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Water works

Aquatic therapy Or hydrotherapy?

Robert Millett sees what is effective and how physios can take a lead

Back in 2002, 40-year-old Sean Healey was holidaying in Portugal with his family. While getting into the pool one day he slipped, fell head first and broke his neck.

At first confined to a wheelchair, Mr Healey, of Sutton in Surrey, has progressed to walking with a frame and, recently, to walking with elbow crutches.  He credits aquatic physiotherapy for much of his progress.

‘It’s one of the best forms of therapy I’ve received and I can’t recommend it enough,’ he says. ‘It’s been absolutely fantastic and one of the main reasons I’ve been able to get on to my crutches.’

The practice can benefit many conditions, says his therapist, Jacqueline Pattman, specialist in aquatic physiotherapy at Brighton and Sussex University Hospitals Trust. Extensive evidence in its favour includes systematic reviews and metaanalyses (for example, Hall J et al. Arch. Phys. Med. Rehabil. 2008; 89: 873-883). It is widely used to treat trauma, neurological, musculoskeletal and myalgic conditions. These include injured athletes, older people who regularly fall and people with arthritis and osteoporosis.

‘It is especially useful with patients who have minimal or no weight-bearing on land,’ says Ms Pattman. ‘They can use the water to work without loading the bone or joint and can practise normal movement patterns, which very often become adapted due to periods of non or partial weight-bearing.’

The buoyancy of the water assists movement, supports limbs and enables the therapist to facilitate resistance exercises. Drag or turbulence can also be used to assist, resist and stabilise. Trained physios can create individual programmes from an array of specialised techniques. 

Water also allows many patients their only opportunity for independence.

‘It’s a fantastic feeling, to be independent and free,’ says Mr Healey. ‘It’s great to be on your own and not need a chair or a frame or crutches or anything else around you.’

What’s in a name?

Aquatic physiotherapy, named in 2008, is a form of hydrotherapy that’s carried out only by suitably qualified physios.

Non-specialist physios may still carry out hydrotherapy. But the Aquatic Therapy Association of Chartered Physiotherapists (ATACP) notes that the term ‘hydrotherapy’ is also used for the very different practices of colonic irrigation and spa bathing. Also, hydrotherapy may be carried out by carers or teaching assistants in homes or special schools, who may not have the underpinning knowledge of anatomy and physiology.

‘Most of the carers will not have the relevant training or expertise in hydrostatics and hydrodynamics to maximise neuromusculoskeletal function and ensure a carryover benefit for when the patient is back on land,’ says Ms Pattman

The ATACP encourages physiotherapy managers to ensure that all staff working in water should possess all the relevant training and qualifications.

‘One common problem encountered with aquatic physiotherapy is that the modern undergraduate curriculum will often not include sufficient theory or practice in the modality to allow a new graduate to work, within their scope of practice, unsupervised in the water,’ says ATACP chair Mike Maynard.

To address this issue, the ATACP has developed a CSP-accredited foundation programme. The two-day course equips physios with the knowledge and skills to work safely and effectively in the water. The course is followed by an assessment phase that requires students to keep a portfolio of their aquatic experience, provide a case study and sit a theory and practical assessment.     

Economic factors

The future of aquatic physiotherapy in the NHS is very much in the hands of commissioners, say practitioners, and many trusts are unaware of its range of benefits.

 ‘Sadly, many trusts will assume a pool is much more expensive to run than it actually is,’ says Mike Maynard. ‘They will then close it to save money, despite the evidence showing that aquatic physiotherapy can be exceptionally cost-effective.’

The pools can generate extra income from self-help or maintenance groups, in which low-risk patients follow a programme for a small fee, or from use outside NHS hours by therapists seeing patients privately.

Seven-year-old Lauren Silverlock, who has cerebral palsy, has noticeably improved the range of movement in her right arm as a direct result of aquatic physiotherapy.

Lauren began by attending a series of NHS hydrotherapy sessions. Her mother, Louise Silverlock, was so impressed by the effects that she continued with private sessions.

‘It has been fantastic for Lauren,’ she says. ‘I wish it could be routinely used as a course of treatment for children with cerebral palsy as it is a huge benefit to them.’

The future of aquatic physiotherapy on the NHS is uncertain in the current climate, but the ATACP remains optimistic.

‘We are working with universities to try to build MSc modules in aquatic physiotherapy and there is a continuing and significant demand for short courses,’ says Mike Maynard.

The ATACP has collaborated with the University of Brighton to develop a data collection tool known as HyDAT, to be presented at the World Confederation for Physical Therapy congress in June. Aquatic physios are asking patients to complete a Measure Yourself Medical Outcome Profile before and after treatment. Both these factors will increase the evidence base and strengthen the case for commissioning. fl

For information

on training or the ATACP, email Aquatic Physical Therapy International,


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