Applying the Occupational Therapy Process in Aquatics for Individuals Across the Lifespan

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Bri Mazzei, OTS, ATRIC

Session Objectives

By the end of this session participants will:

1. Demonstrate an understanding of the role of occupational therapy services across the lifespan.

2. Understand the steps and fluid application of the occupational therapy process

3. Articulate the role and considerations of aquatic therapy in the application of the OT process

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Introduction to Aquatic Therapy

Defined as the “…treatment, rehabilitation, prevention, health, wellness, and fitness of the patient/client population in an aquatic environment with or without the use of assistive, adaptive, orthotic, protective, or supportive devices and equipment” (APTA, 2016).

Introduction into Aquatic Therapy

• Can be used in conjunction with land therapy or as a sole service
• Can be conducted individually, with a caregiver/client partnership, with a group, or population
• Therapist can be in or out of water
• Recognized as a standard modality covered by most insurances, including Medicare Part B
• If PT is covered by the plan, aquatic therapy is most likely also covered

Occupational Therapy Role

• “Achieving health, well-being, and participation in life through engagement in occupation” (AOTA, 2020).
• Use of aquatics as occupational tool
• Promote, facilitate, support, and maintain health and participation
• Motivational and meaningful therapeutic environment
• Application to all areas of occupation

OT vs. Traditional Aquatic Therapy

• Aquatic Therapy:
• Fitness-based with limited OT involvement
• Current protocols are orthopedic-focused
• Outcomes related to balance, coordination, weight-bearing, endurance, strength, pain management, and motor skills
• Occupational Therapy:
• Function-based with limited aquatic involvement
• Current protocols are occupation-focused
• Outcomes related to health, well-being, participation, engagement in occupation, and personal factors

How to Blend OT and Aquatics

• Apply occupational theories and frames of reference to aquatic environment
• COPM, PEOP, MOHO, Neuro-Developmental, Biomechanical, Sensory Integration
• Facilitate and maintain improved health and well-being through aquatic benefits
• Blend OT protocols with Aquatic protocols
• i.e., multisensory regulation strategies with unpredictable command technique

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Benefits of Aquatics

• Sensory disorders
• Limited ROM
• Weakness limiting function
• Lack of coordination
• Acute and Chronic Pain
• Spasticity
• Perceptual/Spatial problems
• Arousal Problems
• Functional mobility and balance
• Orthopedic Injuries or Trauma
• Prenatal
• Neurological
• Rheumatology
• Respiratory/ Post COVID-19
• Circulatory conditions
• Oral motor deficits
• Depression
• Anxiety
• Poor self esteem
• Cardiac diseases
• Motor skill deficiencies
• Developmental delays
• Sleep disorders

…And more!

Benefits of Aquatics

• Buoyancy

Upward thrust of the water

• decreases weight bearing, joint compression forces, stress on connective tissues
• Reduces fear of falling
• Limits blood pooling

Benefits of Aquatics

• Buoyancy
• supports weak muscles
• enhances flexibility and ROM
• changes biomechanical stress and therefore strengthens muscles working in opposition to buoyancy (i.e., shoulder flexors & extenders)
• increases ease of handling (i.e., transfers, STM)
• immersion increases O2 delivery
• No movement necessary!

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Benefits of Aquatics

• Hydrostatic Pressure

Fairly equal force exerted on body by water

• Decreased pain and edema
• The pool is essentially a compression wrap!
• Increased ROM
• Increased venous return and circulation (assists heart pump)
• Decreases HR

Benefits of Aquatics

• Hydrostatic Pressure
• Provides even tactile input
• Turns down reticular system
• Acts as grounding input
• Promotes deep breathing
• Retards muscle atrophy
• No movement necessary

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Benefits of Aquatics

• Resistance

Viscosity and drag forces

• Resistance to movements creates benefits for
• Tone imbalances
• Decreases tone with contractures
• Improving muscle balance (posterior/anterior)
• Increasing cardiac output when appropriate
• Increased time to react
• Functional task retraining
• Decreases edema
• No movement necessary

Benefits of Aquatics

• Temperature
• Warm water (92-96 degrees F)
• Chronic pain reduction
• Decreases tone
• Ideal for children and the elderly
• Neutral water (82-92 degrees F)
• Prenatal
• Obese
• MS
• Arthritis

Benefits of Aquatics

• Who is appropriate?
• Almost anyone!
• No age requirement or limit
• Only contraindication are infections!
• Open wounds, GI, UTI, water-borne infections, COVID-19, etc.
• Function INCREASES in the water!

Service Delivery Approaches in Aquatics

• Direct:
• Providing care in the water with the client(s) to meet outcomes
• Indirect:
• Consultation and/or client advocacy among water fitness groups, swim programs, swim lessons, organizations, and other multidisciplinary teams
• i.e., providing consult on inclusive sensory strategies for swim programs

OT Process

• Process of evaluating, intervening, and targeting outcomes to focus on the therapeutic use of occupations to promote health, well-being, and participation in life
• Fluid and dynamic process, like the water!
• Allows for focusing on overall goals while continually reflecting on and changing plan to accommodate developments

OT Process

• Evaluation
• Occupational Profile
• Analysis of Occupational Performance
• Synthesis of Evaluation Process
• Intervention
• Intervention Plan
• Intervention Implementation
• Intervention Review
• Outcomes
• Select Outcome Measures
• Use Outcome Measures

Evaluation

• Occupational Profile:

summary of a client’s (person’s, group’s, or population’s) occupational history and experiences, patterns of daily living, interests, values, needs, and relevant contexts (AOTA, 2017a).

• Why is the client seeking services?
• What are client’s concerns about their daily routine and activities?
• Make sure to ask about context, performance patterns, personal/environmental factors, priorities, and targeted outcomes

Occupational Profile: Aquatics

• What is the client’s history and comfort level with pools, swimming, and being near water?
• Reiterate that they do not need to swim to receive therapy
• Profile can be developed on-land or in water
• For pediatrics, parents can be interviewed prior to or during pool time
• For adults, many are more comfortable initially out of the pool and on-land interview may increase rapport
• Use the clients’ preferred method and style of communication

Occupational Profile: Aquatics

• Because aquatic therapy is unique to other healthcare settings, the client may not be comfortable sharing their whole background upon initial visit
• Completing and refining profile may take more than one session
• Ensuring the clients comfort with the water is more important than completing entire profile
• Important to use both informal and formal review techniques to establish relationship

Evaluation

• Analysis of Performance

practitioner identifies the client’s ability to effectively complete desired occupations

• Synthesize information from profile
• Complete activity analysis
• Select and use specific assessments
• Client factors
• Performance patterns
• Performance skills
• Client’s contexts

Analysis of Performance: Aquatics

• No in-water standardized tests related to occupation developed…yet!
• Administer standardized tests and questionnaires prior to, during, or following initial eval
• Standardized:
• SF-36, SPM, Sensory Profile, SCOPE, OSA-DLS
• Non-Standardized:
• Functional observation, coordination, balance, ability to float, ocular-motor (dynamic and static), oral motor, ROM screen, water entry/exit, reaction to water, STM, etc.

Analysis of Performance: Aquatics

• Sensory preferences and considerations play a larger role in aquatic therapy due to hydrostatic pressure and buoyancy
• Adult sensory profile may be indicated
• Be aware of precautions/contraindications
• Be aware of breath control
• Plays a large role on body’s systems and ability to regulate and heal
• Always assess during initial eval, especially in the water

Evaluation

• Synthesis of Evaluation Process

Therapist synthesizes the information gathered through the occupational profile and analysis of occupational performance (AOTA, 2020).

• What are client’s values/priorities
• Consider support systems and contexts
• Refine strengths/deficits
• Collaborate on goals

Synthesis of Evaluation: Aquatics

• Collaborate with any existing on-land therapy service providers for the client
• Determine if client has any in-water specific goals
• i.e., increase swimming ability to promote independence, confidence, physical wellness, etc.
• Consider client factors related to changing/locker room time, water tolerance, fatigue level, transportation, etc.

Intervention

Occupational Aquatic Therapy: How are we different?

Aquatic OTs “…use the information about clients gathered during the evaluation and theoretical principles to select and provide occupation-based interventions to assist clients in achieving physical, mental, and social wellbeing; identifying and realizing aspirations; satisfying needs; and changing or coping with contextual factors” (AOTA, 2020).

More than just fitness and swim lessons!

Intervention

• Intervention Plan:

Directs the actions of therapists by describing approaches and types of interventions selected for use in reaching clients’ goals

• Directed by client and their needs/goals
• Consider context, activity demands, performance patterns/skills, and evidence from research
• Develop goals, potential discharge needs, and referrals to others

Plan: Aquatics

• Consider pool space, equipment available, and timeframe
• Connect aquatic goals to land function!
• Consider other professionals the client may be seeing
• Don’t overdo it in the water
• Make the plan client-centered
• Do they want to get hair wet? Do they know how to swim? Are they comfortable with the water? If pediatric, include pool games and jumps.

Plan: Aquatics

• Functional goal examples:
• After 3 weeks, client will balance with min A while seated on noodle in order to improve sitting tolerance at the dinner table.
• After 6 weeks, client will balance with min A while seated on noodle and performing UE tasks in order to improve sitting tolerance at the dinner table.
• After 3 weeks, client will balance with min A while seated on noodle in order to improve proprioceptive awareness.
• After 6 weeks, client will balance with min A while seated on noodle while maintaining box-breathing technique in order to reduce ANS trauma response during unfamiliar tasks.

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Plan: Aquatics

• Functional goal examples continued:
• After 3 weeks, client will balance 3lb item on board for 30 seconds while standing in order to improve function during hostess tasks.
• After 6 weeks, client will balance 6lb item on board for 30 seconds while maintaining LB coordination at 64bpm in order to improve function during hostess tasks.
• After 3 weeks, client will independently blow bubbles with visual cue to promote oral motor function during mealtime.
• After 6 weeks, client will independently blow bubbles with no cue while kicking on kick board to promote oral motor and core control during mealtime.

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Intervention

• Implementation:

Process of putting the plan into action after the initial evaluation process including:

• Therapeutic use of occupations and activities
• Education
• Training
• Advocacy and self-advocacy
• Group intervention
• Virtual intervention

Implementation: Aquatics

• Utilize functional activities and items
• i.e., laundry items, household items, toys, fine motor objects, self care items, clothing, etc.
• Functional/common swimming objects v.s. specialty aquatic equipment
• Include education for continued on-land application
• Tendon glides, nerve glides, environmental accommodations, energy conservation

Implementation: Aquatics

• Maintain ergonomic positioning of client and therapist
• Advocate for use of aquatic therapy through client and provider education
• Group intervention & support groups
• Arthritis, Veteran/PTSD, Prenatal/mommy and me
• Be aware of therapist and client time in water
• No more than 4 consecutive hours of treatment due to hydrostatic pressure

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Intervention

• Intervention Review:

“the continuous process of reevaluating and reviewing the intervention plan, the effectiveness of its delivery, and progress toward outcomes” (AOTA, 2020).

• Modify plan as needed
• Determine need for continuation or discontinuation
• Referral to other services

Review: Aquatics

• Maintain good communication with client
• Assess on-land application and outcomes
• i.e., how is daily function affected?
• Determine need for continuation
• Increase/decrease therapy frequency
• Transition to independent aquatics
• Transition to group aquatics
• Transition to land-based therapy

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Outcomes

• Outcomes describe the results clients can achieve through occupational therapy intervention and are multifaceted and may occur in all areas of concern (AOTA, 2020).
• Should be measured with same method used at evaluation
• Should ultimately be reflected in clients’ ability to engage in their desired occupations

Outcomes: Aquatics

• Administer functional assessments
• Occupational questionnaires, client reports, in water function, etc.
• Monitor in-water and on-land goal achievement
• Mainly patient-reported outcomes (PROs)
• Achieved outcomes ultimately related to health, well-being, and participation in life through engagement in aquatics
• Their daily function is most important!

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Outcomes: Aquatics

• Improved occupational adaptation through aquatics
• Overall response to occupational demands
• i.e., reduced pain, stress, improved performance, improved well-being, improved participation, and increased role competence
• Aquatic intervention ADDs to life!
• Not a medical setting
• Adds a leisure, play, social participation, self-care, and/or fitness occupation
• You can discharge from therapy, but don’t need to discharge from the pool!

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Areas for Growth

• Increase OT involvement in aquatics
• Attend professional/educational events
• Promote aquatic sessions with appropriate clients
• Promote aquatic setting among current educational programs and local, state, and national organizations
• Research opportunities
• Limited research and program development in occupational aquatic therapy

Current Program Development

• Beyond Aquatics
• Murfreesboro, TN
• Occupational Therapy pilot program development
• Significant results related to improved daily function
• Significant client-reported progress and improved QOL
• Full caseload after 4 weeks of implementation

https://www.beyondaquatics.com/occupational-therapy

Current Resources

• Aquatic Therapy and Rehab Institute (ATRI)
• www.atri.org
• Aquatic Therapy & Rehab Support Group
• https://www.facebook.com/groups/271794802847228/
• Related Articles
• https://www.atri.org/articles.html

References

Academy of Aquatic Physical Therapy (2022). APTA: Academy of Aquatic Physical Therapy. https://aquaticpt.org/

American Occupational Therapy Association (AOTA) (2020). Occupational therapy practice framework: Domain & process fourth edition. Bethesda, MD: Author.

Sova, R. (2022). Intro to Aquatic Therapy and Rehab (PDF). Aquatic Therapy and Rehab Institute. 1200_IntrotoAquaticTherapy_Extended_Sova (1).pdf

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Contact Information

Bri Mazzei, OTS, ATRIC

Drake University

Occupational Therapy Doctoral Candidate

May 2022

Email: brimazzei@gmail.com

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