our] way out in the shallower where there is more weight [bearing], which translates slowly to the dry land therapy.” The aquatic environment was reported to enable clients to walk for the first time, as Mei (PT), reported, “I think we’ve seen a number of clients be able to get up onto their feet for the first time, be able to practice standing, be able to start walking in the water, which then translates into being able to walk on land.” She added, “ … and I equate [aquatic therapy] to body weight supported treadmill training, but it’s much less complicated and it’s much more fun and easier”. Betty (KIN) reflected on how water would help clients with SCI/D to regain walking in the aquatic environment,
I have seen that it is transferrable to land. I think it’s just that retraining the nervous system, somewhat with the buoyancy of the water it’s easier to walk with a proper gait so I think your muscle memory just improves much more, so you know, after time it translates and you are seeing gait improvements on land.
Motivating for clients
Being able to regain function and independence in a comfortable and safe environment appeared to motivate clients with SCI/D during AT (Table 2). Ann (PTA) reported a case of one of her clients who lacked motivation for the therapy in general. She explained,
… one of our fellows is not necessarily as motivated or he can’t quite see the next stage where we see potential. So we were able to get him up standing in the [water] … and now he is much more motivated to participate in land therapy and to come to class on time … you know, because now he sees the realism and the potential that ‘oh I can stand!’ and hope.
Discussion
The present study examined the use of AT for clients with SCI/D among ten rehab professionals with different clinical designations (PT, PTA and KIN). The four themes identified across the dataset showed that water is a versatile and unique environment that benefits the multi-dimensional aspects of the health of individuals with SCI/D. AT is viewed by the participants as a therapeutic approach that complements their discipline-specific knowledge in neurorehabilitation, while simultaneously offering both clients and therapists a comprehensive rehabilitation experience that cannot be replicated in land-based therapy. The participants reported that they used the warmth, comfort and versatility of the water’s physical properties to enable function that would be difficult or impossible for the clients with SCI/D to execute on land. The participants successfully integrated AT into their clinical practice despite the barriers that both the participants and clients faced when using AT.
The uniqueness and versatility of the aquatic environment allowed the therapists to apply appropriate assistance or resistance to facilitate desired movement by using buoyancy and drag force, respectively. Immersion was also reported to reduce swelling due to the hydrostatic pressure. The water’s warmth seemed to modulate pain and tone, and to promote whole body relaxation. Some participants found that the aquatic environment improved confidence and problem-solving, sleep quality, swelling and endurance along with being an enjoyable environment to exercise in.
Seven out of ten participants reported not having formal education in AT. One possible reason is the underdeveloped AT education resources in some parts of Canada. Ashton and O’Connor,14 in 2018, explored the context of AT education in Ontario and concluded that there is a need to increase standardized training and implementation. Both underdeveloped education and the heterogeneity of the clients with SCI/D may have influenced these professionals’ preference for relying on their clinical judgement to make decisions on when and how to implement AT. Therefore, furthering AT education and practice in Canada becomes essential for the application of this “magical modality” in the health and wellbeing of individuals with disabilities.
Accessing therapeutic pools, especially in the community, seems to be one of the greatest barriers for implementing AT after SCI/D. While in the rehabilitation centers the barriers cited are predominantly scheduling and staffing, in the community the greatest barrier is the lack of accessible therapeutic pools and costs. Two participants who treated their clients in community and private pools mentioned that it can be very costly for the client to afford all the expenses with transportation, therapists, pool rental and lifeguard. These accessibility barriers in the community may directly influence the inclusion of AT in the client’s discharge plans from the rehabilitation hospitals. Optimistically, perhaps the aging Canadian demographics will change the way communities are building pools and programing; however, more work needs to be done to educate decision makers regarding facility and program design for those with disabilities. Future initiatives could include working with health care professionals, health administrators, individuals with lived experience and community groups to strategize and develop innovative solutions to overcome the barriers to participation in AT. Evaluations of the cost-effectiveness of individual and group-based AT for the SCI/D population is also warranted to inform implementation decisions.
There are a few study limitations to acknowledge. First, some of the interviews were conducted over the phone; hence, non-verbal cues, such as body language, were not observed. Conducting interviews over the phone, however, allowed us to include participants from across Canada. Second, three health disciplines (PT, PTA, KIN) were included in this study; however, other professionals, such as occupational therapists and exercise physiologists, likely offer AT to individuals with SCI/D. Their perspectives were not reflected. Nor were the perspectives of health administrators. Given the financial and organizational barriers to the use of AT post-SCI/D, the perspectives of health administrators would be important to study in the future.
Conclusion
The participants of the present study reported their unique experiences using AT for clients with SCI/D. The effects of AT seemed to encompass multiple body systems, from sensorimotor impairment to physical and psychosocial functions. Despite the barriers, such as a lack of accessibility and clients’ co-morbid health conditions, AT was successfully integrated into the professionals’ practice.
Disclaimer statements
Contributors None.
Conflicts of interest None.
Supplementary Material
Funding Statement
This work was supported by The Craig H. Neilsen Foundation [grant number 440070].
ORCID
Andresa R. Marinho-Buzelli http://orcid.org/0000-0001-7426-631X
Avril Mansfield http://orcid.org/0000-0002-0396-5815
Kristin E. Musselman http://orcid.org/0000-0001-8336-8211
References
- 1.Rick Hansen Institute No Title. The reality of spinal cord injury. In: Facts about SCI – what is spinal cord injury (SCI).
- 2.Becker B, Cole A.. Comprehensive aquatic therapy. 3rd ed Pullman: Washington State University Publishing; 2011. [Google Scholar]
- 3.Becker BE. Aquatic therapy: scientific foundations and clinical rehabilitation applications. PM R. 2009;1(9):859–872. doi: 10.1016/j.pmrj.2009.05.017 doi: 10.1016/j.pmrj.2009.05.017 [DOI] [PubMed] [Google Scholar]
- 4.Frye SK, Ogonowska-Slodownik A, Geigle PR.. Aquatic exercise for people with spinal cord injury. Arch Phys Med Rehabil. 2017;98(1):195–197. doi: 10.1016/j.apmr.2016.07.010 [DOI] [PubMed] [Google Scholar]
- 5.Ellapen TJ, Hammill H V, Swanepoel M, Strydom GL.. The benefits of hydrotherapy to patients with spinal cord injuries. Afr J Disabil. 2018;7(0):450 Available from https://uhn.idm.oclc.org/login?url=http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=prem2&AN=29850439. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Li C, Khoo S, Adnan A.. Effects of aquatic exercise on physical function and fitness among people with spinal cord injury. Medicine (Baltimore). 2017;96(11):e6328 Available from http://journals.lww.com/md-journal. doi: 10.1097/MD.0000000000006328 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Kesiktas N, Paker N, Erdogan N, Gülsen G, Biçki D, Yilmaz H.. The use of hydrotherapy for the management of spasticity. Neurorehabil Neural Repair. 2004;18(4):268–273. Available from http://nnr.sagepub.com/cgi/doi/10.1177/1545968304270002%5Cnhttp://www.ncbi.nlm.nih.gov/pubmed/15537997. doi: 10.1177/1545968304270002 [DOI] [PubMed] [Google Scholar]
- 8.Gorman PH, Scott W, VanHiel L, Tansey KE, Sweatman WM, Geigle PR.. Comparison of peak oxygen consumption response to aquatic and robotic therapy in individuals with chronic motor incomplete spinal cord injury: a randomized controlled trial. Spinal Cord. 2019. doi: 10.1038/s41393-019-0239-7. [DOI] [PubMed] [Google Scholar]
- 9.Stevens SL, Caputo JL, Fuller DK, Morgan DW.. Effects of underwater treadmill training on leg strength, balance, and walking performance in adults with incomplete spinal cord injury. J Spinal Cord Med. 2015;38(1):91–101. Available from http://www.tandfonline.com/doi/full/10.1179/2045772314Y.0000000217. doi: 10.1179/2045772314Y.0000000217 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.da Silva MCR, De Oliveira RJ, Conceição MIG.. Effects of swimming on the functional independence of patients with spinal cord injury. Rev Bras Med do Esporte. 2005;11(4):237–241. [Google Scholar]
- 11.Wall T, Falvo L, Kesten A.. Activity-specific aquatic therapy targeting gait for a patient with incomplete spinal cord injury. Physiother Theor Pract. 2017;33(4):331–344. doi: 10.1080/09593985.2017.1302026 [DOI] [PubMed] [Google Scholar]
- 12.Recio AC, Stiens SA, Kubrova E.. Aquatic-Based therapy in spinal cord injury rehabilitation: effective yet underutilized. Curr Phys Med Rehabil Rep. 2017;5:1–5. Available from http://link.springer.com/10.1007/s40141-017-0158-5. doi: 10.1007/s40141-017-0158-5 [DOI] [Google Scholar]
- 13.Braun V, Clarke V.. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. doi: 10.1191/1478088706qp063oa [DOI] [Google Scholar]
- 14.Ashton A, O’connor E.. Contextualizing aquatic rehabilitative practices in Canada [dissertation]. Ottawa (ON: ): University of Ottawa; 2018. [Google Scholar]
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