The role of aquatic therapy in children with brain or spinal injuries

The word ‘hydrotherapy’ comes from the Greek word hydor (water) and therapia (healing). Therapeutic uses of water have been available from as early as 2400 BC to the present day. However, it was not until the 1920s that exercise in water, as opposed to water immersion only, began to develop.

There is a distinct difference between aquatic physiotherapy (previously termed hydrotherapy) and aquatic therapy, which are:

• aquatic physiotherapy can only be performed by a physiotherapist with additional skills and post graduate training/qualifications for working in the water;

• aquatic therapy can be performed by anyone, and they don’t have to be a physiotherapist. Carers, family, educational staff and support workers can be trained to deliver aquatic physiotherapy programmes.

This weightlessness and ease of movement means it can be possible to stand and step in water unaided when you would otherwise require a walking aid or standing frame on land, or you might not be able to stand at all out of water.

WHAT IS THE DIFFERENCE BETWEEN A HYDROTHERAPY POOL AND ANY OTHER TYPE OF POOL?

Hydrotherapy pools have an increased water temperature (usually between 34ºC and 36ºC) compared to leisure pools. They are used for therapy rather than swimming and are purpose built with fully accessible changing rooms and hoists into and out of the pool and changing rooms.

WHAT ARE THE BENEFITS OF HYDROTHERAPY, ESPECIALLY FOR CHILDREN AND YOUNG PEOPLE WITH BRAIN INJURIES, INCLUDING CEREBRAL PALSY AND SPINAL CORD INJURY?

Water is a great motivator. Therapy that is monotonous and repetitive becomes enjoyable and fun when undertaken in the water. Children and carers can gain confidence and trust with their therapist. It may be the only environment in which they can be on an equal footing and play with their siblings or more able bodied peers, and it enables bonding with your carer or family and skin on skin contact. This can be so important for families who may not be able to handle a child or young person out of the water due to the manual handling, or because of their own health (bad backs, arthritic joints etc).

If you are stood, or supported to stand or be upright with water up to your neck you will also experience a ‘physiological’ response that does not occur on land.

Your heart and lungs will work harder in a positive way because of the pressure of the water causing the blood to be returned more quickly to the heart and being stimulated to take a deeper breath. The effect is similar to if you were exercising.

At this depth you will also experience greater weightlessness than if the water was only at chest or hip level. The buoyant force (apparent weightlessness) reduces the weight going through weight-bearing joints (ankles, knees, hips and the spine) and causes traction (helps reduce pain). In addition, immersion in heated water leads to a release of endorphins – hormones that reduce pain.

This weightlessness and ease of movement means it can be possible to stand and step in water unaided when you would otherwise require a walking aid or standing frame on land, or you might not be able to stand at all out of water. It helps with rehabilitation.

Furthermore, buoyancy can act as a support to your body helping you to relax, or your muscles to be less tense (spasticity), the effect being even greater when the water is heated. Buoyancy can also be used to help you move; you don’t have to lift your limbs or body against gravity, and if you are in the

correct anatomical position buoyancy can cause the movement to happen with very little effort from you. This is important if you have muscle spasticity or dystonia, because out of water physical effort increases muscle tone and it is then more difficult to move.

Water is a very unstable environment though and we don’t have to move very much to lose balance. Fortunately there are lots of techniques that can be used to work on balance, trunk, and head control and stability in a way that simply is not possible on land, or causes so much effort that you become fatigued very quickly or your muscle tone increases.

A physiotherapist will use a range of techniques in the water such as Foundation principles, Watsu® Aquaepps® Halliwick Modified PNF, Aquastretch, Tai Chi and many others.

Some benefits require actual aquatic physiotherapy from an experienced aquatic physiotherapist, others can be achieved by a carer or family member trained by a physiotherapist.

BENEFITS INCLUDE:

• complete freedom of movement in an unencumbered environment. For some children and young people this is the only environment in which they experience their only independent movement without being strapped into equipment

• empowerment, choosing where to move to or from, diving under the water or just chilling out on the surface

• reduced muscle tone and relaxation leading to reduced muscle cramps, night pain, disturbed sleep, and improved feeling of wellbeing. Also makes movement and stretches easier as muscles are less tense

• reduced stress and anxiety

• increased mobility and flexibility

• unencumbered environment so less manual handling for carers and families if your child or young person has complex needs

• improved circulation and skin integrity as long as pool is heated

• a sensory environment that enhances positive behaviours and responses, reduces self-harming and unwanted behaviours in some situations and if access is sufficiently frequent

• reduced effort required to initiate and continue movement, aids flexibility and mobility

• increased balance responses and abilities in all positions

• increased breath control – did you know that some children and young people who are at risk of aspiration (choking if they swallow fluids etc.) have

learnt to dive under the water and even swim?

• increased coordination of breathing with physical activity

• increased muscle strength and power, exercise tolerance, stamina and fitness without damaging vulnerable joints

• improved cardio vascular and respiratory functioning

• increased head and trunk control and strength

• increased proximal control and distal function (fine motor control)

• aid for gait re-education (walking pattern)

• the ability to learn tasks initially not possible on land such as side stepping, climbing or descending steps, getting up and down from the floor, sitting unaided, rolling over etc

• aid for motor function and gross motor development

• learning to swim or propel in water

• making therapy FUN!

Did you also know that, with the correctly trained staff, hydrotherapy can be accessed even if an individual has a tracheostomy or is on a ventilator?

WHAT ABOUT COVID – SHOULD POOLS BE OPEN, IS IT SAFE?

The Aquatic Therapy Association of Chartered Physiotherapists (ATACP), Chartered Society of Physiotherapy (CSP) and Pool Water Treatment Advisory Group (PWTAG) have taken advice from Public Health England and have devised very specific guidelines and standards that follow government guidelines. These are different to the guidelines for swimming pools in leisure centres, and recognise that hydrotherapy pools are for therapy and are used by a vulnerable population. Chlorine in the water is carefully monitored and pool area disinfection is very high due to the nature of hydrotherapy pools.

Some benefits require actual aquatic physiotherapy from an experienced aquatic physiotherapist, others can be achieved by a carer or family member trained by a physiotherapist.

WHERE CAN YOU ACCESS HYDROTHERAPY?

Hydrotherapy can be accessed by some NHS services. Paediatric physiotherapists often use pools in special schools. If you qualify to use a hospice they often have pools available as well. Some special schools, hospitals and hospices hire out their pools. There are a few pools now becoming available for public use and leisure pools are becoming more accessible, although they are often too cold for children and young people with limited movements or poor circulation and the noise can be a barrier.

Lymden Hydrotherapy and Physiotherapy (LHAP) has a purpose-built hydrotherapy pool designed by Dr Heather Epps, leading and expert aquatic neurophysiotherapist with fully accessible changing rooms, pool and physiotherapy gym opening in January 2021 in Surrey. LHAP will be hiring out their pool, running small group and training sessions for families and carers, and intensive rehabilitation blocks consisting of daily gym and hydrotherapy sessions with their physiotherapy team.

For more details or to register your interest contact Mark at mark@lhap.co.uk

DR HEATHER EPPS, ATACP - (Aquatic Therapy Association of Chartered Physiotherapists) accredited physiotherapist