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April 2001


Integrating Land and Water

By Ann L. Charness, PT, MS

Integrating Land and Water

Identification, utilization, and transition are integral components of a synthesized land/pool program

The pool is a specialized environment where the properties of water allow for progressive therapeutic exercise and functional mobility training. Unfortunately, it is also an environment that is misused, especially when therapists believe that therapy in the pool is essentially performing land exercises in the water, and when physicians refer patients who do not make progress on land to the pool as a last resort, even though the properties of water do not allow for elimination or minimization of the client’s impairments and functional limitations. As providers of skilled therapy interventions, therapists using the pool should be able to identify patients who will benefit from therapy in the water and design integrated land/pool programs. Activities done in the pool should allow the patient to perform activities that cannot be accomplished on land. Similarly, the therapist must make sound clinical decisions when determining how to transition the patient from therapeutic interventions in the water to therapeutic exercise and functional training on land.

DESIGNING the INTEGRATED program

A referral for therapy is received that may or may not include specific orders for aquatic therapy. Because function occurs on land, the initial examination and evaluation are carried out on land. When available, the medical record is reviewed. The patient is then interviewed and a history is taken. It is crucial to determine what a day in the life of the client was like premorbidly and to establish the patient’s goals from therapy. The therapist then selects the appropriate tests and measures to examine the patient’s current functional status. The therapist selects relevant functional tasks, determines whether the patient can perform the tasks, and, if not, identifies the impairments that might be limiting function. Further examination is needed to measure the severity of the impairments and to determine whether they are correctable or whether they will need accommodation.

Once the tests and measures are completed, the evaluation process begins. Tests and measures are interpreted so that a diagnosis and prognosis can be established. The diagnosis involves clustering the patient’s signs and symptoms into a diagnostic category for which an evidence-based treatment intervention is established. Prognosis involves identifying the patient’s functional potential within the current episode of care. Associated medical conditions and modifiers (support systems, environment, education, finances, and resources) must be considered when finalizing the prognosis. Long-term functional outcomes are established considering the goals and expectations of the patient. Short-term stepping-stones are laid out to consider potential barriers that may intervene. Then the plan of care to meet established goals is designed. Critical to this is deciding whether the patient is a candidate for an integrated land/pool program.

The patient must be unable to perform exercise, self-care, functional mobility, and vocational and avocational activities on land, and the properties of water need to minimize or eliminate the impairments limiting function on land in order for a land/pool program to be effective. Treatments in the pool must increase exercise tolerance or functional mobility on land. From the initial session in the pool, there must be a plan in place to transition the patient to a land-based program with or without community-based nonskilled aquatic programs.

Once the patient is deemed appropriate for a land/pool intervention, the therapist must select and justify activities that will be performed in the pool and ensure that there is no duplication between pool and land. This does not mean that the patient cannot be working on an activity in the two environments so long as the difficulty or constraints of the task are different. Progressions in function in the pool should result in coinciding functional progressions on land.

There are several guidelines to use when making the transition from pool to land exercise and functional mobility training. Total unloading of the spine can be discontinued when the patient is able to walk and make movements of the trunk in nipple-deep water. When the patient can walk in water at the depth of the anterior superior iliac spine, the effect of buoyancy is insignificant and the patient is ready for gait training on land. The pool can be discontinued when weight-bearing restrictions are removed, when the patient can exercise buoyancy resisted, and when there are no restrictions to using external resistive devices attached to a single location on the limb. The patient is initially progressed from exercise producing a streamlined flow where the resistance of the water is equal to the velocity, to exercise producing a turbulent flow where the resistance is equal to the velocity squared. The patient can be transitioned to a land program when able to move through a turbulent flow in a variety of positions.

The decision to transition a patient from pool to land should not be an all or nothing decision. Therapists must decide which activities the patient can begin to perform on land and which still require the assistance of the properties of water. For example, a patient may be able to transfer from floor to standing on land, but not stoop down to pick up a crate of toys. Practicing lifting using the buoyancy assist of the water in the pool and stooping and getting up on land are appropriate. A patient can also return to the pool later in the comprehensive rehabilitation program when necessary.

The pool should be discontinued when the patient meets established goals and can carry out exercise on land, when the gains made in the pool do not carry over to land, and when the patient fails to make progress both in the pool and on land. In order to minimize inappropriate use of the pool, admission and discharge criteria need to be established and communicated to all referral sources. Strict adherence to these criteria is essential.

Once therapy is completed, the degree to which long-term functional outcomes are met is measured in order to determine efficacy of the interventions. Therapists should also look at cost benefit factors when determining the efficiency and effectiveness of the pool component, bearing in mind the needed resources.1-3 Following is a case study that illustrates this process.

CASE in point

JH is a 36-year-old woman who, in the ninth month of her second pregnancy, was involved in a motor vehicle accident that resulted in a fractured right patella and a shattered acetabulum when her knee hit the dashboard. She lives in a two-story house (bathroom and bedrooms upstairs) with her husband and 8-year-old son. JH is the director of nursing staff development and training at a large rehabilitation hospital, and also serves as primary child care provider and homemaker.

The patient’s immediate medical management was to deliver the baby by cesarean section, and pin the patellar and acetabular fractures. JH spent a week in the acute care hospital and 2 weeks in acute rehabilitation. She is to continue her rehabilitation as an outpatient. The diagnosis was the preferred practice pattern 4H impaired joint mobility, motor function, and muscle performance associated with fracture. Her prognosis was favorable for return to premorbid activities.

The long-term goals to be achieved in 4-6 weeks established by the patient and the rehab team included independence in the following activities of daily living: all transfers including toilet, tub, sofa, car, and floor; ambulation on all surfaces indoors and outdoors without an assistive device; all basic self-care activities without use of adaptive equipment; management of stairs step-over-step without a rail; meal preparation, light housekeeping, and laundry; driving both a car and van; care of the baby; and sitting and working on the computer for 1 hour without a break.

The goals for the first week of outpatient therapy included the ability to: transfer from sit to stand in a standard height chair without armrests; sit and reach for objects on the right at heights placed beyond arm’s length; stand unsupported for 2 minutes and maintain balance when managing clothes for toileting; ambulate on level surfaces indoors with a quad cane and supervision for risk of falls; ascend and descend stairs step-to-step with a rail and quad cane going up leading with the left leg and going down leading with the right leg; stand leaning against the crib and diaper the baby with equipment laid out within arm’s reach; stand holding onto the counter with one hand, and reach for object on the first shelf of a cabinet either above or below the counter; and flex hip to 100° to lift leg into the tub or move foot from the gas pedal to the brake. Her pain was also reduced at rest to 3/10 and during activity to 6/10.

The team deduced that she would benefit from an integrated land/pool program. The therapist justified how the properties of water could minimize or eliminate the patient’s impairments and functional limitations.


TABLE 1: FUNCTIONAL LIMITATIONS AND POSSIBLE IMPAIRMENTS.

1. Dependent in all transfers with the exception of sit to stand from a standard height chair with arms, pain, limited range of motion (ROM), hip & knee flexion, inadequate lumbopelvic stabilization, weakness in right (R) leg, adhesive incisions, edema especially in ankle;

2. Dependent in standing & balancing unsupported, pain, unable to load weight onto (R) leg, ROM deficits hip and knee extension, weakness in (R) leg, edema peripherally in leg, standing tolerance limited to 10 minutes;

3. Unable to walk without a walker/dual handed assistive device, therefore cannot walk and carry, walking tolerance limited to 50 feet, pain, unable to load weight on (R) leg, limited range of motion, weakness in quads, hip extensors;

4. Unable to use stairs without using two hands on rail, therefore cannot carry objects up and down stairs, pain, weakness in hip and knee extensors, abdominals, and hip abductors, decreased hip and knee extension range, edema peripherally in leg, standing tolerance limited to 10 minutes;

5. Difficulty with toileting: difficulty reaching down to manage clothing, and transfer to and from toilet, pain, ROM in hip and knee (R), weakness (R) leg especially hip and knee, cannot stand unsupported, cannot load weight onto (R) leg, standing tolerance limited to 10 minutes;

6. Difficulty with dressing: donning and doffing shoes and socks, cannot don slacks in standing, difficulty retrieving clothes walking with walker, limited hip and knee flexion & hip external rotation ROM, decreased hip flexion strength, unable to load weight onto (R) leg, pain, cannot stand unsupported, cannot walk and carry with need to use walker;

7. Difficulty with bathing in tub: transferring lifting leg into tub and with washing lower legs and feet without adaptive equipment, pain, unable to shift weight in sitting, inadequate hip flexion and external rotation and knee flexion ROM, weakness in (R) leg, unable to stand unsupported, unable to load weight onto (R) leg in standing;

8. Difficulty with meal preparation: retrieving items, standing and reaching into cabinets & refrigerator, getting food items and meals from one area to another, lifting food, standing the time needed to make meal, doing bimanual meal preparation tasks, pain, limited sitting and standing tolerance, unable to stand unsupported, unable to walk without bimanual assistive device, unable to walk and carry, unable to load weight onto (R) leg, unable to crouch/stoop down, limited hip & knee flexion range, weakness (R) leg;

9. Unable to drive: transferring into and out of car, sitting tolerance limited to 10 minutes, inadequate hip & knee flexion ROM, and strength to move foot from gas pedal to brake;

10. Unable to clean house and do laundry: stooping down to retrieve items from ground, unable to stand/walk and vacuum, unable to bend down to dust lower items clean bathtub and toilet, pain, inadequate hip and knee flexion ROM to stoop down, unable to load weight onto (R) leg, unable to stand unsupported, unable to walk without bimanual assistive device, unable to walk and carry, unable to stand and lift, unable to floor to stand transfers; and

11. Unable to take care of newborn: lifting baby while standing, standing, and balancing to change diapers, walking and carrying baby, sitting long enough to nurse baby, standing and reaching, sitting and reaching, standing unsupported to bathe baby, walking with carriage, pain, unable to load weight onto (R) leg in sitting or standing, limited sitting standing and walking tolerance, needs bimanual assistive device for walking thus cannot walk and carry, weakness in (R) leg, inadequate knee, and hip flexion range to stoop down.



TABLE 2. JUSTIFICATION OF ACTIVITIES PERFORMED IN THE POOL.

  • Stretching activities. Neutral warmth of the water prepares the connective tissue for stretching, use of buoyancy assist to move in direction of restricted movement, buoyancy support of the limb allows for relaxation of protective muscle spasm.

    —Hamstrings: standing at side of pool hip flexed, float under knee letting buoyancy extend knee

    —Tendo-achilles: standing at edge of step fairly deep in pool and letting heel drop off the edge

  • ROM activities. Neutral warmth of water prepares connective tissues for stretching, buoyancy assist to move limb in direction of restricted movement, use of buoyancy support allows relaxation of protective muscle spasm, hydrostatic pressure of water reduces edema especially when limb is deeply submerged

    —Hip flexion: standing at side of pool with leg extended letting leg float up to surface of water

    —Knee flexion: standing facing side of pool with hip extended and knee flexed letting foot rise (knee flexion)

    —Hip external rotation: standing at side of pool with hip and knee flexed letting buoyancy support weight of leg, move leg in and out

  • Basic water safety skills especially supine and prone float and recovery, hips and knees flex as recline to float position and as recover returning to vertical, buoyancy assist to flex legs

  • Strengthening activities. Use of buoyancy (buoyancy assist-> support->resist) and hydrodynamic forces (degree to which body is streamlined and velocity of movement) to grade strengthening, use of buoyancy weight relief to decrease pain

    —Hip abductors: supine with increasing speed

    —Hip flexors-extensors: side lying with increasing speed; scissor kicking

    —Knee flexors-extensors: side lying with increasing speed

    —General leg strengthening using Bad Ragaz patterns both unilateral and bilateral-supine, use of turbulence as therapist either pushes patient away from her or when therapist turns patient in water

    —General leg strengthening closed chain – squats, step climbing, pushing off side of pool for swim strokes: weight relief to decrease pain

  • Dynamic lumbar stabilization to strengthen abdominal muscles especially postpartum. Use of buoyancy support to take the weight of the body and allow relaxation and protective spasm, use of buoyancy support to provide postural support and balance, use of weight relief to decrease pain

    —unload spine in deep water

    —pelvic mobility in supported supine: passive and active

    —bridging lying in supported supine with a float under knees

    —pelvic mobility standing in nipple deep water at side of pool to out away from side of pool

    —assisted maintenance of chair position supported on therapist’s knee maintaining neutral pelvis and lumbar spine; add bilateral to unilateral arm and/or leg movements or combinations

    —independent maintenance of chair position maintaining neutral pelvis and lumbar spine

    —walking unloaded in deep water maintaining neutral pelvis and lumbar spine

  • Sit to stand in nipple deep water from high stool to bench to step without using arms – uses buoyancy assist to help stand up, use of buoyancy weight relief
  • Sitting weight shifting onto (R) buttock in nipple deep water – use of buoyancy weight relief, use of buoyancy support for trunk stability and balance
  • Standing and marching in nipple deep water thus loading and unloading (R) leg – buoyancy weight relief, buoyancy support for trunk stability and balance
  • Gait progression. Use of buoyancy weight relief and weight support for trunk stability and balance, use of streamlined to non-streamlined body position hydrodynamic principle, use of increasing velocity hydrodynamic principle, moving from streamlined to turbulent flow hydrodynamic principle, use of hydrostatic pressure to decrease peripheral edema and increase circulation

    —walking streamlined in nipple deep water at slow speed

    —walking less streamlined in nipple deep water at slow speed

    —walking less streamlined in nipple deep water at faster speed

    —walking in nipple deep water and turning 90° in both directions

    —walking backward and sideways in both directions in nipple deep water following same progression as a-d above

    —walking and changing directions from forward to backward and from side to side initially turning after several steps then gradually reducing the number of steps between turns and increasing the speed of walking in nipple deep water

    —walking in nipple deep water with high stepping increasing speed as tolerated

    —walking forward in nipple deep water with plow

    —walking forward in nipple deep water carrying something

    —walking forward into jet in streamlined position at slow speed in nipple deep water

    —progress to more shallow water and repeat sequence above as tolerated

  • Steps in water. Buoyancy weight relief, buoyancy support for trunk stability and balance, buoyancy assist for rising onto step —Start with 2 inch step in nipple deep water holding onto hands of therapist

    —Progress to standing at side of pool in nipple deep water holding on with one hand and mount and descend step

    —If tolerated progress to climbing and descending stairs in nipple deep water with no external support

  • Cardiovascular conditioning. Use of weight relief, use of buoyancy support for postural stability and balance, exercise in environment safe for injured joints

    —Walking supported in unloaded position in deep water

    —Swimming strokes with flutter kick or frog kick



TABLE 3: LAND-BASED THERAPY

1. Deep friction massage to incisions
2. Modalities as needed—hot packs, TENS, ice
3. Distractions and gentle mobilization to hip capsule—grade 1-2 for neuromodulation of pain
4. Gentle patellar mobilization and knee mobilization—grade 1-2 for neuromodulation of pain
5. Retrograde massage to leg in elevation
6. Sit on pillows and weight shift laterally mobilizing lumbar spine PRN and stretching iliotibial band PRN
7. Closed chain lower extremity strengthening exercises in supine, sitting on a wedge, and supported standing at edge of high low table
8. Sit to stand without using hands from high mat gradually decreasing height as tolerated
9. Progression to standing unsupported statically—stand in parallel bars and remove 1 arm maintaining trunk alignment and stability-> removing both hands to standing outside bars with 1 hand on rail and other free-> standing outside bar holding quad cane-> standing outside bar moving quad cane -> standing outside bar not holding on -> standing and reaching within then outside arm span to all sides, etc.
10. Walking with quad cane and support -> stabilization as needed on level floor indoors
11. Standing at counter in kitchen holding on with 1 hand and reach for objects on counter to both sides ( incorporate into meal preparation)
12. Standing at counter in kitchen holding on with one hand and retrieve light items from first shelf of cabinets above and below sink (could do something like unloading dishwasher)
13. Standing in bathroom holding counter with 1 hand as manage clothes with other hand
14. Sitting and donning and doffing socks with adaptive device to crossing 1 leg over the other and leaning down as hip range increases and as patient can load (R) buttock
15. Standing leaning against counter as needed and do meal preparation
16. Toilet and tub transfers gradually removing raised toilet seat and work at lifting legs into tub possibly with strap to assist at the beginning



Ann L. Charness, PT, MS, is assistant professor, Department of Rehabilitation Sciences, MCP Hahnemann University, Philadelphia. She is the former president of the Aquatic Physical Therapy Section of APTA.

REFERENCES
  1. Guide to Physical Therapist Practice. Alexandria, Va: APTA; 1999:4H1-13.
  2. Styer-Acevedo J, Cirullo JA. Integrating land and aquatic approaches with a functional emphasis. Orthopedic Physical Therapy Clinics of North America: Aquatic Physical Therapy. 1994;3:165-178.
  3. Aquatic Physical Therapy Section. Developing an Aquatic Physical Therapy Program: A “How To” Manual for Developing and Implementing Your Program. Fairhope, Ala: APTA; 1998:27-29.

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