Water You Waiting For?

It may seem daunting, but aquatic therapy is easier to implement—and more rewarding—than you may think.

Put yourself in a student-athlete’s shoes for a moment. Up to a week ago, you were a star on the basketball court, a hard worker with high aspirations. Then came that awful moment that changed everything. While fighting for a rebound, you landed on an opponent’s foot and partially tore two ligaments in your ankle. Ever since, you’ve been hobbling around, struggling both with the pain in your ankle and the unremitting force of gravity, and feeling nothing like the talented athlete you were so recently. You’d give anything to feel mobile again, but you know you have months of intensive rehabilitation in front of you.

As an athletic trainer, you’ve no doubt worked with this type of student-athlete before and been frustrated by your inability to help him or her feel whole again. Well, as many athletic trainers have discovered, there is a place where even the most seriously injured athletes can feel weightless and free—the water. And more and more athletic trainers are using water as a medium in which student-athletes can get quality, and quantity, rehab accomplished.

But wait a minute, you say. That sounds great, but it’s not for me or my program. First of all, I don’t have the time to add one more modality in my training room, and second, my athletic director won’t give me the funds to buy my own specialized pool.

This scenario may resonate with many of you, but both problems can be dealt with. This article will show you how, based on advice from athletic trainers who have worked out these issues in their programs.

For Mind, Body and Soul
There are several reasons water is such a tremendous medium for rehabbing an athlete. First of all, it is literally the source of life: It’s where each of us grew as a fetus. Water also makes up the largest portion of each of our tissues. So, whether because of this or because it just feels good, water provides a psychological balm.

Putting an injured athlete into the water is also physically supportive, as it provides buoyancy to help keep the athlete’s weight off an injured joint. This buoyancy also gives the athlete the feeling that he or she can do more in the pool than out. Without the constant battle against gravity, injured limbs move much more freely—an effect that cannot be underestimated. It may give your athletes added confidence that they can get through their rehab successfully.

“Athletes feel a good sense of accomplishment and goal-setting in the pool because of the buoyancy,” says Michael Gilmartin, ATC, Head Athletic Trainer at the University of Illinois-Chicago. While Gilmartin does not have any aquatic therapy units in his facility, he does use the school’s two pools, because, he says, “Student-athletes do feel that they can accomplish a lot more in there because they’re more pain-free, and because they can move around a lot more easily.”
“We use our pool early on postsurgically to provide a passive, safe environment,” says Dennis Corbin, MS, ATC, Assistant Athletic Director for Medical and Support Services at Western Michigan University. “We’ll put someone in there and the buoyancy unloads them. It’s very soothing. It’s a way for the whole extremity to get supported, and the athlete feels much more comfortable doing range-of-motion activities in that environment.”

“I think being in the water gives athletes a sense that they have more control than when they’re out of the water,” adds Rob Blanc, MS, ATC, Head Athletic Trainer at the University of Pittsburgh, who uses both an aquatic therapy pool and the school’s lap pool. “If you have a shoulder injury and you try to lift your arm parallel to the ground when you’re out of the water, you have to fight against gravity. If I put you in the water and have you do that, the sense is that your arm is being supported by the water as you lift. So it takes less muscular activity, but you’re still going through the same range of motion.”

Not only does water make it easier for the athlete to move, it also decreases the pain of injury. That’s one of the reasons Sue Walsh, MEd, CSCS, ATC, Director of Sports Medicine at DePaul University, likes to have injured athletes rehabilitate in the aquatic therapy pool. “I think the medium of the water helps tremendously when they have swelling and for comfort,” she says. “Pain inhibits normal function—I can make an exercise really functional, but if it hurts someone, we’re defeating the purpose. For us, it’s a place to put somebody where they can be pain-free.” Besides, she adds, athletes are eager to be active again and being confined to gentler body-weight exercises or lifting light weights is frustrating for those motivated to make progress in their rehab.

Finding the Time
There is a large body of literature that supports the use of aquatherapy in rehabbing athletes. (For previous Training & Conditioning articles, go to our Web site, , and enter “aquatic therapy” into the search field.) Many of you do not need to be convinced that it would benefit the student-athletes at your institution. But, between caring for the scores of athletes that you’re responsible for, and fulfilling all the other duties that go with your job, you already have enough on your plate. Fortunately, adding a pool to your list of rehab equipment is easier than you may think.

What does this entail? First is the management issue of making time to get to the pool or aquatherapy unit. Athletic trainers who use aquatherapy know they have to schedule it into their days. “You have to be cognizant that aquatherapy does require supervision,” says Corbin. “It does require one-on-one work. It’s not something where you can be taping ankles on one side of the room and have someone in the pool and expect that to be a quality workout. It requires the type of management and motivation that you get from one-on-one work, but if you schedule your time, it’s very manageable.”

“It is probably a little more time-consuming, but my approach is that we see good-enough results that it’s worth the time,” says Blanc. “I’m a firm believer in using a lot of different rehabilitation techniques, and I think that using the pool is very beneficial, so we just make sure we make the time to do it.”

One popular way to make the time is to set aside a certain portion of the day for water workouts. Another way is to hold student-athletes to scheduled appointments. For Gilmartin, who does not have a unit in his athletic training room, this method has been crucial. “We probably see 60 people a day in the training room,” he says. “I have a staff of two assistants and about 30 students. The scheduling problem is two-fold. It’s getting the kids in so we can do it with them individually, and the other component is making sure the pool is available. So, we schedule them.”

Athletic trainers who have the equipment in their facilities know that this makes life easier for them, especially if they previously did rehab in the general-use pools. Still, there may be scheduling problems where several athletes need to use the pool at one time. Michael O’Shea, MS, ATC/L, Head Athletic Trainer at the University of Houston, has solved that problem by placing his facility’s aquatic therapy unit in a circuit-training system. “Sometimes, we might have to have people wait to use it,” he says. “But instead of having people wait 20 minutes at a time, we’ll have people go through a circuit where they go in the SwimEx [aquatherapy unit], and then ride a stationary bike right there in the wet room, then we’ll have them go in the cold whirlpool, and then back to the SwimEx. By having them going in a circuit, it keeps everyone moving.”

There is another option that may allow you to create time in your schedule for aquatherapy: utilize your student athletic trainers. Corbin allows student athletic trainers to supervise athletes in the pool, with some provisos, of course. “It depends on where they are in their program, for instance,” he says. “Obviously, we don’t bring a kid in the first day and say, ‘Oh, by the way, go put that athlete through a workout.’ But, the whole idea of teaching is getting people to a point where they can do things with some semblance of independence. So, we work to that end. We supervise them as they require it. We don’t let them individually develop protocols, per se, but once the protocol is developed, and they’ve been through it a few times, we will allow [them to provide] some supervision. That helps considerably with time management.”

Learning the Ropes
One advantage that student athletic trainers in those programs will have is that they will begin their careers having been trained in aquatherapy. Otherwise, they’ll have to learn about it the same way most of today’s ATCs did—on their own. Of those athletic trainers we spoke with, Gilmartin was the only one who received training in aquatic therapy as a student.

“Back when I was a student athletic trainer, the head athletic trainer I worked with and I started fooling around with it,” he says. “From there, you read articles about it and you might incorporate people’s ideas.”

Today, Gilmartin combines his experience with suggestions from his student athletic trainers, and even the injured athletes themselves, to develop protocols for his patients. “We have at least one in-service on aquatic therapy every year, led by myself or one of my assistants, for the group of student athletic trainers,” he says. “We even make our athletes a part of it. We go over the rehab with them, and as we advance, we’ll ask them, ‘What do you think we should do?’ And then we take their suggestions. If they’re good, we include them. If they’re not, we tell them what we should do instead. That way, they’re a part of it.”

Others, such as Corbin, are self-taught. “I think there is enough out there in the literature of how people have used aquatherapy,” he says. “But the big thing for us is having it here and doing it. There are seminars that are put together by different companies. You get some basic concepts and ideas, you get guidelines from the physicians as to what they’re trying to accomplish at the different phases of rehab, and then you use your imagination, your training, and your expertise to devise different ways to personalize the workout for the athlete. Try things. After a while, you’ve got yourself a pretty good set of standards and protocols to go by.”

Athletic trainers using aquatherapy agree that the technology seems a lot more intimidating than it really is. “At first we thought, ‘What are we going to do?’” says O’Shea. “But then we said to ourselves, ‘You’re making it more than it is. It’s not that hard. Just think of the things you do, and think of the movements that particular joint goes through, and it makes sense.’”

This underscores a major benefit of aquatherapy. Because it is still in its infancy, and the medium of the water permits low-impact, low-stress exercises, aquatherapy allows an athletic trainer to use his or her imagination in developing protocols that work. “One of the things that I really like about using the pool is the only thing that stops you is your creativity,” says Blanc. “A lot of people are apprehensive to get started with something because they think, ‘I don’t know what I’d do.’ But you just go out and start doing things. One of the first things we did was we got in the pool ourselves and did things to see how it felt, what worked and didn’t work, and what was comfortable and what was uncomfortable. Now, we’ve gotten suggestions from the athletes who say, ‘Let me try this.’ Throw a kid in the pool and think about what you’re trying to do. There’s a lot of different ways to do it.”

Like the others, Walsh has learned the most by doing. “You read the books, and people tell you things,” she concurs. “You get the basics, and from there you catapult yourself into, ‘Hey, that’s kind of cool. Let’s try this.’ That, to me, is what makes what we do so fun: You can try different things with the athletes.”

Reaping the Rewards
With so many advantages, it’s no wonder that water therapy is making waves in the athletic training room. It provides comfort and support to rehabbing athletes and a safe environment for athletic trainers to experiment with protocols that can be individualized for each athlete. “Aquatherapy definitely cuts down on rehabilitation time, and there’s no question that it has made an impact in our program,” says Blanc. “It’s not the only thing we use that’s changed the way we bring people back, but it’s certainly been a big element in the change in the mentality of getting people back much earlier. It has really allowed us to push people along when they didn’t think they could be.”

As Blanc found out after going from using his school’s pool to getting an aquatic therapy unit in his athletic training room, there are advantages to having your own dedicated unit. But, he stresses, the main thing is to get acquainted with the modality wherever you can. “The big thing is,” Blanc says, “if there isn’t a pool sitting right in front of you, it’s not something you think about making part of your rehabilitation process. But if you make it a priority of rehabilitation protocols, you’re definitely going to get results. If you start to use the pool, you’re really going to enjoy what you’re doing and you’re going to find that the athletes will enjoy it and respond to it. I think it will grow on you if you just take the time to do it.”

If you’re wondering what to do with athletes who are apprehensive about working out in water, see the bonus editorial on our home page for some suggestions.

Sidebar: Floating Rehab
Michael Gilmartin, ATC, Head Athletic Trainer at the University of Illinois-Chicago, was in the midst of rehabbing a student-athlete with an ACL tear when we called him to talk about aquatic therapy. He described the protocol that he will use with the injured athlete over the next several weeks.

“Usually, we start about four weeks postsurgery. We have the athlete just start walking in the pool in chest-high water, just walking forward and backward. Obviously, the deeper you go, the more resistance you get. A distance of about 200 yards or so is adequate to start, but make sure the gait is okay and there’s no pain.

“As we progress, we want the athlete to bear weight more on the affected leg, so we’ll go into shallower water. We have stairs going into the water where the athlete can do a lot of straight-leg raises, with hip extension, hip flexion, abduction, adduction. You can vary the resistance in a number of ways. The speed you move the limb can give you more resistance, or sometimes you can put a fin on or some kind of device around the ankle that creates more resistance in the water.

“As the athlete is able to tolerate more, we’ll start doing some quarter squats in the water, using both legs, again, starting out in chest-high water. Then we can go in the shallower water as strength increases, trying to get the quads and the hamstrings involved. At this point, we might go to single-leg squats—quarter squats—if the strength is there, in chest-high water. All of that helps develop not only strength but proprioception because the water pushes you around a little bit too. Again, this is done pain-free. If all of this is easy, we just keep advancing.

“The next step, at week six or seven, we stop the walking in the shallow water, and we start running in deeper water, chest-deep. It’s just a high-knee running—knees high up to the chest, real controlled, no pain. It’s a very low-stress activity on the joint itself, it works hip flexion to fatigue, and it gets the range of motion in the hip and the knee.

“After week six and seven we’ll go to about week eight or 10 with more deep-water running, but other running activities can be initiated: butt kicks and those kinds of runs, and striders, where you exaggerate your stride in the water, amplifying your full range of motion in a running kind of stride. Again, this is low-intensity stuff because we’re not trying to condition them right now.

Here’s where we actually start swimming activities as well, not just the running on the bottom—but carefully. We add flutter kicks by having the athlete hang on to the edge of the pool, and increase it by using the kick boards and going across the pool. Then we increase that with intensity, how fast we’re going, how many repetitions across the pool back and forth. From there we’ll go to upper-body strokes as well because it’s just a little bit harder to stay up than with the kick board. We also add treading water as they can tolerate it in a little deeper water. Again, this is getting their range of motion back. If we want to increase the work load we increase it usually by yardage at this point. For example, if we’re having the athlete go back and forth across the pool six times, we’ll increase it to eight.”

Gilmartin then continues the progression with a variety of low-impact activities until the athlete is ready for exercises out of the pool.

By Lorraine Berry

Lorraine Berry is an Assistant Editor at Training & Conditioning.
Training & Conditioning, 10.5, July/August 2000, http://www.momentummedia.com