the aquatic therapist

Ask Andrea: Chemo Chemicals

Dear Andrea: I'm a registered massage therapist, specializing in aquatic therapy and am seeing a new patient who has some lumbar issues and a knee that might need replacing down the road. She is also presently receiving chemotherapy for ovarian cancer. While there needs to be no discussion about the positive effects of immersion for her back and knee, my concern is with the effects of the chlorine in the pool while she's undergoing chemo. My pool is chlorinated while her pool in her hometown is salt-water. What advice can you share about the effects of chlorine in conjunction with chemotherapy?

Questioning in Seattle

Dear Questioning: Thank you for your question. Salt water pools are still chlorinated pools. State statute requires that all public pools have a halogen (e.g. chlorine/bromine) in them for sanitation. A "salt water" pool is just a pool that brings chlorine in a solid (NaCl or salt) and the uses electricity to split the Na from the Cl (thus rendering Chlorine). It's really not necessarily any easier on your skin. For more info on salt water generation, see Alison Osinski's info here

http://www.alisonosinski.com/?p=419  (tab down to inline generator);

and here:

http://www.carefreeclearwater.com/saltwaterpools.html

A better choice may be a pool that doesn't just rely on a stand-alone halogen for disinfection. Look for a pool that uses a supplemental system like ozone or ultraviolet light. These systems have dual options for disinfecting the water so that a lower level of halogen can be used. More info here:

http://www.alisonosinski.com/?p=432

I hope this helps!

Andrea

I'm a registered massage therapist, specializing in aquatic

therapy and also operating a breast health clinic. I've attended several workshops with experts in

the cancer field in Seattle and Toronto.

Just Added: Endless Pools Workshop in Philly

We just added a new class for our East Coast members. On April 27-28, 2012 we will be teaching our Ortho/Neuro Survey class at the Endless Pools facility in Aston, PA. While the workshop is being held primarily for the benefit of Endless Pools customers and potential customers, it is also open to outside registrants. Price is $595 and pre-approval through the Pennsylvania PT Board is being applied for.

Aquatic Therapist Alert: You don't even know you're thirsty...You spend too much time in the pool.

DRINK. DRINK. DRINK. Everyone tells you to drink water when you work in the pool. But, dang it, you are never thirsty. So the day rolls on with nary a sip.

Well guys, your body is tricking you into a low grade, long term dehydrated state with serious consequences.

Why? Well, we all understand the effects of hydrostatic pressure on edema control in the legs.We even get the fact that this volume shift creates an extra pre-load on the heart ... in effect making each contraction more powerful.

What we fail to realize is that this same shift in volume creates a sustained stimulation of the cardiopulmonary baroreceptors and reduction of a dipsogenic (ahem... fancy term for thirst) stimulus.

This volume-induced stimuli of  fluid receptors sends a message to your brain saying

Control of an Exoskeleton for Realization of Aquatic Therapy Effects

Kyoungchul Kong;   Hyosang Moon;   Doyoung Jeon;   Tomizuka, M.; Dept. of Mech. Eng., Univ. of California at Berkeley, Berkeley, CA, USA. Control of an Exoskeleton for Realization of Aquatic Therapy Effects. Mechatronics, IEEE/ASME Transactions on. 2010; 15(2): 191-200.

Exoskeletons are attracting great attention as a new means of rehabilitation devices. In such applications, control algorithms of exoskeletons are often inspired by nature for natural and effective assistance for patients. In this paper, a control algorithm inspired by aquatic therapy is introduced.

Aquatic therapy provides various beneficial effects for rehabilitation based on useful properties of water, e.g., buoyancy and drag. The proposed controller calculates joint torques equivalent to the buoyant and drag forces.

Then, an exoskeleton-type assistive device generates the calculated joint torques to provide the similar effects as aquatic therapy.

In this paper, the Sogang University biomedical assist robot is utilized as a testbed. This paper also discusses the mechanical impedance of actuators, which obstructs implementation of controllers in practice. The resistive forces generated by actuators are precisely modeled and compensated to realize the control algorithm inspired by aquatic therapy correctly and effectively.

Aquatic Therapy Versus Conventional Land-Based Therapy for Parkinson's Disease: An Open-Label Pilot Study

Jamile Vivas PhD, PT, Pablo Arias PhD and Javier Cudeiro PhD, MD. Aquatic Therapy Versus Conventional Land-Based Therapy for Parkinson's Disease: An Open-Label Pilot Study. Archives of Physical Medicine and Rehabilitation. August 2011, 2(8): 1202-1210

Abstract

Objectives

To assess and compare 2 different protocols of physiotherapy (land or water therapy) for people with Parkinson's disease (PD) focused on postural stability and self-movement, and to provide methodological information regarding progression within the program for a future larger trial.

Design

Randomized, controlled, open-label pilot trial.

Setting

Outpatients, Parkinson's disease Center of Ferrol - Galicia (Spain).

Participants

Individuals (N=11) with idiopathic PD in stages 2 or 3 according to the Hoehn and Yahr Scale completed the investigation (intervention period plus follow-up).

Interventions

After baseline evaluations, participants were randomly assigned to a land-based therapy (active control group) or a water-based therapy (experimental group). Participants underwent individual sessions for 4 weeks, twice a week, for 45 minutes per session. Both interventions were matched in terms of exercise features, which were structured in stages with clear objectives and progression criteria to pass to the next phase.

Main Outcome Measures

Participants underwent a first baseline assessment, a posttest immediately after 4 weeks of intervention, and a follow-up assessment after 17 days. Evaluations were performed OFF-dose after withholding medication for 12 hours. Functional assessments included the Functional Reach Test (FRT), the Berg Balance Scale (BBS), the UPDRS, the 5-m walk test, and the Timed Up and Go test.

Results

A main effect of both therapies was seen for the FRT. Only the aquatic therapy group improved in the BBS and the UPDRS.

Conclusions

In this pilot study, physiotherapy protocols produced improvement in postural stability in PD that was significantly larger after aquatic therapy. The intervention protocols are shown to be feasible and seem to be of value in amelioration of postural stability–related impairments in PD. Some of the methodological aspects detailed here can be used to design larger controlled trials.

Key Words: Hydrotherapy; Parkinson disease; Physical therapy modalities; Rehabilitation

Abbreviations: BBS, Berg Balance Scale; FRT, Functional Reach Test; PD, Parkinson's disease; TUG, Timed Up and Go; UPDRS, Unified Parkinson's Disease Rating Scale

Aquatic Therapy University (ATU) classes, trainings & continuing education (2012)

Pool Therapy for the Female Client Feb 4-5, 2012

Aquatic Therapy for Total Hip/ Knee Feb 10-11, 2012

Hands-On Aquatic Therapy Techniques March 9-10, 2012

Water-Based Interventions for the Neuro Client April 13-14, 2012

Marketing Strategies for the Aquatic Therapy Manager Sept 7-8, 2012

Function in Water: Closed-Chain Progressions Oct 12-13, 2012

More details at: www.swimatu.com

Ask Andrea: Quizzical Referrals

Here is an intriguing question I received last month. Perhaps the answers can help you in your practice.

Dear Andrea: My current struggle is finding ways to obtain appropriate referrals from our primary land-based therapists. How can I get them to send me patients at the beginning of their treatment instead of when it is too late or when they are tired of seeing them? They also have a nasty habit of sending them back to me when it is time for them to transition back to land? HELP!

Curious in Columbus

Dear Curious: Your woes are common. Therapy pools are often seen as dumping grounds (when all else fails and then they wonder why the patient isn't immediately better). Take for example treating TKR patients in the water. Once the patient is 6-8 weeks s/p surgery, they are probably past the optimum period for aquatics (unless they had complications, underwent manipulation, had ROM issues, etc). I always tell my students to ask themselves 5 questions before choosing aquatics. Perhaps these will help?

1. Does the patient have "fixable" impairments or functional limitations? If not, should not be receiving skilled care (land or water) for anything but short term instruction.

2. Does the patient require the skilled aquatic care of a therapist? If not, refer the patient to aquatic post-rehab specialists, personal trainers or group classes.

3. Does the patient require the special properties of water in order to address their impairments and limitations? If not, or if all things are "equal", the patient should be treated on land. Why? Aquatic therapy is more expensive (both to provide and to the payer) and aquatic intervention is less functional as people do not live in water. Additionally, the ability for people to continue their exercise program is limited in most cases, in contrast to a home exercise program. (To have a huge evidence-based argument about the benefits of these properties, attend the Aquatic Therapy Boot Camp at ATU).

4. Is aquatic-based intervention for this diagnosis supported by the literature? (To have a huge evidence-based argument about the benefits of these properties, attend any of our 2012 classes).

5. Does the patient show carryover of any improvements to land? Patients should be reassessed every week on land (can be short 5 minute tests, but should happen on land) for functional improvement. If they improve in water, that is great, but it won't fly in the world of insurance. They need to show carryover.

As far as returning them to water time and again... I usually tell the patient I am delighted that they love the water and promptly refer them to a (private pay) post-aquatic professional or group class. Those who really want to continue will pursue it. Those who are looking for a free ride in a warm water pool with no effort towards independent work... disappear.

Warm (water) regards,


Andrea Salzman, MS, PT
Director of Programming, ATU

(If you have a question for Ask Andrea and would like to see her answer in The Aquatic Therapist blog, feel free to email her at info@swimatu.com)

Aquatics Director in Harrisburg, VA pays $50,000/year.

Aquatics Director in Harrisburg, VA pays $50,000/year.

Details here.

Wanted: Aquatic Therapist (Los Angeles, CA)

Water PT Specialists Inc

Posted: September 7, 2011

Address: Los Angeles, CA 90045

Occu: Aquatic therapy

Type: Full-time

Description: Aquatic Physical Therapist wanted full time Monday - Friday 10:00 - 5:00 pm. We work out of YMCA pools in Westchester and Culver City. We offer exclusively aquatic PT. Our therapists are in the pool with the patients doing both ther ex and manual therapy in the water. Position requires valid CA PT license and at least two years experience with orthopedic PT. No aquatic experience necessary, we will provide training. We are looking for someone confident and fun to join our team. Opportunity for growth and leadership as we are hoping to expand in the near future. We offer Blue Shield health benefits for full time employees.

Apply online at: http://aquaticnet.jobamatic.com/a/jbb/job-details/556512

Wanted: Aquatic Therapist (Fairfax, Virginia)

Northern Virginia Training Center

Posted:August 23, 2011

Address:Fairfax, VA 22032

Occu:Aquatic therapy

Type:Part-time

Description:The candidate selected for the part time( 20 hrs per week) Aquatic Therapist position will be responsible for providing services to the individuals who live at NVTC and to the community through the RCSC program. This person will plan, organize the aquatic therapy sessions with the RCSC individuals and provide consults with NVTC by implementing aquatic assessments.In this position the Aquatic Therapist will act as a lifeguard for both NVTC and the RCSC program as needed.In addition, the Aquatic Therapist will assist with maintaining a healthy and safe pool environment.

Apply online at:  http://aquaticnet.jobamatic.com/a/jbb/job-details/548557

Wanted: Aquatic Therapist (Simi Valley, California)

Sterling Physical Therapy & Aquatics

Posted:September 4, 2011

Address:2315 Kuehner Drive, Suites 114-117 Simi Valley CA

Occu:Aquatic therapy

Type:Full-time, Permanent

Description:Full time position, M-F 9am-6pm Aquatic therapy and land/manual as dictated by patient census. We have a new on-site SwimEx pool in it's own suite. All treatment is one-on-one 1hr. No group sessions offered. Responsible to evaluate and treat aquatic and land patients. Clinical Director is very supportive and open to new protocols and programs. Excellent opportunity to develop and excel in your specialty. Great pay, full benefits. Non physician owned facility. Pristine reputation in the medical community.

Apply online at: http://aquaticnet.jobamatic.com/a/jbb/job-details/555494

A potential benefit of aquatic therapy... bladder cancer???

File it under "I didn't want to know"...

Researchers found an increased risk of bladder cancer associated with exposure to water disinfection byproducts.

Risks tended to be higher for exposure through showering, bathing, and swimming in pools compared with drinking water. Download PDF here.

The ADA Compliant Pool - It all changes starting now

It's not déjà vu, but it does seem like we've been here before. Fresh from an industry-shaking experience with VGB, another government mandate has arrived which will force public pool operators to spend money on pool equipment/alterations they hadn't planned for. This one's called ADA. Read more Aqua Magazine article here.

For instance, did you know that the deepest water that an ADA-compliant ramp can let out into is.... (drum roll please) 30".

Most pools start at 3' or 3.5' deep, so this is a rule destined to drive people to choose lifts instead of ramps to be considered ADA compliant.

More aquatic therapy data here.

 

 

Would you hire this PT to provide aquatic therapy?

Whistleblowing hero... or neurotic ramblings? You decide.

http://factoidz.com/why-medicare-is-going-broke-and-wont-be-around-much-longer/

 

Aquatic therapy statistics

Aquatic therapy statistics now available to industry. http://www.aquaticnet.com/media-statistics.htm

Aquatic Therapy Command Center. http://www.aquaticnet.com - International clearinghouse of information for the aquatic therapist, aquatics facility and pool patient. Home of Aquatic Therapy University. Provides CEUs / trainings/ courses / continuing education for the physical therapy provider, occupational therapist, speech therapist, athletic trainer and others. Answers questions such as: What is aquatic therapy for? What water therapy equipment should I buy? Where can I find a hydro pool or therapy pool? What is the difference between aquatic physiotherapy and hydrotherapy? Do I need special education or certification to perform aquatic therapy and rehabilitation?

Aquatic exercise programme for children with autism spectrum disorders

Fragala-Pinkham MA, Haley SM, O'Neil ME. Group swimming and aquatic exercise programme for children with autism spectrum disorders: A pilot study. Dev Neurorehabil. 2011;14(4):230-41.

Source

Research Center for Children with Special Health Care Needs, Franciscan Hospital for Children , Boston, MA , USA.

Abstract

Objective: To evaluate the effectiveness of a 14-week aquatic exercise programme for children with autism spectrum disorders (ASD). Design: Non-randomized control trial. Methods: Twelve children participated in this pilot study with seven participants in the aquatic exercise group and five in the control group. The programme was held twice per week for 40 minutes per session. Swimming skills, cardiorespiratory endurance, muscular endurance, mobility skills and participant and parent satisfaction were measured before and after the intervention. Results: No significant between-group changes were found. Within-group improvements for swimming skills were found for the intervention group. Programme attendance was high. Parents and children were very satisfied with the programme activities and instructors. Conclusions: This pilot programme was feasible and showed potential for improving swimming ability in children with ASD. Exercise intensity was low for some participants, most likely contributing to a lack of significant findings on fitness outcomes.

Aquatic Therapy Insanity Sale (until midnight)

 

50% off GROUP-COUPON... It's live at www.swimatu.com. Sale is on until midnight July 4th

 

50% Group-Coupon Alert: Aquatic Therapy Insanity on July 4th

Help build the aqua-buzz. Retweet, post on facebook, and send to listservs...

Click here to see the July 4th ATU Groupon

http://tinyurl.com/3jn9x56

Starting at midnight, July 4th, therapists can buy books, equipment, bibliographies, distance-learning DVDs and more for 50% off. Better yet? They can book any of our 18 hour aquatic therapy classes for $300 (a $600 value).

Book early; we plan to cap the classes before the 24 hours is over!

--
Andrea Salzman, MS, PT
Director of Programming
Aquatic Resources Network/ Aquatic Therapy University
3500 Vicksburg Ln #250 Plymouth, MN 55447
800-680-8624 Main 888-514-6133 Fax
www.swimatu.com
"Therapist Founded. Therapist Grounded."

Comparing land and aquatic exercise for people with hip or knee arthritis on function, mobility and other health outcomes.

Batterham SI, Heywood S, Keating JL. Systematic review and meta-analysis comparing land and aquatic exercise for people with hip or knee arthritis on function, mobility and other health outcomes. BMC Musculoskelet Disord. 2011 Jun 2;12(1):123. [Epub ahead of print]

Abstract

BACKGROUND:

Aquatic and land based exercise are frequently prescribed to maintain function for people with arthritis. The relative efficacy of these rehabilitation strategies for this population has not been established. This review investigated the effects of aquatic compared to land based exercise on function, mobility or participants' perception of programs for people with arthritis.

METHODS:

Medline, CINAHL, AMED and the Cochrane Central Register of Controlled Clinical Trials were searched up to July 2010. Ten randomised, controlled clinical trials that compared land to aquatic exercise for adults with arthritis were included. Study quality was assessed with the PEDro scale. Data relevant to the review question were systematically extracted by two independent reviewers. Standardised mean differences between groups for key outcomes were calculated. Meta-analyses were performed for function, mobility and indices that pooled health outcomes across multiple domains.

RESULTS:

No differences in outcomes were observed for the two rehabilitation strategies in meta-analysis. There was considerable variability between trials in key program characteristics including prescribed exercises and design quality. Components of exercise programs were poorly reported by the majority of trials. No research was found that examined participant preferences for aquatic compared to land based exercise, identifying this as an area for further research.

CONCLUSION:

Outcomes following aquatic exercise for adults with arthritis appear comparable to land based exercise. When people are unable to exercise on land, or find land based exercise difficult, aquatic programs provide an enabling alternative strategy.

Is aquatic therapy useful for post CVA patients? Should water-based intervention be a part of neuro rehab?

Mehrholz J, Kugler J, Pohl M. Water-based exercises for improving activities of daily living after stroke. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD008186.

Source

(a) Wissenschaftliches Institut, Private Europäische Medizinische Akademie der Klinik Bavaria in Kreischa GmbH, Kreischa, Germany, (b) Sektion Therapiewissenschaften, SRH Fachhochschule für Gesundheit Gera gGmbH, Gera, Thueringen, Germany, 07548.

Abstract

BACKGROUND:

Water-based exercises are used in rehabilitation and might help to reduce disability after stroke.

OBJECTIVES:

To investigate the effect of water-based exercises for reducing disability after stroke.

SEARCH STRATEGY:

We searched the Cochrane Stroke Group Trials Register (last searched August 2010), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 4), MEDLINE (1966 to April 2010), EMBASE (1980 to April 2010), CINAHL (1982 to April 2010), AMED (1985 to April 2010), SPORTDiscus (1949 to April 2010), the Physiotherapy Evidence Database (PEDro, April 2010) and OT Seeker (1969 to April 2010). In an effort to identify further published, unpublished and ongoing trials we handsearched relevant journals and conference proceedings, searched trials and research registers, checked reference lists and contacted authors.

SELECTION CRITERIA:

We included studies using random assignment.

DATA COLLECTION AND ANALYSIS:

Two review authors independently selected trials for inclusion, assessed trial quality and extracted the data. The primary outcome was activities of daily living.

MAIN RESULTS:

We included four trials involving 94 participants in this review. There was a significant improvement in activity of daily living (mean difference (MD) 13.20 points on the 'Capacidad funcional' (functional capacity) subscale of the Brazilian-Portuguese version of the SF-36; 95% confidence interval (CI) 8.36 to 18.04; P < 0.00001) and on muscle strength (MD 1.01 Nm/kg; 95% CI 0.19 to 1.83; P = 0.02) but these results should be interpreted with caution because population numbers were small and the results are based on single studies. There was no significant improvement in ability to walk (MD 0.14 m/s; 95% CI -0.32 to 0.606; P = 0.55), postural balance (MD 3.05 points; 95% CI -3.41 to 9.52; P = 0.35) or fitness (MD 3.6 (VO(2max); 95% CI -0.53 to 7.73; P = 0.09) after water-based exercises treatment compared to control. Adverse effects were not reported.

AUTHORS' CONCLUSIONS:

The evidence from randomised controlled trials so far does not confirm or refute that water-based exercises after stroke might help to reduce disability after stroke. There is a lack of hard evidence for water-based exercises after stroke. Better and larger studies are therefore required.

Does Aquatic Vertical Traction Change Spinal Height and Back Pain?

 

 

Simmerman SM, Sizer PS, Dedrick GS, Apte GG, Brismée JM. Immediate changes in spinal height and pain after aquatic vertical traction in patients with persistent low back symptoms: a crossover clinical trial.PM&R. 2011 May;3(5):447-57.

Source

Cleburne Physical Therapy, Cleburne, TX(⁎).

Abstract

OBJECTIVE:

To investigate the effect of aquatic vertical traction on spinal height, pain intensity, and centralization response compared with a land-based supine flexion position for patients with low back pain and signs of nerve root compression.

DESIGN:

Single-blind, repeated-measures crossover design.

SETTING:

Outpatient physical therapy clinic.

SUBJECTS:

Ninety-eight subjects were recruited using consecutive sampling, with 28 men and 32 women of a mean ± standard deviation (SD) age of 59.6 ± 11.6 years completing testing.

INTERVENTION:

Each subject participated in 2 sessions that consisted of loaded walking for 15 minutes, followed by either 15 minutes of land-based supine position or 15 minutes of aquatic vertical traction.

MEASUREMENTS:

Spinal height change, measured using a commercial stadiometer, was determined after completing loaded walking and after each intervention.

RESULTS:

The mean ± SD height change of 4.99 ± 2.88 mm after aquatic vertical traction was similar to that of 4.21 ± 2.53 mm after the land-based supine flexion (P = .0969). Paired t-test indicated that both interventions resulted in significant increased height (P < .0001). Decreases in pain after aquatic intervention (2.7 ± 2.1 cm) were significantly greater than decreases after land intervention (1.7 ± 1.7 cm; P = .0034), and centralization of symptoms was more pronounced after aquatic vertical suspension compared with the supine land-based flexion condition (P < .0001). A significant correlation between height change and both pain reduction (r = 0.39; P = .001) and centralization (r = 0.29; P = .013) was observed for the aquatic intervention only.

CONCLUSION:

Although both the aquatic and land interventions produced significant increases in overall spinal height, the aquatic intervention produced greater pain relief and centralization response in subjects with low back pain and signs of nerve root compression.

Establishing an Acceptance and Discharge Criteria for Aquatic Therapy

This sample provided courtesy of How to Successfully Launch an Aquatic Therapy Practice manual.

Comprehensive Aquatic Therapy Policy & Procedure manual available for sale here.

 

Sample Discharge Criteria for Pool Therapy

Policy: The following procedures will be followed during the discharge of any pool patients

Procedure:

1. A person referred by a physician for pool therapy will be evaluated and treated as soon as possible. A person referred to pool therapy will be accepted when:          

• Signed written orders exist detailing: name, diagnosis, precaution, rehab potential, goals, duration of treatment, frequency of treatment and treatment requested and
• The patient is diagnosed with a disease or condition which is likely to improve with pool therapy,

       and,

• The patient or patient representative agree on a course of treatment proposed or ordered as interpreted to them by pool therapist.

 

2. Priority for evaluation/treatment will be given to patients in the following order:

a. Inpatients and those in acute need of service.

b. Outpatients and less acute need of service.

 

3. A patient will be discontinued from pool therapy when:

• Therapy is discontinued by a physician.
• The goals have been met.
• The course of therapy as prescribed has been completed.
• An outpatients insurance program will no longer cover therapy and the patient chooses not to pay

      privately.

• In a two week period, there is no evidence of progress toward stated goals.
• When two consecutive appointments are missed without notifying the therapist.

 

4. Outpatient therapy will continue as orders indicate or are renewed every thirty days.

 

5. A referring professional is notified when a patient is discharged or when a substantial change in the treatment program is indicated.

 

6. If the referring physician is outside the medical center the therapist will send copies of documentation to the physician as requested.

 

Aquatic Integrative Therapy offers a complementary treatment for.... Fertility?

Aquatic Integrative Therapy offers a complementary treatment for fertility and a profound means of supporting the psychological, spiritual and physical needs of a woman in the pre-conception process says aquatic therapist and teacher, David Sawyer.  Here are just some of the benefits of IAT he has observed and described over the past decade:

• a support to the pregnancy
• the relief of physical discomfort
• a bonding opportunity between mother and prenate
• a means to clear energetic patterns in the ancestral lineage
• gives the father a taste of the world in which his baby is living

Read case study

Comprehensive Aquatic Therapy, 3rd edition (May 2011 release)

 

Hot off the presses!

 

Comprehensive Aquatic Therapy (CAT) authors just got their first-eyes copies of this 3rd edition. 

 

Over 8 years in the making.... It's HUGE.

 

At 560 pages and 1.5" thick, it's 140 pages bigger than the 2nd edition. It's truly the quintessential guide to aquatic therapy. 

• Get yours shipped today
  
• View contents

 

Comprehensive Aquatic Therapy remains the acknowledged reference text for aquatic therapists the world over. Featuring extensive updates from the 2nd edition, in this edition the editors have included extensive case studies, with multiple choice questions and answers as didactic content.New chapters have been added, covering the entire scope of aquatic therapy practice, including innovative new techniques with material for program development, including staff training and marketing.