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December 2003


Winter Warming

By Andrea Salzman, MS, PT
Aquatic specialty techniques bring new meaning to therapeutic immersion.

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 gift (a Midwestern-themed calendar that reported fun facts like “the temperature at which flesh freezes”), all the roads back home were frozen shut. I was here for the duration. Since then, I have tried to discover what the native people do to keep limber in the winter months (read: October through April). I tried snowmobiling; I tried ice fishing. But after 4 years in Minnesota and 6 in Wisconsin, I have finally found my winter calling: warm water immersion. Now some may not give immersion its due as a true winter sport. These people obviously live south of the Mason-Dixon Line. Be logical. A pool user must wear a swimsuit, and in my book, any activity requiring a piece of clothing that includes a verb in its title is automatically a sport. Plus, there is nothing like immersion in warm water for release of stress and promotion of relaxation.

Aquatic therapy versus spa therapy

It is important to understand that water can be used for both passive immersion and active tasks or exercise. There are two main categories of aquatic passive modalities: spa therapy or “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 labeled 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 United States, the term hydrotherapy is typically used as a synonym of the term “whirlpool bath” and is used predominantly to describe wound care.

Many people believe that the power of immersion is in the activity that occurs once immersed (eg, gait training, therapeutic exercise, functional task simulation). In fact, the American Medical Association describes aquatic therapy as an attempt by a therapist to improve function through the application of aquatic therapeutic exercises. But there is still a case to be made for the joys of inactivity and stillness. So, open your mind to a marriage of Old World spa therapy and New World aquatic therapy, and learn what wonders creative pool programming can offer your clients.

Aquatic specialty techniques

Ai Chi: This technique refers to a form of active aquatic therapy modeled after the principles of Tai Chi and yogic breathing techniques. Ai Chi is typically provided in a hands-off manner (the provider stands on the pool deck to allow the client to view the complex patterns). 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 (aquatic PNF): Modeled after the principles and movement patterns of PNF, 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 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 (TTTA): This is a set of guiding principles that help practitioners create functional therapeutic activities for patients to perform in water. 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 that 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 PNF, Bad Ragaz is always performed in a hands-on manner by the provider. 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 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. During active Fluid Moves, the student is guided in an exploratory process, following a sequence of movements based on the early developmental stages of an 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, Halliwick is typically performed in a hands-on manner by the provider and 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 that 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, 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.

The ARC: In Danville, Ill, Mick and Sue Nelson have combined the luxury and indulgence of spa therapy with the functional benefits of aquatic therapy, and dubbed it the aquatic relaxation chamber (ARC). Used only within the Nelsons’ clinic, the ARC 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, watching the soothing visual image of the beach at sunset, and 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....

Andrea Salzman, MS, PT, is founder of the Aquatic Resources Network, Amery, Wis, (www.aquaticnet.com), an online network of more than 10,000 aquatic therapy providers. Acknowledgements

The operational definitions of specialty techniques given in this article were constructed by the author and various experts in the field for the publication Evidence Based Aquatic Therapy (Amery, Wis: Aquatic Resources Network; 2004). These experts include: Jun Kunno and Ruth Sova (creators of Ai Chi); David Ogden and Lynette Jamison (authors of Aquatic Therapy Using PNF Patterns); David Morris (coined term “aquatic task-type training approach”); Gwendolyn Garrett (author of Bad Ragaz Ring Method. In: Ruoti RW, Morris DM, Cole AJ, eds. Aquatic Rehabilitation for Health Professionals); Debbie Ashton (creator of Fluid Moves); Johan Lambeck (spokesman for the International Halliwick Association); and Howard Dull (creator of Watsu). References
  1. Metathesaurus Medical Subject Headings and Annotation Note. Washington, DC: National Library of Medicine, MeSH Number E2.780.108,1993.
  2. Metathesaurus Medical Subject Headings and Annotation Note. Washington, DC: National Library of Medicine, MeSH Number E2.780.450,1991.

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