EVIDENCE-BASED AQUATIC THERAPY PROTOCOLS for the GERIATRIC PATIENT: Beginning, Intermediate and Advanced Progressions for Age-Related Disorders

EVIDENCE-BASED AQUATIC THERAPY PROTOCOLS FOR THE GERIATRIC PATIENT: Beginning, Intermediate and Advanced Progressions for Age-Related Disorders

GE801: An Aquatic Therapy University Geriatric Studies Course

(2nd Edition) Table of Contents

Learning Objectives Page Incorporate manual therapy techniques into geriatric practice to increase 3 healing and patient satisfaction

Describe the aquatic therapy triad: PT, OT and Speech and how they 7 work together in the aquatic setting. AT Aquatic Therapy University, our tiered progression gives you the Recite aquatic precautions and contraindications specific to the geriatric 12 continuum you need to map out and client achieve your professional aquatic goals for years to come. You can spe- Provide an therapeutic quick-view. Describe why aquatic therapy may be cialize in a certificate tracks or are free 21 the treatment of choice. Find recent scientific literature, including out- to put together your own course of study. Each class contains between comes studies, which supports aquatic therapy 16-32 hours (with over 60% of each class hands-on pool lab). Osteoporosis 15 Specialty Tracks: Join us year after year and work towards your certificate Arthritis & Joint replacement in our specialty tracks. All ATU credits 33 can all be applied to your final 70-hour certificate in: Neurological dysfunction & Balance deficits 63 • GS: General Studies

• MS: Musculoskeletal Studies Progress any task and thinking outside the box. Modify for spouse or 88 • PS: Pediatric Studies caregiver to perform. • GE: Geriatric Studies Pool labs and photos 105 • SS: Sports Medicine Studies Samples of aquatic techniques: Demonstrate aquatic tasks or activities 132 Campuses: ATU courses are avail- from each of the following specialty techniques (as each relates to the able in 7 cities across the United geriatric client): Ai Chi, Bad Ragaz Ring Method, Watsu. (See other sec- States with our main campus located tions for ideas from Halliwick, Sensory Integration and other techniques) in Minneapolis, MN

Examining protocols from the literature: Locate what aquatic protocols 138 exist in the geriatric scientific literature and assess them for usability in the clinic. Integrate aquatic interventions into existing land-based protocols.

Examine how augmentative communication can be used in the pool set- 164 ting.

Online resources: Access free online resources to help craft additional 170 progressions

Meet the Creators of the Manual:

Andrea Salzman, MS, PT Email: [email protected]

Andrea graduated from the University of Alabama at Birmingham with a Masters degree in physical therapy. Salzman is the Founder and Owner of the Aquatic Resources Network, the largest multidisciplinary clearinghouse of information on aquatic therapy. She is Vice Presi- dent of 10K Health, LLC, a temporary staffing agency. She currently serves as Program Direc- tor for Aquatic Therapy University and has assisted hundreds of facilities during the start-up and training phases of their aquatic practice. In 2010, Salzman received the highest honor given to an aquatic physical therapist from the American Physical Therapy Association, the Judy Cirullo Leadership Award.

She has served as:

• Editor-in-Chief, Journal of Aquatic Physical Therapy;

• Manager, Regions Hospital Therapy Pool;

• Adjunct Faculty, College of St. Catherine's PT program:

• Functional Design Consultant; Aquatic Therapy Facilities:

• ARN Database Creator, 19,000 aquatic professionals;

• Aquatic Health Research Database (AHRD) Creator, 8000 abstracts and growing;

• Author, 5 aquatic therapy-related texts;

• Monthly columnist, Aquatics International, Advance for PTs, Onsite Fitness

Kim Gordon, MPT Email: [email protected]

Kimberly graduated from Mayo Clinic's School of Health Related Sciences with her Master's degree in Physical Therapy. She has spent 10 years practicing primarily in outpatient physical therapy, beginning her practice in an outpatient sports medicine facility in Florida and later managing the facility.

Kim currently works for a privately owned clinic in Rochester, MN and manages a clinic in Plainview, MN. Kim splits her time between pool and land therapy and also specializes in Women's Health with a focus on pelvic floor dysfunction, SI dysfunction, and prenatal/ postpartum care. She has discovered many advantages using pool therapy for this particular population.

Kim also holds a certification in Pilates training and has taught Pilates for over 10 years. She currently teaches at the health club in which her clinic is located. She specializes in Pilates for those with a history of low back pain and in prenatal Pilates class that pre- pares women for childbirth.

Healing & Patient Satisfaction in Geriatrics

Title: Incorporate manual therapy techniques into geriatric practice to increase healing and patient satisfaction

Source: Salzman, Andrea. Aquatic Therapy Protocols for the Geriatric Client. Aquatic Therapy University seminar: Min- neapolis, MN; Oct 7-8, 2011

There have been several studies which looked into the distinction between patient satisfaction versus actual functional improvement. Patients who make functional improvements with aquatic therapy... but who are unhappy with the care they receive, do not feel that therapy was "of benefit". In order for aquatic therapy to be effective, you need to ensure that you have a satisfied customer. And this means getting into the water, putting your hands on the client, using manual and hands-on techniques, and listening to their concerns and complaints. Beattie et al1 examined what elements contributed to a satisfied customer: Maximizing patient satisfaction is a sound philosophy from both a clinical perspective and a business perspective. Satisfied patients are more likely to adhere to treatment and to continue to seek health care at a given facility. Our findings indicate that adequate time spent in patient care and the professionalism of the therapist and clinic staff are more important for patient satisfaction than are the location of the facility, the quality of equipment, and the availability of parking. We believe that, in the current health care environment, the emphasis on cost-cutting, high patient volume, and the use of "care extenders" can reduce the time for the patient-therapist interactions that appeared to contribute to satisfaction. The results of their study showed that patient satisfaction with care was most strongly correlated with the quality of patient-therapist interactions. This includes the therapist:

• spending adequate time with the patient,

• demonstrating strong listening and communication skills, and

• offering a clear explanation of treatment. Note that, non-patient care issues such as clinic location, equipment, and parking are less important in de- termining patient satisfaction. Patient Satisfaction Versus Treatment Effect Dr. Steve George published a nice paper characterizing the ability of a particular questionnaire item assess- ing patient satisfaction to distinguish between satisfaction with treatment effect versus satisfaction with treatment delivery after physical therapy treatment of low back pain.2

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Healing & Patient Satisfaction in Geriatrics

The findings suggest that patient satisfaction with Measuring Client Satisfaction in symptoms is weakly associated with other satisfaction items and more related to self-report measures of Speech & Language Therapy treatment effect. The results remind us that patient satisfaction is a multidimensional construct and that a “Patient satisfaction may be considered to be one of the patient being "satisfied" with care may have little to do desired outcomes of care, even an element in health status with whether the patient is actually better. itself…It is futile to argue about the validity of patient satisfaction as a measure of quality. Whatever its strengths and The Paradox limitations as an indicator of quality, information about pa- Health care professionals are in a Catch-22. We want to tient satisfaction should be as indispensable to assessments help our patients heal; yet we've been robbed of many of quality as to the design and management of health care of the instruments we need to do so. systems.”

By law, psychologists aren't allowed to touch their pa- Why does it matter? Weisman and Koch (1989) have indi- tients anymore. Clinical psychologist James Mossman, cated that satisfied clients are more likely to follow their PhD" puts it this way “We are expected to help them practitioners' recommendations for treatment. Further- without touch —an immensely more difficult task. That more, research has shown that client satisfaction (or dissat- leaves the touching to you [physical therapists], to isfaction) is an indicator of other client behaviors, such as heal, for you are licensed to touch." choice of practitioners or programs, disenrollment, use of services, complaints, and malpractice suits (Ware, 1987). But physical therapists aren't supposed to touch the According to Harper Petersen (1989), the following aspects mind. "Unfortunately, your touch has boundaries," of care are found in the professional literature as significant continues Dr. Mossman. "It is for the body, whereas I components of client expectations: am permitted to (touch) the mind. And so we come full circle, neither of us able to use the tools we need to • Being comfortable; heal, and the patient does not get [wholly] better." • Being treated as a mature individual;

Dr. Mossman captured the paradox. Physical therapists • Getting information about what will happen; touch the body. With that touch comes patient emo- • Learning how to participate in care; tions to which few others are privy. Patients who confide in us and would never confide in a relative, a psy- • Feeling safe; chologist, or even a family physician find themselves • Needing reassurance; vulnerable during a simple toilet transfer. Why? It seems likely that this has a lot to do with the fact that • Feeling more in control; we touch our patients. Tiffany Field, PhD, agrees. • Decreasing stress; and

The Institute • Having staff available to listen. In 1992, Dr. Field established the first (and only) center Source: Frattali C. Measuring Client Satisfaction. ASHA web- in the world dedicated to examining the therapeutic site. http://www.asha.org/SLP/healthcare/Measuring- effects of touch. The Touch Research Institute (TRI) at Client-Satisfaction/ the University of Miami School of Medicine was cre- ated with a startup grant from Johnson & Johnson. Today, it receives 80 percent of its funding from the Na- tional Institutes of Health.

Healing & Patient Satisfaction in Geriatrics

The older some people get, the more they want to be touched, but the opportunity to be touched by friends and family is markedly reduced, and many people simply do not like touching older people.

Dr. Field believes that touch, and in particular, massage, is much more than just "running hands over the surface of the body." TRI has participated in more than 100 studies attempting to show that touch affects the nervous, circulatory, immune and hormonal systems of the human body. Although TRI originally made headlines for its studies on massage with premature babies, the institute has long since branched out into studies on adolescents, adults and the elderly. Somewhere along the way, most of us learned it is inappropriate--even invasive--to touch our elders. Dr. Fields addresses one of the many situations physical therapists face each day. "The older some people get, the more they want to be touched, but the opportunity to be touched by friends and family is markedly reduced, and many people simply do not like touching older people." She continued, "Spouses are often separated from each other in nursing homes. And other obstacles like bedsides and poorly designed wheelchairs make touching difficult. These obstacles highlight the need for providing additional touch opportunities such as touch materials and objects to be held, children and pets for older people to touch, and massages and dancing opportunities." In a society that has been overzealous to avoid "bad touch," all touch has been tainted. And so we create a

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Healing & Patient Satisfaction in Geriatrics

class of walking-wounded. Therapists are in a unique position. We get to combine a specific (hopefully therapeutic) intervention with touch. We are in a unique and envi- able position: Not only are we allowed to touch our patients, we are expected to do so. We are one of the few professionals left who have this privi- lege. For therapists who take their patients into a warm water pool, especially those who incorporate manual techniques, touch is inevitable. Submerge the patient in a thermoneutral therapy pool, and you eliminate the temperature gradient between skin and air. Have her close her eyes; she instantly loses the ability to determine where her body ends. Immerse her ears, and you eliminate sound. Lift her feet from the bottom of the pool, hold her in a flexed position, she feels safe like an infant. Let her body rise and fall in the water with her breath. In the pool’s three-dimensional environment, the water itself becomes the plinth. The therapist does not have to work as hard to position the patient. Gravity loses its strength and the body’s joints are unloaded (yet available, unlike when positioned on a plinth). The warmth of the water establishes an environment of relaxation and peacefulness. The patient is touched and touch by itself is often healing. Fluid move- ments are easier to perform than their counterparts on land. Joint mobilization, soft tissue elongation, and massage become less like therapy and more like dance. All told, the pool is a wonderful place to pro- duce patient improvement while ensuring patient satisfaction. References 1. Beattie PF, Pinto MB, Nelson MK, Nelson R. Patient satisfaction with outpatient physical therapy: instru- ment validation. Phys Ther. 2002;82:557-65. 2. George SZ, Hirsh AT. Distinguishing patient satisfaction with treatment delivery from treatment effect: a preliminary investigation of patient satisfaction with symptoms after physical therapy treatment of low back pain. Arch Phys Med Rehabil. 2005 Jul;86(7):1338-44.

The Aquatic Therapy Triad: PT, OT & Speech

Learning Objective : Describe the aquatic therapy triad: PT, OT and Speech and how they work together in the aquatic setting.

Source: Dickinson, K, Salzman A. Evidence-Based Aquatic Therapy for the Pediatric Client. Aquatic Therapy University seminar: Minneapolis, MN; November, 2011.

For decades, physical therapy has found a home in the pool. In the 1990’s, occupational therapists started taking their patients into the water. But for the most part, SLPs did not choose the pool as a valuable treatment environment.

Things have started to change dramatically. Speech and language therapists across the world are seeing the kind of communication which naturally occurs in the pool setting — and they are coveting it. The pool has truly become a triple threat: PT, OT and Speech are all becoming powerhouses in the water.

Each facility must determine what works best for scheduling pool time and this may change from one week to the next. It is important to keep the line of communication open between therapists and make sure there is no duplication of services. Finally, the team should decide what is in the best interest of each individual client.

There are several ways to organize therapy so that all discipline shave the chance to work in water. Here are a few suggestions:

• Different therapists provide aquatic therapy on different days

• Therapists alternate weeks – i.e.: OT does aquatic, while PT treats on land, and switch the following week.

• PT provides first half in land, second half in water, OT provides first half of session in water, second half on land

• Co-treating – depends on facility It is important to realize that a big portion of the skill set necessary for life can be practiced in (and before and after!) getting in the water. For example:

1. Dressing skills – PT, OT

• Into/ out of bathing suit

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