the aquatic therapist

Help: We have an allergic reaction everytime we get into the therapy pool

HELP! We have a pool that uses chlorine and two aquatic therapists have developed a sensitivity to it with severe skin outbreaks. What can we do?

ANSWER: Sorry you are having problems. Unfortunately, it can be an occupational hazard of being an aquatic therapist especially if you spend more than 4 hours in the water a day.

Unfortunately, a halogen sensitivity, once developed, usually remains. So what does a chlorine allergy look like? For one, exposure to the same levels of chlorine will typically result in a similar response.

The best answer is to reduce the overall amount of halogen (e.g. chlorine) in your pool. This is best done by adding a supplemental disinfection system (such as an ozone generator) to your pool. It can reduce the amount of chlorine you need to use by 7x.

More info on how to reduce chlorine with supplemental systems (especially Tips #36, #47, #54). 

**************************************

Rashes are a common complaint with both pool and spa users. Rashes may be caused by a reaction to chemicals in the water or by a bacterial infection. The first step in investigating rash outbreaks should be to identify the cause. The simplest way to differentiate chemically- and bacterially-induced rashes is the incubation period (onset longer than 12 hrs; probably not chemically induced).

Best Practices to Reduce Chemical Rashes

• Maintain the proper sanitizer level at all times – this not only provides oxidation but also prevents bacterial growth, including Pseudomonas aeruginosa that will cause bacterial rashes.
• Maintain proper pH and alkalinity – improper pH has been linked to some irritant rashes.
• Use routine supplemental oxidation to reduce combined chloramines and bromamines. Supplemental treatments include quick-dissolving chlorine compounds (cal hypo, dichlor, granular trichlor, lithium hypo, and bleach), non chlorine shock-oxidizers (monopersulfate), and ozone. Supplemental oxidation is particularly important when using bromine compounds (BCDMH, DBDMH or sodium bromide).
• In spas, routinely replace the water. There are several guides available for this, including one from the APSP (visit APSP’s website at http://apsp.org/54/index.aspx for a free download of APSP’s complete Water Treatment Information Bulletins.)
• When the water appears cloudy or foamy, the facility should be closed at once.

These all seem rather obvious. Yet in reported cases one or more of these were not followed by the operator.

The single largest group reporting chemical rashes is hydrotherapists (therapists providing therapy in aquatic settings). These individuals are exposed to chlorine- or bromine-treated water up to ten hours per week. The temperature and bather loading of these therapy pools resembles hot tubs.

One Israeli study revealed that 45 percent of the 190 therapists surveyed developed skin disease after beginning work (Lazarov, Nevo, Pardo, and Froom. 2005. Self-reported skin disease in hydrotherapists working in swimming pools. Contact Dermatitis 53:327-331). The authors concluded that skin disease for hydrotherapists is an occupational hazard resulting from cumulative exposure.

So what is the exact cause of chemical rashes? We don’t know. The published cases do not provide enough information on the treatment system being used by the facility or chemistry discovered during the incident investigation.

We do know that hypobromous acid (the active portion in “bromine”) is a poor oxidizer when compared to hypochlorous acid (the active portion in “free chlorine”). We also know that hypobromous acid reacts with organic matter to form combined bromamines, just as free chlorine does. And bromamines and chloramines are known skin irritants.

A further complication is that there is no readily available test to determine the concentration of combined bromamines. OTO and DPD kits measure only total bromine, which includes the free bromine and combined bromine.

Excerpted from: The Association of Pool and Spa Professionals.  Chemically-induced Rashes. Recreational Water Quality. (A Publication of the APSP Recreational Water Quality Committee). Jan 2008. Available at: http://apsp.org/APSPRWQE-news/Jan16/rash.htm

Free research download: A water-based training program that include perturbation exercises to improve stepping responses in older adults

REFERENCE:  Itshak Melzer, Ori Elbar, Irit Tsedek, and Lars IE Oddsson. A water-based training program that include perturbation exercises to improve stepping responses in older adults: study protocol for a randomized controlled cross-over trial. BMC Geriatr. 2008; 8: 19.

DOWNLOAD THE | Abstract | Full text/PDF |

GERIATRIC TRAINING OPTIONS:

Attend Feb. 12-13, 2010 class -  Water-Based Intervention for the Geriatric Client: An Aquatic Therapy Primer

Attend Oct. 8-19, 2010 class - Novel Aquatic Balance, Proprioception and Fall Prevention Strategies

Question: Why would aquatic therapy have to be "better" than land-based therapy?

This is Part 3 of a multi-part series.

Independent medical review is the process where physicians review medical cases in order to provide claims determinations for health insurance payers, workers compensation insurance payers or disability insurance payers. These physicians are contracted to provide objective, unbiased determinations on what the root cause of the treatment was, whether or not there is medical necessity, if there was a sentinel event, what was the reason for it, etc.

Eavesdrop on some of the recent decisions which addressed whether aquatic therapy is medically necessary. In the past two postings on this issue, the reviewer found that aquatic therapy was necessary.

In this posting, the reviewer found that aquatic therapy was as effective as land-based therapy... but that this should lead to its denial. These findings seem capricious and ill-informed -- the reviewer state b/c there is no literature which supports the effectiveness of aquatic therapy as better than land-based therapy, that aquatic therapy should not be considered a reimbursable service. What a strange thought.

First of all, the foundational contention is wrong. There have been dozens of studies in the last 10 years which have shown that aquatic therapy offers an advantage over land-based therapy for pain and many other facets of treatment.

Second, if 2 treatment choices are equally effective -- but both are effective -- why deny one as medically unnecessary?

Read these decisions for yourself.

The Case: A 54-year-old female enrollee has requested aquatic-based physical therapy (PT) from a non-contracted provider for the treatment of her knee status post total knee arthroplasty.

Findings: The physician reviewer found that although aquatic therapy is certainly a choice of modality for treatment, there is no proven benefit over land-based PT in the treatment of osteoarthritis of the knee/hip. The study by Wyatt and colleagues found that both aquatic and land-based exercise programs were beneficial for osteoarthritis. Bartels and colleagues review of several studies for aquatic exercise for knee and hip osteoarthritis determined that the available studies were not conclusive to recommend aquatic therapy over land-based therapy. This reviewer did not find any published randomized, controlled trials comparing the effects of land-based versus aquatic PT for patients following TKA. Ulrich and colleagues study regarding focused rehabilitation treatment of poorly functioning TKA recommends various rehabilitation techniques, but they do not include aquatic therapy. Based on the totality of the available evidence, aquatic therapy following TKA has no proven benefit over land-based PT. Here, although this patient had improvement in ROM, aquatic therapy is not proven to be superior to traditional (i.e., land-based) physical therapy. The gains may have been made had the patient continued land-based therapy.

Read full decision here...

The Case: The patient is a 48-year-old female with degenerative disc disease and myofascial neck pain. She has been receiving physical therapy (PT) and it has apparently been helpful. The patient's provider prescribed continued physical therapy and aquatic evaluation and therapy. The patient's request for authorization of continued physical therapy and aquatic evaluation and therapy was denied by the Health Plan based on a determination that the therapies are not medically necessary.

Findings: A review of the record shows that the patient was receiving physical therapy and that it was beneficial. Some instruction in a home exercise program was provided, but the PT progress notes indicate the patient had not been fully instructed. Since land-based physical therapy was helpful to the patient, aquatic therapy would not be medically necessary at this time. The patient should continue with the land-based physical therapy in order to complete all of the instruction necessary for a home-based exercise program. Three times per week for three weeks would be a reasonable time frame. Based upon the information set forth above, I have determined one of the requested therapies is medically necessary for treatment of the patient's medical condition. The Health Plan's denial should be partially overturned.

The Case: A 45-year-old female enrollee requested authorization and coverage of continued speech therapy, cognitive therapy, physical therapy, and aquatic therapy. The Health Plan denied the request indicating that the requested therapies are not medically necessary for treatment of the enrollee's traumatic brain injury.

Findings: One physician reviewer performed a medical necessity Independent Medical Review. The physician reviewer partially overturned the Health Plan's denial on the basis that the requested physical therapy is medically necessary but speech therapy, cognitive therapy, and aquatic therapy in excess of the therapy already approved by the Health Plan is not medically necessary.

Read full decision here...

Accelerated Rehab after ACL Surgery Includes Aquatic Therapy

Attend 2010 seminar - Aquatic Therapy Training Options for the Collegiate, Professional and Elite Athlete

Bridey-Lee Momberg, Quinette Louw, Lynette Crous. Accelerated hydrotherapy and land-based rehabilitation in soccer players after anterior cruciate ligament reconstruction:a series of three single subject case studies. SAJSM. 2008; 20(4): 109-114.

DOWNLOAD FULL TEXT (PDF)

Objective. To investigate the effectiveness of accelerated rehabilitation and accelerated hydrotherapy after anterior cruciate ligament (ACL) reconstruction in male athletes participating in soccer.

Design. A non-concurrent single subject, multiple baseline design (ABA design) was conducted over 10 weeks. A series of three N=1 studies was conducted to assess the effect of an accelerated hydrotherapy programme on pain, function, and range of motion.
Setting. The study was conducted at a private physiotherapy practice in Port Elizabeth, South Africa.

Interventions. The land rehabilitation programme was a homebased programme supervised every week by the physiotherapist. The accelerated hydrotherapy consisted of a 6-week programme, and participants attended two treatment sessions of accelerated  hydrotherapy per week each of 30 minutes' duration.

Main outcome measures. The knee injury and osteoarthritis outcome scale (KOOS) as a subjective measure of pain, function and quality of life; the goniometer to measure active knee ROM and the 6-minute walking test (6MWT) as an objective measure of function.

Results. All three patients demonstrated good improvement during the treatment phase for the KOOS scale and progressed well

CORESPONDENCE:
Professor Quinette Louw
Division of Physiotherapy
Department of Interdisciplinary Health Sciences
Faculty of Health Sciences
Stellenbosch University
PO Box 19063
Tygerberg 7505
Republic of South Africa
Tel: +27(021) 938 - 9301
Fax: +27(021) 931-1252
E-mail: qalouw@sun.ac.za
Bridey-Lee Momberg (BSc, MSc Physiotherapy (OMT))
Quinette Louw (BSc, MASP, PhD)
Lynette Crous (BSc, MSc)
Division of Physiotherapy, University of Stellenbosch

Frail elderly... Does water exercise improve ADLs in nursing-at-home residents?

Sato D, Kaneda K, Wakabayashi H, Nomura T. Comparison of 2-year effects of once and twice weekly water exercise on activities of daily living ability of community dwelling frail elderly. Arch Gerontol Geriatr. 2009 Jul-Aug;49(1):123-8. 

Previous research suggests that water exercise improves the activities of daily living (ADL) ability of the frail elderly, but the specific frequency and intensity of such programs is unclear.

This study aims at comparing the effects of once- and twice-weekly water exercise on the ADL ability of frail elderly receiving nursing care for 2 years. The design is a prospective randomized longitudinal study. Participants were assigned to two different exercise groups (Group 1 and Group 2). Group 1 participated in a 60-min exercise session once a week, for 2 years, while Group 2 attended the session twice a week.

Exercise sessions were divided into a 10-min warm-up on land and 50 min of exercise in water. The 50-min water exercise program consisted of 20 min walking, 10 min ADL exercise, 10 min stretching and strength exercises, and 10 min relaxation in water.

ADL ability and lower muscle strength were measured before the beginning of exercise and 6 months, 1 year, and 2 years after the program had started.

Significant group differences occurred for bathing transfer and stair climbing at the 2-year measurement. These results suggested that at least twice-weekly water exercise was necessary to maintain the ADL ability and KEX of the frail elderly during the 1-year water exercise period and for one additional year afterward.

Comprehensive Human Science, University of Tsukuba, 1-1-1 Tennodai, Tsukuba City, Ibaraki 305-8574, Japan. ds5592@gmail.com

Aquatic Therapy University: Water-Based Intervention for the Musculoskeletal Client: An Aquatic Therapy Primer

Water-Based Intervention for the Musculoskeletal Client:
An Aquatic Therapy Primer

Taught By: Andrea Salzman, MS, PT
January 15-16, 2010
Minneapolis, MN
$595

Get details on this course -- and 18 other aquatic therapy classes held in 2010 -- at Aquatic Therapy University or www.aquatic-university.com

PREREQUISITES

A 4-hr ATU Bootcamp is offered at no additional cost immediately prior to this class (see next column for schedule). This class is required before taking any ATU course (current water-gurus excepted).

ABOUT THIS 2 DAY CLINICAL- INTENSIVE SEMINAR

A 18 hr. training module packed into 2 days (4 hr. Boot Camp plus 14 hr. main course). Designed to rapidly introduce clinicians to basic treatment ideas for the musculoskeletal patient. Will provide an overview of treatments pertinent to pediatric, adult and geriatric practices. Includes a “sampler lab” of the most clinically useful elements of popular aquatic specialty techniques and research findings which support aquatic therapy. Provides an introduction to the following techniques: Watsu®, the Bad Ragaz Ring Method, Ai Chi, Task Type Training Approach, the Aquatic Berg (for balance), Aquatic Sensory Integration (ASI) and drills loosely based on the Halliwick Method.

LEARNING OBJECTIVES

1. Describe why aquatic therapy may be the treatment of choice if (a) the patient is difficult to support or handle, (b) the patient is in pain, or (c) if the therapist cannot adequately access the patient’s body on land, (d) the patient has LE swelling (lecture).
2. Recite 3-4 aquatic precautions and contraindications specific to the musculoskeletal patient (lecture).
3. Locate what payers (including Medicare) have to say about aquatic therapy for the musculoskeletal patient (lecture).
4. Make a 3 minute verbal “case” for providing aquatic therapy services for a patient with a specific musculoskeletal condition. Be able to identify and locate supportive research to bolster case (lecture).
5. Progress a specific aquatic task from a lower level of function towards increased independence (lab)
6. Perform 3-4 aquatic therapeutic movements, tasks, or exercises designed to:

   • increase strength
   • improve ROM
   • decrease pain and muscle spasm
   • improve trunk stability
   • improve posture, weight-bearing, balance, gait and proprioception
   • improve functional skills (lab)

   7. Demonstrate 1-2 aquatic tasks or activities from each of the following specialty techniques (as each relates to the musculoskeletal client):

   • Aquatic adaptations of the Berg
   • Aquatic Blanket Drills (ABDs)
   • Aquatic manual therapy and stretching
   • Aquatic yoga
   • Bad Ragaz Ring Method
   • Functional skills training
   • Progressive resistive exercise
   • Proprioceptive neuromuscular facilitation (PNF)
   • Trunk stabilization
   • Watsu (lab)

   8. Working with a partner, design and implement a 15-minute aquatic treatment plan (including equipment selection) for 1-2 of the following:

   • s/p fracture, internal trauma, sprain, strain or dislocation
   • s/p joint replacement (e.g. TKR)
   • s/p tendon or ligament repair (e.g. ACL)
   • arthritis
   • chronic pain syndromes (e.g. fibromyalgia)
   • back and neck dysfunction (lab)

Dry hydrotherapy -- Is it covered by insurance? Should it be?

Dry hydrotherapy, also referred to as aquamassage, water massage or hydromassage, is a treatment that incorporates water with the intent of providing therapeutic massage.

Is it therapeutic? Maybe...

Is it reimbursable? Not according to several insurance companies.

Just to name a few, these payers now find DH experimental or investigational.

• Cigna
• Aetna
• BCBS North Carolina

Why one company says your practice should include dry hydrotherapy anyway.

In dry hydrotherapy, the water is contained in a bed or chair, and the patient is separated from the water by a waterproof barrier, such as a vinyl cover. The user remains fully clothed and dry during the treatment. Pumps or water jets circulate, pulsate and spray the water within the contained area. Streams of pulsating water are sent along the patient’s body as the individual sits or lies on the device. The treatment is generally provided in chiropractor or physical therapy offices.

Independent Medical Review supports "aquatic therapy" as medically necessary: Part II

Independent medical review is the process where physicians review medical cases in order to provide claims determinations for health insurance payers, workers compensation insurance payers or disability insurance payers. These physicians are contracted to provide objective, unbiased determinations on what the root cause of the treatment was, whether or not there is medical necessity, if there was a sentinel event, what was the reason for it, etc.

Eavesdrop on some of the recent decisions which addressed whether aquatic therapy is medically necessary. Their findings might help you support your own treatment choices.

This is Part 2 of a multi-part series.

The Case: The patient is a 54-year-old female with a history of fibromyalgia and pain in her neck, right hip, feet, knees, hands and wrists. The patient has requested reimbursement for the aquatic therapy provided in February 2005 and prospective authorization for additional aquatic therapy. The Health Plan has denied these requests based upon a determination that the therapy was/is not medically necessary.

Findings: Although the patient has a chronic condition, she had not had much relief with traditional land-based physical therapy alone. A trial of aquatic therapy was reasonable and consistent with Medicare guidelines and standards within the medical community. The aquatic therapy provided in February 2005 was medically necessary and should have also included a component of patient education. Authorization for ongoing aquatic therapy is not medically necessary, as the patient should have been provided with the instruction necessary to continue her aquatic exercise program independently. Based upon the information set forth above, I have determined that although additional aquatic therapy is not medically necessary for treatment of the patient's medical condition, the therapy provided in February 2005 was medically necessary for treatment of the patient's medical condition. The Health Plan's denial should be partially overturned.

Read full decision here...

Medicare rules for use of community pool - apply to private practice, physicians office, outpatient hospital or outpatient SNF

Just a reminder of a change that happened in Medicare policy last summer...

According to the CMS:

When therapy services may be furnished appropriately in a community pool by a clinician in a PT or OT private practice, physician office, outpatient hospital, or outpatient SNF, the practice/office or provider shall rent or lease the pool, or a specific portion of the pool. [Emphasis added]

The use of that part of the pool during specified times shall be restricted to the patients of that practice or provider. The written agreement to rent or lease the pool shall be available for review on request. When part of the pool is rented or leased, the agreement shall describe the part of the pool that is used exclusively by the patients of that practice/office or provider and the times that exclusive use applies.

Other providers, including providers of outpatient physical therapy and speech-language pathology (OPTs or rehabilitation agencies) and CORFs, are subject to the requirements outlined in the respective State Operations Manual regarding rented or leased community pools.

Medicare Benefit Policy Manual- Chapter 15 – Covered Medical and Other Health Services (See Section 220C) (Revision 109, 08-07-09)

Independent Medical Review supports "aquatic therapy" as medically necessary - Part I

Independent medical review is the process where physicians review medical cases in order to provide claims determinations for health insurance payers, workers compensation insurance payers or disability insurance payers. These physicians are contracted to provide objective, unbiased determinations on what the root cause of the treatment was, whether or not there is medical necessity, if there was a sentinel event, what was the reason for it, etc.

Eavesdrop on some of the recent decisions which addressed whether aquatic therapy is medically necessary. Their findings might help you support your own treatment choices.

This is Part 1 of a multi-part series.

The Case: A 65-year-old female enrollee has requested water exercise with a physical therapist for treatment of her knee pain.

Findings: The physician reviewer found that the rehabilitative management of patients following total joint arthroplasty should be individualized and geared toward the specific functional needs of a given patient. A recent randomized controlled trial by Rahmann and colleagues has demonstrated the beneficial effects of aquatic physiotherapy following total joint arthroplasty.

In this patient's case, there is a significant pain component that could limit functional recovery. It is therefore likely that the patient will better tolerate and progress with an aquatics-based program as opposed to a land-based therapeutic exercise program. The requested services are medically appropriate and likely to result in an improved outcome for this patient as compared to land-based therapy.

Read full decision here...