|Author: Dina Melchiorre|
|PT Advances Aquatic Therapy|
|Jim Irvin, MPT is Coordinator of Aquatic Physical Therapy
(APT) at the Desert Samaritan Medical Center (DSMC) in Mesa, Arizona. Since joining the aquatics program in 1995, much of Irvin's energy has gone into increasing awareness about aquatics and building a solid referral base for the program. "Aquatic physical therapy is offered here on-site at the hospital. We've found that patients, physicians and fellow PTs have come to recognize and appreciate our program.
"The use of aquatic therapy can be traced back to seventeenth century Europe when people would soak in heated spas," explains Jim Irvin, MPT. "Aquatics has been recognized in the United States for past 20 years or so, but it's really only been in the last five years or so that aquatics has taken off."
Irvin says the patients in APT range in age from 16 to 98-years-old. "The 98-year-olds are more apt to get into water and not be afraid to fall. They can work on walking and can get quality care and have a good time," he explains. "Our average patient is in the range of 40. Our most common cases are low back pain, followed by athletic injuries."
Prior to joining the aquatics program, Irvin was working in outpatient orthopedics at DSMC. "I have been with APT for almost five years now. That was when the program was just being designed. When I was asked to coordinate the aquatics program, I was told I had six months to make it work," Irvin recalls with a chuckle. He says he rose to the challenge of promoting the program, which he pursued in any way possible. "I spent a lot of time going out and talking to physicians to help them understand what aquatics can do.
"At that time, there was a great misconception about aquatics. We were getting just those patients who were in really bad shape, who had tried all kinds of therapy - acupuncture, you name it - but weren't getting relief. People would come to us after three or four years of back pain with severe atrophy in their legs," Irvin explains. "Patients quickly found that in the water, with relief from the pressure of their own body weight, they could begin to move without pain."
In the early days, when the APT program was young, Irvin says he would make presentations and tell physicians, "Give me one patient. If you or that patient is not satisfied, then you do not have to send any others." He explains that as more patients were experiencing success in the water, the program gradually built a good referral base. "Now quite a few physicians send us patients on a regular basis.
"There is one local anesthesiologist who regularly refers patients to the program." Irvin continues. "He had back issues of his own, and loved working with us. Since the anesthesiologist works with a lot of people with pain, administering epidurals to calm inflammation, he sends patients to us to work in the water for follow-up PT."
According to Irvin, DSMC's Aquatic Physical Therapy program is doing 30 - 40% of the hospital's outpatient physical therapy business. "We have a heated 15 x 30 foot outdoor pool that is covered by a large tent-like canopy to offer protection from the sun and weather." The aquatic programs run from early morning into the evening. He says in the warm Arizona air, the outdoor pool is very pleasant for patients. Irvin says he commonly jokes, "I actually get paid to be in the pool all day."
Irvin works very closely with his program's immediate staff, comprised of two physical therapists, three technicians and one athletic trainer. This team works hand-in-hand with DSMC's land-based Outpatient Physical Therapy program. "We do a lot of co-treating. Everyday I make calls and several physical therapists get on the phone to discuss patients' needs and progress.
"What's different about working in aquatic programs, is that patients are almost never left unattended, and generally train in the water for about an hour at a time," Irvin explains. Since there may be 5 - 6 people training in the pool at one time, he says the staff has the responsibility of circulating and monitoring the pool at all times. "Much of our administrative work, such as progress notes on patients, must wait until after treatments are finished at the end of the day."
Irvin says he tends to work with patients on Mondays, Wednesdays and Fridays, seeing an average of 18 - 20 patients each day. He will usually spend Tuesdays and Thursdays working on departmental procedures, following up on phone calls, and doing presentations at PT schools, staff in-services, and for athletic trainers, insurance professionals and third party payers. Irvin also has the responsibility of program development and designing aquatic treatment protocols.
Describing the water's healing properties, Irvin illustrates with an example of how aquatic PT would benefit a person with lower back difficulties. "Buoyancy helps remove the pressure of weight on spinal tissues. A person chest-deep in water only experiences one fourth of the amount of gravity as on land," he explains. The depth of the water used can easily be controlled depending on which section of the pool is used, because the depth range of the pool is from three to 15 feet."
The heat of the water, regularly set at 92 - 94 degrees Fahrenheit, also helps relax the muscles to eliminate some of the pressure and increases muscle and joint elasticity. Patients who experience chronic lower back problems enjoy the pool because it offers a break from their pain. Irvin says people who have partial weight-bearing ability can ambulate with assistance earlier in the water than they could on land.
Discussing a couple of the techniques the program uses, Irvin says, "We work with all different kinds of equipment to create currents in the water. These currents offer the body gentle resistance. We will, in the case of people with lower back problems, have them maintain their neutral spine and hold themselves in place. We tell them 'don't let the water move you,''' Irvin explains. "We use simple things, like a cafeteria tray, to create currents in the water. We also have patients exercise holding partially-full, sturdy, plastic bottles to increase their strength.
"Everything we do is based on land principals. For quadriceps strengthening, we do knee extensions in the water just as you would on land. All of the theory is the same, its just a different gymnasium," says Irvin. "We adapt an exercise, like the squat, that would, on land, progress by having weight added. In water we add speed, or have the patient work in shallower water to reduce buoyancy. With other exercises we increase resistance by creating a current in the water."
Two specialty programs of DSMC's Aquatic Physical Therapy program are the Lumbar Stabilization program (just described, where people stand with a neutral spine), and Aquatic Dynamics, a sport specific training and conditioning program for football and basketball players. "The athletes in Aquatic Dynamics are able to work on their skills in the water. We do sprint drills in the water to add strength, speed and help players maintain form. The program enables athletes to supplement their off-season training regimen in the water to reduce stress on the musculoskeletal system. This allows them to train at a high intensity with a reduced risk of injury," says Irvin. "I've seen athletes shave time off their speed, gain strength, and improve vertical jumps. I love working with athletes, that's how I got into to PT in the first place."
Irvin calls himself an "oft-injured athlete." In college he played basketball, primarily pick-up games. "I dislocated my shoulder and had to have surgery. I worked with a PT day in and day out, trying to get rehabilitated," he recalls. "That's when I decided I would really love working with people." While pursuing a Bachelor's degree in Biomechanics, Irvin considered a career in orthopedic surgery because of his interest in movement and how the body works. "I soon found that in orthopedic surgery, I would have limited contact with the patient after surgery. I liked the role of the PT. Being in the trenches, working directly with people and playing a large part in their success appealed to me," he says. "I thrive on patients' minor successes, like walking without crutches or being able to comb their own hair."
Among many stories of success, Irvin describes a special case involving a 40-year-old woman with an incomplete spinal tumor. "I remember she was extremely motivated. After lots of hard work she was able to ambulate while holding onto the pool deck. She didn't care that she was being assisted, or that it was only in the pool that she could do it, her goal was to be able to use her legs to walk."
As well as the rewards, Irvin says there are also some challenges associated with aquatic PT. "The fact is that healthcare is extremely challenging for outpatient physical therapy, especially in the orthopedic realm. Getting reimbursements, and getting physicians to refer patients into aquatics programs, takes constant work.
"We need people to understand that beginning to use the water's properties early on and getting patients started closer to the time of injury helps to boost their progress," he continues. He uses cases of ankle surgery as an example. "If we can help get people started in the water when they are not yet bearing weight, we can begin to work their joints and muscles. They can transition toward land when they start to bear more weight."
Recent technological developments are benefiting aquatics, Irvin says, coming from companies' willingness to develop underwater equipment especially for aquatic PT. "There are underwater treadmills, and machines to create currents. One company is now doing underwater EMGs testing," he explains. "I would like to get into studies developing and testing uses for the equipment."
Irvin proudly reports that he and his team recently patented a piece of equipment tailor-made for the Lumbar Stabilization program. Their development can also be used for a cardiovascular workout. They designed a board made of plastic which is calculated to be dense enough to bend - not break - under the strain of the water's resistance, and still be able to float. The board has a shutter mechanism that can be used to increase resistance, as well as handles for a person to hold onto, making it easier to move through the water.
"The equipment company, OPTP, just sent another prototype to make sure it is holding up. It is doing great. PTs love it," Irvin reports. "We also know how important it is to be able to produce it at a reasonable cost for everyone." Irvin says he is excited because the project was based on staff observations about the needs of their patients.
Along with his work at DSMC, Irvin loves being involved with students. He is the Aquatics Clinical Educator, an adjunct faculty member at Kirksville College of Osteopathic Medicine in the Greater Phoenix area. Irvin also enjoys his affiliation with Northern Arizona University, another school that sends interns to DSMC's APT department. "We pretty much have an intern all year round. I love to teach, to educate people about water."
In the future, Irvin says he will stay involved in aquatics, possibly by teaching through continued education. "My mission is not to compete with other land-based PT programs, but to let them know there is another treatment option that can help," he explains. "Aquatics is advancing by leaps and bounds. The challenge is to get the word out to educate other PTs, physicians, interns, and others.
"I see myself expanding my role as educator into an ambassador for aquatics," he states. "I would like to tour the nation to give talks about aquatics to healthcare professionals. I am interested in doing what I can to expand this field as long as I'm in it."
Jim Irvin earned his Masters in Physical Therapy from the University of Southern California in 1995. He earned his Bachelors of Science Degree in Biomechanics from Arizona State University in 1992.
Dina Melchiorre is a freelance writer from the Philadelphia area. She is on the Editorial Staff of NEWSLine for Physical Therapists and PT Assistants.