Abstract
Context/objectives
Aquatic therapy (AT) has been reported to be beneficial for individuals with spinal cord injury or disorder (SCI/D); however, AT has also been reported to be underutilized in SCI/D rehabilitation. We aimed to understand the knowledge and current practice of AT for clients with SCI/D by physiotherapists, physiotherapy assistants and kinesiologists across Canada.
Design/Method
A survey with closed- and open-ended questions was distributed (July-October 2019) to professionals through letters sent by professional associations. Non-parametric analyses were used to compare AT knowledge and practice between AT and non-AT users; content analysis was used to identify the themes from open-ended questions.
Results
Seventy-eight respondents from 10 provinces were included in the analysis: 33 physiotherapists, 5 physiotherapy assistants and 40 kinesiologists. Respondents using AT (73%) reported greater knowledge of AT benefits and confidence to apply AT than respondents not using AT (p<0.01). Four themes were identified: 1-Variety of physical and psychosocial benefits of AT for people with SCI/D; 2-Attainment of movement and independence not possible on land; 3-Issues around pool accessibility; and 4-Constraints on AT implementation.
Conclusions
Respondents implemented AT to improve health outcomes for patients with SCI/D, despite facing challenges with pool accessibility and numerous constraints. Respondents who provided AT reported having better knowledge of AT and a supported AT practice in the work environment than respondents not providing AT. This study will inform AT stakeholders and institutions when considering strategies to increase the access to AT after SCI/D.
Keywords: Aquatic therapy, Survey, Spinal cord injury
Introduction
Immersion in water is an ancient therapeutic approach that evolved to encompass a wide range of aquatic therapies to restore the health and function of individuals with neurological, cardiopulmonary and orthopedic conditions.1–3 The hydrodynamic properties on an immersed individual while exercising in water results in bodyweight offloading due to the buoyancy force, provides resistance to movement due to water viscosity, and supports the body and reduces swelling due to graduated hydrostatic pressure.1,4 The warm water is reported to decrease pain in people with multiple sclerosis5, Parkinson’s Disease6 and fibromyalgia;7 and to decrease blood pressure in older adults.8 The gains in sensorimotor function after aquatic therapy are often accompanied by the reduction of depression and improvement of overall quality of life.9–11
There is fair evidence to support the use of aquatic therapy (AT) for individuals with spinal cord injury or disorder (SCI/D),12,13 despite the paucity of randomized controlled trials (RCT). Underwater treadmill training significantly improved lower limb strength, balance function and gait speed of individuals with incomplete SCI/D after eight weeks of exercise, three times a week.14 The respiratory function of individuals with incomplete SCI/D was enhanced after 24 60-min sessions of AT, three times per week.15 A case study of an individual with chronic, incomplete tetraplegia demonstrated improved gait speed and function after a 6-week AT program with maintenance of these outcomes at the 4-week follow-up.16 There is also evidence that AT reduces the severity of spasms after SCI/D.17 Despite the support in the literature for beneficial use of AT for SCI/D, AT is still argued to be underutilized in SCI/D rehabilitation.18
Recently, an exploratory qualitative study investigating AT use among common administrators of AT, i.e. physiotherapists (PT), PT assistants (PTA), and kinesiologists (KIN) supported the development of the current study.19 The AT administrators explained that the aquatic environment provided a range of therapeutic interventions that encompass multi-dimensional benefits for individuals with SCI/D, from physical to psychosocial benefits.19 However, they experienced barriers to its use, such as limited pool accessibility, a lack of AT-specific educational opportunities, and management of clients’ comorbidities.19 This initial study involved a small number (n=10) of AT professionals and did not produce quantitative data concerning the provision of AT in Canada.
The present study aimed to extend the previous qualitative study with the goal of describing and quantifying the current practice of AT for individuals with SCI/D by a larger number of PT, PTA and KIN. More specifically, we aimed to quantify the AT knowledge and use of PT, PTA and KIN, and to identify common barriers and facilitators to the implementation of AT for the SCI/D population. We hypothesized that: (1) AT users would be more knowledgeable on the use of AT for people with SCI/D than non-AT users; and (2) AT users would have greater support in their practice to apply AT for SCI/D than non-AT users. A comprehensive understanding of the barriers and facilitators to the implementation of AT for individuals living with SCI/D is needed to develop strategies to improve access to this long-standing therapeutic approach.20
Methods
A survey, based on the results of our interviews with common administrators of AT,19 was developed to assess the use of AT for individuals with SCI/D among PT, PTA and KIN across Canada. This study was approved by the institutional research ethics board.
Survey development
This survey was developed to ensure the constructs related to AT were tailored to the practice with individuals with SCI/D, ensuring content validity. First, the research team and two people living with SCI/D developed a survey based on a previous valid and reliable survey.21 The first draft of the survey included closed-ended questions about demographics and AT knowledge and practice, as well as two open-ended questions on the barriers and facilitators to AT implementation. The ten participants of our previous study19 reviewed the survey and commented on whether the survey was structured to achieve its goal. Based on their feedback, the survey was revised. The final version of the survey (Appendix) was translated into French, and both versions were created in electronic format on LimeSurvey.
The final survey consisted of five sections: (1) demographics; (2) knowledge of AT for SCI/D; (3) professional current practice for clients with SCI/D; (4) frequency of AT use for common therapeutic goals; and (5) barriers and facilitators to AT implementation. For sections 2 and 3, we used Likert-scale options for responses with descriptive anchors: strongly disagree, disagree, neither agree nor disagree, agree and strongly agree. For section 4, we used the following Likert-scale response options: most of the time (≥80%), frequently (60%-79%), sometimes (41%-59%), occasionally (21%-40%), rarely (1%-20%) and never (0%). Section 5 consisted of two open-ended questions on barriers and facilitators of AT implementation with no word limit. To ensure all survey respondents worked with clients with SCI/D, the first question asked what percentage of the respondent’s client caseload was SCI/D. If a respondent answered 0%, the survey ended.
Survey respondents: inclusion criteria, recruitment and consenting
Canadian PT, PTA and KIN were invited to participate in the survey through electronic communications of the provincial physiotherapy associations, the Neuroscience Division of the Canadian Physiotherapy Association, provincial and national associations of kinesiologists and Canadian Aquatic Rehab Instructors (CARI). We recruited professionals who: (1) were currently licensed/allowed to practice in Canada, and (2) had worked with at least one client with SCI/D in the past year. Consent to participate was implied if the professional accepted to participate and proceeded with completing the survey. Surveys were completed anonymously.
Analysis of the survey data
Survey data were automatically collected in LimeSurvey from July to October 2019. Data were then exported from LimeSurvey to Microsoft Excel for data cleaning. Open-ended responses in French were translated to English by a member of the research team (CG).
The demographic data were analyzed by creating a frequency table to report the absolute number and percentage of participants with certain characteristics. Hours of professional practice were described as median (interquartile range). Information on missing data were reported at the bottom of each table.
Index scoring was applied to convert the closed-ended descriptive responses into numeric values.22 For example, questions about AT knowledge and current professional practice were assigned numerical values as follows: −2=strongly disagree, −1=disagree, 0=neither agree nor disagree, 1=agree, 2=strongly agree. For questions regarding the therapeutic goals, index scores were assigned as follows: 0=never, 1=rarely, 2=occasionally, 3=sometimes, 4=frequently, 5=most of the time. Index scores were assigned to create a summary scores (i.e. mean ± 1 standard deviation). A Mann–Whitney U test was used to compare each of the knowledge and current practice statements between those who used and did not use AT.
A conventional content analysis was used to analyze the text responses to the open-ended questions.23 Two researchers (AMB and KC) independently identified preliminary codes consistent throughout the dataset. Then the researchers met to finalize the codes and identify themes. An in-person peer debriefing session with four members of the research team (AMB, KC, KM and CG) followed to support the credibility of analysis.
Results
A total of 107 individuals clicked the survey link, from which 101 agreed to participate. Twenty-two respondents did not work with clients with SCI/D and hence were excluded. One respondent who identified as an athletic therapist was also excluded. Data from 78 respondents were included in the analysis; 57 respondents (73.1%) used AT in their practice while 21 (26.9%) did not.
Demographics
Most respondents were women (87.2%) and were in the age group of 25–34 years (60.3%) (Table 1). Respondents were mostly KIN (51.3%) and PT (42.3%). Only 5 PTA who used AT in their practice participated. Most respondents had Bachelor (56.4%) and Master (clinical) (25.6%) degrees, practicing in a variety of therapeutic fields and settings. Participants responded from all over Canada: Ontario (47.4%), British Columbia (18%), Quebec (6.4%), Alberta (6.4%), New Brunswick (5.1%), Nova Scotia (5.1%), Northwest Territories (5.1%), Newfoundland (3.9%), Yukon (1.3%) and Prince Edward Island (1.3%).
Table 1.
Demographic variables.
| Variables | Used AT (N=57, 73.1%) | Did not use AT (N=21, 26.9%) | Total (N=78) |
|---|---|---|---|
| N (%) | N (%) | N (%) | |
| Age (years) | |||
| 18–24 | 2 (3.5) | 2 (9.5) | 4 (5.1) |
| 25–34 | 33 (57.9) | 13 (61.9) | 46 (60.0) |
| 35–44 | 15 (26.3) | 3 (14.3) | 18 (23.1) |
| 45–54 | 4 (7.0) | 1 (4.8) | 5 (6.4) |
| 55–64 | 3 (5.3) | 2 (9.5) | 5 (6.4) |
| 65–74 | 0 | 0 | 0 |
| >75 | 0 | 0 | 0 |
| Gender | |||
| Man | 8 (14.0) | 2 (9.5) | 10 (12.8) |
| Woman | 49 (86.0) | 19 (90.5) | 68 (87.2) |
| Non-binary/third gender | 0 | 0 | 0 |
| Prefer to self-describe | 0 | 0 | 0 |
| Prefer not to say | 0 | 0 | 0 |
| Professional/Educational background | |||
| PT | 23 (40.4) | 10 (47.6) | 33 (42.3) |
| PTA | 5 (8.8) | 0 | 5 (6.4) |
| KIN | 29 (50.9) | 11 (52.4) | 40 (51.3) |
| Years of professional practice | |||
| < 5 years | 16 (28.1) | 11 (52.4) | 27 (34.6) |
| 5–10 years | 19 (33.3) | 3 (14.3) | 22 (28.2) |
| 10–15 years | 7 (12.3) | 4 (19.0) | 11 (14.1) |
| 15–20 years | 9 (15.8) | 1 (4.8) | 10 (12.8) |
| > 20 years | 6 (10.5) | 2 (9.5) | 8 (10.3) |
| Highest level of education completed | |||
| Diploma | 5 (8.8) | 0 | 5 (6.4) |
| Bachelors | 31 (54.4) | 13 (61.9) | 44 (56.4) |
| Masters (clinical) | 14 (24.6) | 6 (28.6) | 20 (25.6) |
| Masters (thesis based) | 2 (3.5) | 2 (9.5) | 4 (5.1) |
| PhD | 1 (1.8) | 0 | 1 (1.3) |
| DPT (doctor in physiotherapy) | 0 | 0 | 0 |
| Other | 4 (7.0) | 0 | 4 (5.1) |
| Present area of practice* | |||
| Generalist | 20 (35.1) | 13 (61.9) | 33 (42.3) |
| Aquatic therapy/hydrotherapy | 31 (54.4) | 0 | 31 (39.7) |
| Cardiovascular | 7 (12.3) | 4 (19.1) | 11 (14.1) |
| Geriatric | 12 (21.1) | 21 (38.1) | 33 (42.3) |
| Neurology | 26 (45.6) | 5 (23.8) | 31 (39.7) |
| Spinal Cord Injury | 33 (57.9) | 4 (19.1) | 37 (47.4) |
| Orthopaedic | 28 (49.1) | 4 (19.1) | 32 (41.0) |
| Pediatric | 7 (12.3) | 2 (9.5) | 9 (11.5) |
| Sports | 14 (24.6) | 8 (38.1) | 22 (28.2) |
| Woman's health | 2 (3.5) | 4 (19.1) | 6 (7.7) |
| Other | 4 (7.0) | 0 | 4 (5.1) |
| Current healthcare setting* | |||
| Acute care | 2 (3.5) | 6 (28.6) | 8 (10.3) |
| Inpatient rehabilitation | 22 (38.6) | 7 (33.3) | 29 (37.2) |
| Outpatient rehabilitation | 27 (47.4) | 8 (38.1) | 35 (44.9) |
| Private practice | 24 (42.1) | 10 (47.6) | 34 (43.6) |
| Home/community care | 15 (26.3) | 7 (33.3) | 22 (28.2) |
| Long-term care | 5 (8.8) | 4 (19.1) | 9 (11.5) |
| Research | 2 (3.5) | 2 (9.5) | 4 (5.1) |
| Educational | 2 (3.5) | 1 (4.8) | 3 (3.8) |
| Other | 2 (3.5) | 2 (9.5) | 4 (5.1) |
*Respondents were allowed to select more than one option.
Knowledge of aquatic therapy
Only a third of respondents (34.6%) received AT instruction in their educational programs (Table 2). However, the majority of respondents using AT (61.4%) reported using at least one source of continuing education. This included taking AT courses (42.1%), searching on AT-related websites (42.1%), searching on the internet (38.6%), and/or reading scientific and professional journal articles (35.1%).
Table 2.
Professionals’ education in aquatic therapy.
| Variables | Used AT (N=57, 73.1%) | Did not use AT (N=21, 26.9%) | Total (N=78) |
|---|---|---|---|
| N (%) | N (%) | N (%) | |
| AT instruction as part of educational program | |||
| Yes | 21 (36.8) | 6 (28.6) | 27 (34.6) |
| No | 32 (56.1) | 14 (66.7) | 46 (59.0) |
| Not sure | 4 (7.0) | 1 (4.8) | 5 (6.4) |
| Pursuit of continuing education/knowledge in AT | |||
| Yes | 35 (61.4) | 5 (23.8) | 40 (51.3) |
| No | 22 (38.6) | 16 (76.2) | 38 (48.7) |
| Source of continuing education in AT | |||
| Internet search | 22 (38.6) | 5 (23.8) | 27 (34.6) |
| Aquatic therapy-related websites | 24 (42.1) | 3 (14.3) | 27 (34.6) |
| Continuing education courses | 24 (42.1) | 3 (14.3) | 27 (34.6) |
| Scientific and professional journal articles | 20 (35.1) | 2 (9.5) | 22 (28.2) |
| Other | 6 (10.5) | 1 (4.8) | 7 (9.0) |
*Note. In the source of continuing education, the respondents were allowed to answer more than one option.
For knowledge statements concerning AT, the index scores of respondents who provided AT were significantly greater than that of respondents who did not use AT (U = 123–411, P= <0.0001 to P=0.025), except for the item stating “There is evidence to suggest that AT improves health for people with SCI/D” (U = 516, P = 0.374) (Table 3).
Table 3.
Professionals’ knowledge of aquatic therapy for SCI/D.
| Statement | Use of AT | Strongly Disagree (−2) | Disagree (−1) | Neither Agree nor Disagree (0) | Agree (1) | Strongly Agree (2) | Index Score Mean (SD) | P Value |
|---|---|---|---|---|---|---|---|---|
| 1. I know how to provide aquatic therapy for clients with SCI. | Yes | 0% | 3.5% | 7.0% | 73.7% | 15.8% | 1.0 (0.6) | <.0001 |
| No | 33.3% | 38.1% | 9.5% | 19.1% | 0% | −0.9 (1.1) | ||
| 2. I am aware of the benefits of aquatic therapy for clients with SCI. | Yes | 0% | 0% | 1.8% | 47.4% | 49.1% | 1.5 (0.5) | .025 |
| No | 4.8% | 14.3% | 9.5% | 38.1% | 33.3% | 0.8 (1.2) | ||
| 3. I understand the physical properties of the aquatic environment (e.g. buoyancy, resistance) and how to apply them in aquatic therapy. | Yes | 0% | 1.8% | 0% | 52.6% | 46.5% | 1.4 (0.6) | <.0001 |
| No | 4.8% | 23.8% | 9.5% | 47.6% | 14.3% | 0.4 (1.2) | ||
| 4. There is evidence to suggest that aquatic therapy improves health for people with SCI. | Yes | 1.8% | 0% | 24.6% | 49.1% | 22.8% | 0.9 (0.8) | .374 |
| No | 0% | 4.8% | 33.3% | 42.9% | 19.0% | 0.8 (0.8) | ||
| 5. I have sufficient training in aquatic therapy. | Yes | 0% | 15.8% | 35.1% | 31.6% | 15.8% | 0.5 (1.0) | <.0001 |
| No | 42.9% | 23.8% | 23.8% | 9.5% | 0% | −1.0 (1.0) | ||
| 6. I have confidence in my aquatic therapy skills. | Yes | 0% | 5.3% | 15.8% | 55.4% | 19.3% | 0.9 (0.8) | <.0001 |
| No | 38.1% | 28.6% | 19.1% | 14.3% | 0% | −0.9 (1.1) | ||
| 7. I am confident in my decision-making regarding which patient should and should not receive aquatic therapy. | Yes | 0% | 1.8% | 17.5% | 52.6% | 26.3% | 1.1 (0.7) | <.0001 |
| No | 28.6% | 9.5% | 47.6% | 14.3% | 0% | −0.5 (1.1) |
Note. Statements 2,4,5, 7 have 1 missing data in both groups. Statement 6 has 1 missing data in the YES group.
Current practice
SCI/D clients made up 1-20% of the respondents’ caseload (Table 4). Their clients with SCI/D spanned all ages and were primarily seen in the subacute and chronic phases of recovery.
Table 4.
Professionals’ practice.
| Variables | Used AT (N=57, 73.1%) | Did not use AT (N=21, 26.9%) | Total (N=78) |
|---|---|---|---|
| N (%) | N (%) | N (%) | |
| Percentage of SCI/D client caseload | |||
| 1%-20% | 25 (43.9) | 15 (71.4) | 40 (51.3) |
| 21%-40% | 12 (21.1) | 4 (19.1) | 16 (20.5) |
| 41%-59% | 4 (7.0) | 2 (9.5) | 6 (7.7) |
| 60%-79% | 5 (8.8) | 0 | 5 (6.4) |
| ≥ 80% | 11 (19.3) | 0 | 11 (14.1) |
| Years working with clients with SCI/D | |||
| < 5 years | 26 (45.6) | 15 (71.4) | 41 (52.6) |
| 5–10 years | 15 (26.3) | 3 (14.3) | 18 (23.1) |
| 10–15 years | 9 (15.8) | 2 (9.5) | 11 (14.1) |
| 15–20 years | 4 (7.0) | 0 | 4 (5.1) |
| > 20 years | 3 (5.3) | 1 (4.8) | 4 (5.1) |
| Age group of clients## | |||
| < 18 years old | 0 | 0 | 0 |
| ≥ 18 years | 30 (52.6) | 13 (61.9) | 43 (55.1) |
| All ages | 25 (43.9) | 8 (38.1) | 33 (42.3) |
| Time since injury of the clients* | |||
| < 1 month post-SCI | 4 (7.0) | 3 (14.3) | 7 (9.0) |
| 1–3 months post-SCI | 19 (33.3) | 4 (19.1) | 23 (29.5) |
| 3 months to 1 year post-SCI | 30 (52.6) | 5 (23.8) | 35 (44.9) |
| > 1 year | 28 (49.1) | 14 (66.7) | 42 (53.8) |
| Setting for aquatic therapy practice* | |||
| Community pool | 27 (47.4) | 27 (34.6) | |
| Hospital pool | 21 (36.8) | 21 (26.9) | |
| Clinic pool | 2 (3.5) | 2 (2.6) | |
| Other | 7 (12.3) | 7 (9.0) | |
| Pool accessibility | |||
| Yes | 53 (93.1) | 6 (28.6) | 59 (75.6) |
| No | 4 (7.0) | 14 (66.7)# | 18 (23.1) |
| Type of accessibility* | |||
| Ramp | 36 (63.2) | 36 (46.2) | |
| Stairs | 44 (77.2) | 44 (56.4) | |
| Lift | 44 (77.2) | 44 (56.4) | |
| Ladder | 30 (52.6) | 30 (38.5) | |
| Other | 4 (7.0) | 4 (5.1) | |
*Respondents were allowed to select more than one option. #One missing data in the group who did not use AT. ##Two missing data in the group who used AT.
Respondents using AT spent 3 (1-7) hours per week of their practice time dedicated to AT. The majority of respondents accessed pools located in the community (47.4%) or in hospitals (36.8%), with only two respondents (3.5%) providing AT in private clinic pools. Almost all respondents who used AT in their practice had access to a pool (93.1%) whereas only 28.6% of those who did not provide AT in their practice had access to a pool.
When comparing the groups (AT use vs. no AT use), the index scores of the statements related to current practice were significantly higher in the group providing AT compared to the group that did not (U = 124-295, P= <0.001 to P = 0.001) (Table 5). This means that respondents who provided AT had access to therapeutic pools, frequently provided AT for clients with SCI/D, combined AT with land therapy, and felt supported in the work environment in their choice to provide AT. However, one third of respondents who used AT (31.6%) disagreed with the statement “I have sufficient time to provide AT in my current practice”, which corroborates with the respondents’ report in the open-ended questions related to barriers to AT implementation.
Table 5.
Professionals’ practice of aquatic therapy for SCI/D.
| Statement | Use of AT | Strongly Disagree (−2) | Disagree (−1) | Neither Agree nor Disagree (0) | Agree (1) | Strongly Agree (2) | Index Score Mean (SD) | P Value |
|---|---|---|---|---|---|---|---|---|
| 1. My clients with SCI have access to therapeutic pools. | Yes | 3.5% | 19.3% | 22.8% | 43.9% | 7.0% | 0.3 (1.0) | .001 |
| No | 28.6% | 23.8% | 33.3% | 14.3% | 0% | −0.7 (1.1) | ||
| 2. I frequently use aquatic therapy approaches with my clients with SCI. | Yes | 3.5% | 5.3% | 33.3% | 40.4% | 14.0% | 0.6 (0.9) | <.0001 |
| No | 57.1% | 23.8% | 14.3% | 0% | 4.8% | −1.3 (1.1) | ||
| 3. I use aquatic therapy in individuals with conditions other than SCI. | Yes | 7.0% | 1.8% | 3.5% | 40.4% | 43.9% | 1.2 (1.1) | <.0001 |
| No | 47.6% | 23.8% | 9.5% | 9.5% | 9.5% | −0.9 (1.4) | ||
| 4. I prefer to use aquatic therapy in conjunction with land therapy options for my clients with SCI. | Yes | 1.8% | 0% | 15.8% | 43.9% | 35.1% | 1.1 (0.8) | <.0001 |
| No | 19.1% | 4.8% | 57.1% | 14.3% | 4.8% | −0.2 (1.1) | ||
| 5. I have sufficient time to provide aquatic therapy in my current practice. | Yes | 3.5% | 31.6% | 14.0% | 33.3% | 14.0% | 0.2 (1.2) | <.0001 |
| No | 47.6% | 19.1% | 9.5% | 19.1% | 0% | −1.0 (1.2) | ||
| 6. I feel supported to use aquatic therapy in my work environment. | Yes | 1.8% | 7.0% | 17.5% | 43.9% | 26.3% | 0.9 (1.0) | <.0001 |
| No | 52.4% | 19.1% | 14.3% | 14.3% | 0% | −1.1 (1.1) |
Note. There are 2 missing data for all statements in the YES group and 1 missing data for the statement 5 in the NO group.
Frequency of AT use for therapeutic goals
Respondents frequently provided AT to improve the function, well-being, range of motion, muscle strength and balance of their clients with SCI/D (i.e. index scores > 3.5) (Fig. 1). AT was also frequently used to reduce pain and improve gait and upper limb function.
Figure 1.
Mean of index scores of therapeutic goals. Index scores were assigned as follows: 0=never, 1=rarely, 2=occasionally, 3=sometimes, 4=frequently, 5=most of the time.
Facilitators and barriers to AT implementation
Forty-seven respondents (60.2%) reported their perspectives on the benefits of AT for SCI/D and 60 respondents (76.9%) reported on the barriers to AT implementation. The following four themes were identified: 1-Variety of physical and psychosocial benefits of AT for people with SCI/D; 2-Attainment of movement and independence not possible on land; 3-Issues around pool accessibility; and 4-Constraints on AT implementation.
Theme 1-Variety of physical and psychosocial benefits of AT for people with SCI/D
Multi-benefits of AT encompassing physical, psychological and functional domains were identified by the respondents. One respondent reported, “We have seen improvements with SCI clients with respect to improved postural control above the level of injury, functional activities (lift training for transfers, sit to stand for incomplete SCI), improved gait quality, increased endurance and tolerance to activities.” Pain was reported to be relieved in warm water, as described by this respondent: “Aquatic therapy enhances my practice by offering an environment in which exercise can be performed with less pain which often limits my patients on land”. Furthermore, improvements in wellbeing, mental health and confidence were also often reported, as this respondent stated, “I have found that aquatic therapy benefits the SCI population in various ways, ranging from general strength and flexibility to increasing the clients’ confidence, wellbeing and general mental health as well.”
Theme 2-Attainment of movement and independence not possible on land
Respondents suggested the aquatic environment gave clients a sense of freedom they were not able to experience on land, due to less gravity during water immersion. One respondent wrote, “If I could use it [AT] more often it would benefit patients that are in too much pain to do the exercises on land, to have gravity off the table, improving strength with light resistance with all movements”. Another respondent reported how the aquatic environment allowed clients to explore their movement performance, “It [AT] provides a space where clients feel supported by the water to try new movements which otherwise may not be accessible to clients on land.”
Theme 3-Issues around pool accessibility
Respondents identified numerous barriers for clients with SCI/D to access AT in hospital settings and in the community. A few challenges in hospital settings were reported by the participants such as the lack of staffing/resources to utilize the pool to its maximal potential, time constraints, and restrictions on pool use from an infection control perspective.
A community pool is usually the option for clients with SCI/D after discharge from rehab hospitals; however, these pools posed numerous challenges. One respondent reported,
Having to use community pools both the therapist as well as the client are at the mercy of the pool schedule and having to use “open” or “public” swim times can be very crowded spaces, having to be cognizant of children/families playing within the pool etc.
Furthermore, cost with transportation, membership cost to aquatic centers in the community, caregiver support, lack of trained staff, and accessibility in the pool and change rooms were also identified as barriers to providing AT in the community.
Theme 4-Constraints on AT implementation
Scheduling and time constraints were the most frequently reported barriers to providing AT to clients with SCI/D, followed by staffing constraints and clients’ comorbidities (i.e. bowel and bladder incontinence). The time and personnel required for changing and showering was often reported as a limiting factor. As one of the respondents stated, “As we access a community pool, we have to arrange transportation and allow time for changing, therefore a scheduled pool session takes nearly 1.5–2 h with only 45 min of actual therapy time and often requires a PT and a PTA.” The client’s fear of water and staff education in AT were mentioned by a few respondents as barriers to providing AT. One respondent reported, “[There is] not much education spread; learned minuscule amounts [of AT] in schooling.”
Discussion
The present study investigated the knowledge, perceptions and current practice of AT for individuals with SCI/D through a survey distributed to PT, PTA and KIN across Canada. Of all respondents, 73.1% used AT in their practice, primarily in community and hospital pools. Compared to those who did not use AT, respondents providing AT pursued continuing education and scored higher in the knowledge section of the survey. Respondents who used AT felt supported to use AT in the work environment. A wide range of benefits were reported by the respondents, from improved sensorimotor function to psychological well-being. AT was reported to offer the client with SCI/D an opportunity to gain function and independence in a way not possible on land. Pool accessibility and constraints around therapeutic pool use were mentioned as major barriers to AT utilization.
Most respondents (60%) did not receive AT instruction in their educational program and respondents who did not use AT scored significantly lower in AT knowledge than respondents who used AT. Canadian physiotherapy programs are reported to usually include 1-2 h of theoretical and/or practical class time on AT in their curriculum (Ashton, 2018).24 Barriers to including AT in the PT curriculum were access to pool facilities, feasibility for large class sizes, and lack of knowledgeable PT professors in AT education and practice.22 Most professionals providing AT both in Ashton’s study24 and in the present study seem to pursue AT education after graduation.
In addition to issues around accessible pools in the community, other factors likely influenced our respondents’ choice to provide AT, such as the support in the work environment for AT and having sufficient time to offer AT as part of their practice. The results on the closed-ended questions validate what the respondents reported on the barriers to AT implementation, where “insufficient time to apply AT” was one of the primary constraints. Indeed, respondents mentioned the extra-time needed for clients’ showering and changing was a factor limiting the use of AT for individuals with SCI/D.
Participants in this study identified AT as a unique approach to facilitate functional movement after SCI/D, in a way not possible on land. The uniqueness of the aquatic environment was also elucidated in our exploratory study.19 For instance, water was described to be an ideal environment for clients to explore their movement performance (e.g. walking, transfers), due to less gravity, the soothing effect of warm water to diminish pain, and reduced fear of falling.19,25 Respondents reported that individuals with SCI/D also improved their sense of well-being and confidence when exercising in water, while improving function, range of motion, muscle strength and balance.
Despite the numerous benefits of AT for the health and function of individuals with SCI/D, the implementation of AT faces challenges related to pool accessibility, cost, transportation, clients’ comorbidities, pool scheduling, staffing, and professionals’ education.19,24 Certain barriers could be mitigated by educating healthcare professionals, clients and community stakeholders on the benefits of providing AT. For instance, more in-depth and standardized AT education and training in school curricula could be implemented in the physiotherapy, kinesiology and physiotherapy assistant programs across Canada. There could be more robust AT knowledge dissemination for stakeholders on the value of AT, aimed at improving access to therapeutic pools in the community. Existing therapeutic pool programming could be optimized to attend to the needs of people with lower-functioning abilities. This must address the pool architecture (i.e. entry/exit) as well as the building entrance, showering and toileting areas. Furthermore, pool scheduling could accommodate all clients’ needs by providing more flexible hours of use and costs could be contained with one fee per client, inclusive of the support persons.
Limitations
There was a discrepancy in the percentage of respondents in the group who used AT and in the group who did not use AT, which may have compromised the comparison among these two groups. This discrepancy is probably due to selection bias when recruiting participants to take part in a study investigating aquatic therapy post-SCI. The open-ended questions within a mixed-method survey possibly limited the respondents’ reporting of their perspectives of AT due to the absence of probing questions and verbal dialogue. Nonetheless, the sample sizes of both groups (i.e. those that use AT and those who do not) were adequate for exploring the barriers and facilitators to AT implementation for people living with SCI/D.26 We recognize that “aquatic therapy” is not a protected terminology or technique, and a variety of professionals other than PT, PTA and KIN might use AT for their clients. We chose to survey these three classes of professionals, who are common administrators of AT. The reported benefits of aquatic therapy arose from participants’ clinical experiences. Further experimental studies are warranted to determine the effectiveness of aquatic therapy post-SCI, including examining the translation of therapeutic gains from the aquatic environment to daily life.
Conclusion
This study describes the perspectives of Canadian PT, PTA and KIN on the use of AT for SCI/D by specifically examining their background, knowledge, and current practice, and their experiences with implementation barriers and/or facilitators. This survey allowed detailed investigation of a larger number of professionals practicing AT in several healthcare settings across Canada. AT was reported to promote physical and psychosocial benefits to its users, despite barriers around pool accessibility, time and cost. This study will support health care providers and institutions when considering strategies to increase the access to AT after SCI/D.
Disclaimer statements
Contributors None.
Conflicts of interest The authors have no conflicts of interest to declare.
Funding Statement
This work was supported by Craig H. Neilsen Foundation grant to KEM; CIHR new investigator award to AM.
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