An Aquatic & Rehab Institute, Inc. Publication

September 2006 • Volume 9 • Issue 2 Therapeutics andFitnessCombined Using an Underwater ExerciseUsing anUnderwater Bike: Stomas, Ostomies,andAppliances: Implications forAquaticTherapy Burdenko Method W Individuals withFibromyalgia: A Look at aLiteratureSample Aquatic Therapy for Implementing the ith Children Table of Contents

Feature Articles The Aquatic Therapy Journal is Stomas, Ostomies, and Appliances: Implications for Aquatic Therapy ...... 3 published biannually by the Sue Skaros, BA, BS, PA-C; Sarah Lundeen, MSN, NP Aquatic Therapy & Rehab Charles Mathison, BSN, CWOCN and Mary Otterson, MD, MS Institute, Inc. and the Aquatic Association. The Aquatic Using an Underwater Exercise Bike: Therapeutics and Fitness Combined . . . 11 Therapy Journal articles are peer Carrie Paterson, BS, F.J. Gaenslen School, Milwaukee, WI reviewed to insure the highest quality information. Implementing the Burdenko Method With Children ...... 16 Paula Ray, OTR & Tera Galloway, CPT ATRI prohibits discrimination on the basis of race, color, religion, Aquatic Therapy for Individuals with Fibromyalgia: ...... 21 creed, sex, age, marital status, A Look at a Literature Sample sexual orientation, national origin, Janet MK Gangaway, DPT, OCS, ATC, ATRIC , or veteran status in the Assistant Professor of , University of Hartford, CT treatment of participants in, access to, or content of its pro- Feature Columns grams and activities. Pool Problems: Chlorine Smell ...... 7 Articles may be submitted as a Alison Osinski, Ph.D., Aquatic Consulting Services, San Diego, CA contribution to the profession; no remuneration can be made. Interface: Aquatic Therapy Professionals Interact with…Educators ...... 9 Carrie Paterson, BS, Physical Education Specialist, Submissions should be directed to F.J. Gaenslen School, Milwaukee, WI Managing Editor Susan J. Grosse, [email protected]. Research Review ...... 15

For permission to reprint for New for Your Library ...... 15 academic course packets, please send a written request to Around and About the Industry ...... 23 [email protected]. Web Waves ...... 25 For Subscription and Membership information, please contact Others AEA, [email protected], From the Editors ...... 2 phone: 941.486.8600 Jalkanen Foundation and ATRI Award Scholarships ...... 10 Opinions of contributing authors for Aquatic Therapy Studies do not necessarily reflect the ICATRIC Updates ...... 25 opinions of AEA and ATRI. ©2006 AEA/ATRI-Nokomis, Florida ATRI Mission Statement Volume 9, Issue 2 The Aquatic Therapy & Rehab Institute, Inc. (ATRI) is a non-profit, educational corpo- Managing Editors: Sue Grosse ration dedicated to the professional development of health care providers in the area of Ruth Sova aquatic therapy. Offering educational courses, ATRI provides opportunities to advance the competencies, knowledge and skills of the aquatic therapist. Graphic Design: Carolyn Mac Millan

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On the Cover: Learn more about utilizing the Burdenko Method with children in the article by Paula Ray and Terra Galloway, found on page 17.

1 Aquatic Therapy Journal • September 2006 • Volume 9 • Issue 2 Sue Skaros, BA, BS, PA-C Stomas, Ostomies, and Appliances: Sarah Lundeen, MSN, NP Charles Mathison, BSN, CWOCN Implications for Aquatic Therapy Mary Otterson, MD, MS

In the exam room was a middle-aged With a urostomy, urine no longer emp- An ileostomy involves fecal drainage woman returning to our clinic after ties from the bladder. Instead, a section from the last part of the small intestine. having part of her bowel removed. She of small bowel is separated out to create Evacuated material will be quite liquid. was adapting well to having a stoma, a new bladder, and urine drains out of A colostomy drains fecal contents from and felt “fine”, but still seemed a bit the stoma into a disposable appliance or the large bowel or colon. Because this “down-in-the-dumps”. When asked collection bag. Some urostomies are is the part of the bowel where water is what her biggest concern was about continent, meaning they do not drain reabsorbed, evacuated matter will be having a stoma, she replied, “I can’t go into a bag. Instead, they require period- less liquid, and thicker than that from anymore, and I really miss ic catheter insertion to empty the neo- the small intestine (Hollister 2003). it!” Staff tried to reassure her she cer- bladder. Initially, there are bacteria in tainly could go swimming, but she con- the urine from normal bowel flora, but Every stoma is just a little bit different. tinued to be skeptical. She was afraid within a very short time, unless there is Some protrude, others don’t. They her appliance (bag) might fall off, or an infection, urine in this bowel seg- should never be painful, but they she might leak material into the water. ment becomes sterile. Stool no longer should be bright pink and moist. She said she would be “absolutely mor- enters this part of the bowel (Hollister, Because of the significant blood supply tified” if this happened and was afraid 2003). However, urine in the collection to the bowel, they may bleed easily if to even try. bag is considered contaminated. bumped or rubbed. This is not abnor- mal, usually occurs in small amounts, Her concerns are very real concerns. With an ileostomy or colostomy stool and stops within a very short time. Of However, are they realistic? Can is no longer evacuated through the rec- course, persistent or vigorous bleeding people with stomas engage in aquatic tum and anus. Instead, it is collected in would necessitate a phone call to activities? What about clients with a disposable appliance that must be the client’s Wound, Ostomy and indwelling catheters or tubes? What are periodically emptied. People with Continence Nurse (WOCN) or physi- the risks? What if an appliance leaks? ileostomies and colostomies are unable cian (Hollister, 2004). Worse yet, what if it falls off or comes to control the elimination process. They out? Is it better to just avoid problems are, however, able to prevent spillage Stomas are usually ready for immersion and have these individuals stay out of and leakage of fecal contents by using in water, whether bath or swimming, by pool water? Or, is the fear greater an appliance, thus having their elimina- the time the surgical wound has com- than reality? tion under control. pletely healed. However, a stoma should not be immersed without first obtaining clearance from the surgeon. Stomas All clients with fresh (less than two A stoma is a surgically created opening months old) stomas should obtain a in the skin to allow drainage of urine release from their surgeon before engag- or fecal material. (See Figure 1*) It ing in aquatic activities. Open water results from to remove the uri- activities (as opposed to pool-centered nary bladder, or part of the bowel ones) should be undertaken with cau- because of disease or injury. The type tion. The higher load of bacteria and of surgery an individual undergoes parasites found in open water may pre- determines the appliance system which clude those individuals who are must be used in place of natural immunosuppressed or who have med- human anatomy. Once an appliance is ical conditions, such as kidney failure functional, and all surgical sites are which can predispose them to infection. healed, an individual is expected to resume regular activities. While excre- Appliances and tion of waste is no longer controlled Aquatic Participation by the individual, presence of an appli- *Figure 1— Ileostomy Anatomy supplied courtesy Appliances are devices used when nor- ance which catches this waste allows of Hollister Incorporated, 2000 Hollister Drive, mal anatomy is no longer able to per- them to be considered continent. Libertyville, IL 60048-3781 form its usual function. Prosthesis is ® 3 Aquatic Therapy Journal • September 2006 • Volume 9 • Issue 2 the term used when a device is used to case for individuals with urostomies, as of infected matter around the catheter replace a missing part of the anatomy. it is a known physiologic response that into the water, as well as erosion of For the purpose of this article, the urine output is increased when people catheter tip and balloon into the wall, term “appliance” will be used for both are immersed in water which is cooler with subsequent bleeding. In addition, conditions. than normal body temperature. every time the drainage system is opened to disconnect the catheter from a There are two main types of pouching Catheters are another type of drainage drainage bag, bacteria are reintroduced systems used with stomas—One-piece system. Some clients may have a tube into the system causing more contami- system and Two-piece system. The one- protruding from the stoma, such as a nation (WOCN, n.d.). Simply wrapping piece system has the tape, skin, barrier, supra-pubic tube for draining the blad- an occlusive dressing around the and pouch in layers and adheres direct- der, a gastrostomy tube into the stom- catheter where it enters through the skin ly to the skin. This system requires ach, or a jejunostomy tube into the is insufficient to reduce spread of poten- complete removal whenever the pouch small bowel. The last two of these are tially infectious material into the water. needs to be changed. However, it can be for purposes. These catheters Therefore, clients who cannot remove emptied without removing the device. may be capped when not in use. In these catheters or place them inside of The two-piece system has a separate addition, if these devices are very pli- an ostomy appliance adhering directly to adherent skin barrier with a plastic able, they can be covered with an occlu- the skin, should not participate in aquat- flange on it. The pouch has a reciprocal sive dressing to keep them away from ic activities. flange, which allows it to be attached to water exposure. the skin barrier, and it can be removed Aquatic Pre-participation for changing without disrupting the Indwelling catheters are considered to skin barrier. This device can also be be contaminated. Bacteria most often Precautions emptied without removing the pouch associated with this contamination are Clients with stomas can take precau- (Hollister, 2003). usually opportunistic skin flora which, tions to minimize likelihood of having a more often than not, pose more of a leak. After changing the flange, at least In addition, there are disposable, tem- threat to the client than to others. several hours, preferably overnight, porary bags that can be used by clients However, individuals who have associ- should lapse before engaging in aquatic who have continent stomas or drainage ated illnesses such as diabetes, kidney activities. This allows adequate adher- catheters, and choose not to, or cannot failure, or cancer, or are immunosup- ence of the adhesive substance to the cover them with an occlusive dressing. pressed may also have contamination skin. The flange can be reinforced with Mini-bags and non-drainable low pro- with Methicillin Resistant Staphylococ- waterproof tape if the client is still con- file bags are also available, and might be cus aureus (MRSA) and Pseudomonas cerned about leakage. An optional belt preferable for aquatic activities. species, which may cause problems to may be added to many appliances Pouches with built in filters for releas- others in aquatic settings (Maki, 2001). which will keep the appliance close to ing gas need to be avoided for use dur- For additional information on working the body. Rubber belts are preferable to ing aquatic activities because they allow with individuals with MRSA, please cloth ones as cloth belts have a tenden- the drainage bag to fill with water, and refer to Skaros, S. (2006). MRSA – cy to stretch when wet (Ostomy cause effluent to leak back out through Shark or Guppy? Aquatic Therapy Association of Southwestern Indiana, the filter. (Ostomy Association of Journal. 8(1), pp 11-15, February. 2006). A pouch cover can be worn to Southwestern Indiana, 2006). People help disguise the pouch, in addition to with ostomies, or their caregivers, are Ideally, rigid or non-pliable tubes keeping it close to the body (Hollister, taught how to care for, empty, clean, should be removed, with the approval 2003). Wearing a second swim suit or and change their appliances before and of the client’s physician, and the stoma a tighter undergarment, such as biking after their surgical procedures covered with an occlusive dressing shorts or a stretch panty girdle, under a (CaregiverPA, 2006). (Op-Site™ or Tegaderm™) before swim suit can help hold the appliance engaging in any aquatic activities. in place, and reduce chance of it falling Pouches may be closed and require Another option is to have the client off. However, undergarments should removal and disposal, or drainable place the tube inside of an attached not be tight enough to restrict flow which can be emptied repeatedly. temporary ostomy appliance, creating of effluent into the bag (Ostomoy Drainable devices are designed for fecal a closed system while they engage in Association of Southwestern Indiana, systems using either a clamp or plastic aquatic activities. If they cannot be 2006). fasteners and for urinary systems using covered or enclosed, clients should not a drain valve with or without an exten- engage in aquatic activities, including Male clients might consider wearing a sion (Hollister, 2003). Draining these aquatic therapy. boxer-style suit with an added appli- pouches immediately before entering ance pouch on the inside. Females the pool minimizes possibility of leak- Attempts to place non-pliable devices should choose suits made of “busy” age. Depending upon how quickly the under an occlusive dressing may involve patterned fabric with ruffles, sashes, or appliance fills, the client may need to folding the catheter, causing pressure on bows to help camouflage the presence leave the pool periodically to empty the the bladder, stomach, or bowel wall. of an appliance (Ostomy Association of bag. Usually, this would only be the This can cause spasming and extrusion Southwestern Indiana, 2006). ® September 2006 • Volume 9 • Issue 2 • Aquatic Therapy Journal 4 Other tips include— Contraindications to not just those with stomas or catheters. • Clients should not eat or drink for Aquatic Activity Aquatics is contraindicated for any- several hours before engaging in one— When is aquatic activity, including • who has had recent open surgery aquatic activities as this will increase aquatic therapy, contraindicated for fecal output. At the least, they should (having an incision and open clients with stomas or tubes? Even wound), and has not been released by refrain from chewing gum, drinking though chlorine, ozone, and bromine his or her surgeon. carbonated beverages and beer, or are effective disinfectants, not all poten- • with open sores, open wounds, or drinking through a straw within two tial pool contaminating organisms are active skin infections. hours of going in the water because able to be destroyed in a timely manner • with skin breakdown—areas where this will increase gas output, and (MMWR, May 25, 2001). Therefore, the skin is red, raw, and painful. cause the bag to fill more quickly. before answering this question, several • with active infection and/or fever • Clients who have concerns about factors need to be considered— involving any body system. odor from their bags can consider • What kind of facility is involved? • with diarrhea, defined as other than using some mint mouthwash (not red Large, small, indoor, outdoor, open normal, healthy fecal output of an as this can look like blood) or Certs™ water, or pool? There is far less risk individual with a small bowel stoma in the pouch (Ostomy Association of of infection in a large community size and appliance, whether or not it may Southwestern Indiana, 2006). swimming pool than in a small therapy be infectious (Healthy Swimming, • Clients should empty their pouch pool, as the larger quantity of water 2006). when it is 1/3 to 1/2 full, making sure dilutes contaminants. Open water • who is incontinent of either feces or facilities are more likely to have larger to clean off the outside of drainage urine—even if they wear diapers. quantities of bacteria and parasites tabs before resealing (Hollister, Individuals with properly functioning than are pool facilities, thus posing a 2003). This should be done even if it appliances are considered to have risk of infection for individuals with means briefly leaving the pool during continence under control. Diapers are appliances. not designed for exposure to large aquatic activity. • What is the temperature of the water? • Female clients should consider wear- amounts of water that aquatics partic- There is far less risk of infection with ipation provides. They are inadequate ing a “tankini” or two-piece type of minimal exposures in regular use for preventing spills and leaking suit to allow for ease of “burping” the pools with cooler water temperatures when soaking wet, even with a rub- collection bag if it fills with gas. than in therapy pools with warm berized outer pant (CDC, 2002). • Clients with colostomies should, if water temperatures. • who require an indwelling catheter possible, irrigate their ostomies in • Is the client continent? If not, can which cannot be covered by an occlu- order to remove accumulated fecal their incontinence be confined and sive dressing or temporary appliance, matter prior to entering the water. controlled by an appliance? and/or in whom covering results in • Remember, heat and exposure to • Can the client, or their caregiver, be possible injury to the client. water will shorten life of the skin bar- compliant with good stoma hygiene rier, requiring more frequent chang- and care? ing (Ostomy Association of South- • Are clients with stomas or catheters Putting It All Into western Indian, 2006). being held to the same hygiene stand- Perspective • Skin barriers require changing at least ards as anatomically intact clients? The biggest problem an individual with every seven days—more often if there “Normal” clients can experience a stoma or catheter faces is their own are skin problems, liquid effluent, or episodes of fecal incontinence when self-esteem. Initially, they live in con- in warm, humid environments. passing flatus (gas). Individuals may stant fear of “being different” and/or • Soaps which may interfere with the pass small amounts of urine either in having the appliance fall off or leak. In or out of the water. Babies, prior to adhesives should be avoided. The reality, a well-fitted appliance is very being toilet-trained, are participating client’s WOCN is a good resource secure. If clients are reluctant to partici- in infant swim programs even though regarding this concern. pate in aquatic activities, they might be they have no control over their bowel encouraged to observe pool activity • Clients should keep a spare appliance or bladder functions. So, if no effort while dressed in their pool attire. with them in case of problems. is being made to check for “skid Advising them to spend a little extra • If the skin appears red, becomes marks” and yellow stains on the time shopping for clothing which will be painful, or the appliance is not stay- underwear of anatomically intact “just right” can go a long way in helping ing attached, the WOCN or physician individuals, the same standard of them to adjust to engaging in aquatic should be contacted for advice and continence must apply to those with activities. There are many resources care (Hollister, 2003). stomas and catheters. available on the internet, as well as through their WOCNs, which can be of Following these few hints will help the Taking the above questions into consider- great help in addressing their concerns. client feel more secure and comfortable ation, when are aquatic activities, includ- with their aquatic experience, and mini- ing aquatic therapy, contraindicated? While changes in weight, certain soaps mize risk of an adverse event. These criteria apply to all individuals, and lotions, and improper application ® 5 Aquatic Therapy Journal • September 2006 • Volume 9 • Issue 2 of the skin barrier can predispose and immaculate skin care are key to Conclusion clients to have accidents, once they maintaining a continent appliance. The Individuals with stomas are far less like- become used to the device, there are more experience and positive results ly to cause contamination of swimming few problems. Experts at ConvaTec stoma and catheter users have, the and therapy pools than are those who (Bristol-Meyers, Squibb, 2005) even more their self-esteem will grow and are anatomically intact. Concerns about note risk of having an appliance fall off their fears lessen. clients with stomas, catheters, and tubes in water is extremely small. Most adhe- are generally unfounded. Because sives have been designed to not only be Should the worst possibility, a large leak anatomical differences of individuals secure in water, but also bond more or an appliance falling off with fecal with stomas are visible, they cause con- tightly when exposed to water. exposure, occur, decontamination of cern. But, in reality, with only a few Additionally, they state, “You could dive the facility should be undertaken fol- exceptions, individuals who have these in the water off the highest diving lowing Centers for Disease Control and appliances are not only quite able to par- board and your bag will stay in place— Prevention (CDC) guidelines, under ticipate in aquatic activities, but also your shorts may come down, but the supervision of the facility’s certified pose no risk to themselves or others bag won’t!” (ConvaTec, 2005, Chapter pool operator (MMWR, 2001). while doing so. In fact, aquatic participa- 12). However, the authors advise Anatomically intact participants who tion, including aquatic therapy for other against trying this. fail to take a naked, hot, soapy shower conditions, can be most beneficial. before entering the water are constantly Participation in aquatics, particularly for With today’s adhesives and appliances, depositing, into the water as they swim, someone who has always enjoyed water risk of leakage is even less likely. small amounts of fecal matter which activity, is part of the normalization Making sure the appliance fits well and has adhered to their bottoms. This process. Aquatic activity improves over- is properly applied is a major step in poses a far greater, and more frequent all fitness, including strengthening of preventing leakage. Reinforcing the skin threat of pathogenic exposure than does abdominal muscles, important for sup- barrier with water proof tape, wearing a an occasional, rare, small leakage inci- port of internal organs. Gastrointestinal belt, pouch cover, and close fitting gar- dent from a client with a stoma or system function is improved through ments, frequent emptying of the bag, catheter (CDC, 2006).

Your reading and study of Stomas, Ostomies, and Appliances: Implications for Aquatic Therapy by Skaros, et. al. can result in 2 ICATRIC/AEA approved CECs. First, study the article. Then complete the study guide assignments as described below. Send your completed assignment and the course fee to Aquatic Consulting & Education Resource Services, 7252 W. Wabash Avenue, Milwaukee, WI 53223. Study of this article must be completed no later than March, 2008. Please allow 4-6 weeks for processing, and your receipt of completion verification. Course fees depend on CEC verification requested. Fees are non-refundable.

ICATRIC = $30 AEA = $20 ICATRIC and AEA = $45 AEA Member discount 20% ICATRIC = $24 AEA = $16 ICATRIC and AEA = $36

Stomas, Ostomies, and Appliances: ACERS #ATJ503/AEA #6832 H Implications for Aquatic Therapy CEC Study Guide Skaros, et. al.

Assignment Preparation – All assignments must be typed. Handwritten material will not be accepted. Start with a cover sheet including your name, mailing address, phone, e-mail address, and CEC article title. Then, begin another sheet of paper and answer the following questions/complete the following applications. If answering a question, state the question prior to supplying the answer. If documenting an application, state the application requirement and then provide your response.

Comprehension – 1. What is a stoma? 2. Following surgery, when can an individual with a stoma go swimming? 3. What types of aquatic venues pose least risk to an individual with an appliance? 4. What type of collection bag is recommended for aquatic participation? 5. Related to aquatic participation, when should an individual be advised to drain and/or change their appliance?

Application – List 10 hints to give an individual with an appliance to facilitate aquatic participation.

® September 2006 • Volume 9 • Issue 2 • Aquatic Therapy Journal 6 regular exercise. To exclude individuals Swimming Pools – United States Authors with stomas from the aquatic environ- 1999. Morbidity and Mortality Susan Skaros, PA-C, is on ment without evidence of a real con- Weekly Report. 50(20),411. May 25. staff at the Medical College tamination risk, would be unfounded Convatec. (2005). Living with a of Wisconsin. She completed and discriminatory. N Colostomy: The Interactive seven and a half years of Colostomy Lifestyle Website. Bristol- practice in Occupational References Meyers Squibb 1999-2005, Chapter Medicine before joining the MCW staff. She has also worked in emergency CaregiverPA. (2006). Personal Care 12, 18. http://www.ostomysupport. info/leak.html. medicine at Sinai-Samaritan Medical Center. Skills Development: Ostomy Care. Her aquatics background is extensive, includ- Healthy Swimming. (2006). Fecal Philadelphia, PA: Pennsylvania ing Red Cross IT status in lifeguard training, Department of Aging. http://care- Accident Response Recommenda- small craft, and water safety. She is also a Red giverpa.psu.edu/manual/text/s5-13- tions for Pool Staff. Atlanta, GA: Cross IT in Emergency Response. She can be ostomy.htm. January 22. Centers for Disease Control. reached at [email protected]. Centers for Disease Control. (2002). www.healthyswimming.org. Mary Otterson, MD, MS is an Associate Questions and Answers for Aquatic January, 20. Hollister. Inc. 2003). Ileostomy: Professor of General Surgery at the Medical Staff. Atlanta, GA: CDC, Division of College of Wisconsin and Chief of Surgery at Parasitic Diseases. What’s Right for Me? Libertyville, IL: Hollister Incorporated. the Zablocki VA Medical Center in Milwaukee, http://www.cdc.gov/healthyswim- WI. She specializes in caring for patients with ______. (2004). Managing Your ming/faq/operators4.htm. June 4. inflammatory bowel diseases who require sur- ______. (2001). Responding to Fecal Ileostomy. Libertyville, IL: Hollister gical procedures. Accidents in Disinfected Swimming Incorporated. Venues. Morbidity and Mortality ______. (2003). Urostomy: What’s Sarah Lundeen, NP, MS is a surgical Weekly Report. 50(20),416-417. Right for Me? Libertyville, IL: Nurse Practioner at the Medical College of Wisconsin, Froedtert Memorial Lutheran May 25. Hollister Incorporated. Hospital in Milwaukee, WI. Her practice ______. (2002). Healthy Swimming: Maki, D. and Tambyah, P. (2001). Engineering out the Risk for focuses on patients who need or have under- Why is Diarrhea in the Pool a gone intestinal surgical procedures. Problem? Atlanta, GA. Infection with Urinary Catheters. Emerging Infectious Diseases. 7(2), http://www.cdc.gov/healthyswim- Charles J. Mathison RN, ming/faq/operators2.htm. June 4. 342-346. March/April. BSN, CWOCN, is a ______. (2002). Healthy Swimming: Ostomy Association of Southwestern Certified Wound, Ostomy, Questions and Answers for Aquatic Indiana. (2006). Hints and Tips. and Continence Nurse Staff; What Do I Need to Know Evansville, IL: Evansville Ostomy Specialist. He is the Program Coordinator of Wound, About Swim Diapers and Pants? Chapter. http://www.ostomy. Ostomy and Continence Services at Froedtert Atlanta, GA. evansville.net/hints.htm. January 16. Wound, Ostomy, and Continence Hospital, Milwaukee, WI. He can be reached http://www.cdc.gov/healthyswim- at [email protected]. ming/faq/operators4.htm June 4. Nurses Society. (n.d.) Clinical Fact ______. (2001). Prevalence of Parasites Sheet: Indwelling Catheters. in Fecal Material From Chlorinated Glenview, IL: http://www.wocn.org.

TRR Feature Column: Pool Problems

Chlorine Smell

Alison Osinski, Ph.D. Aquatic Consulting Services, San Diego, CA

Question: Why do some pools 17th atomic element and a member of you are exposed to high concentrations smell like chlorine? Is there really the family of elements known as halo- in the air. too much chlorine in the water? gens. Chlorine is highly reactive, and found in nature only in combination Interestingly though, today few pools with other products. It is neither flam- actually use chlorine for sanitation and Answer: Chloramines mable nor explosive, but chlorine is oxidation, and the odor most bathers combustible if it reacts with other associate with swimming pools is not Chlorine is a yellowish-green gas made incompatible materials. Chlorine gas is chlorine. In addition to elemental chlo- by passing an electrical current through a respiratory irritant, about 2.5 times rine gas, there are five chlorine com- a solution of salt water. Chlorine is the heavier than air, and can be deadly if pounds commonly used for pool water ® 7 Aquatic Therapy Journal • September 2006 • Volume 9 • Issue 2