Medically-Directed Water Therapy Programs in Arizona
- 1. Medically-Directed Water Therapy Programs in Arizona Table 1:List of MWT Programs in Arizona There were limitations to the process of gathering descriptive data with the telephone survey. Thirty- five percent of the programs did not respond to a request for information. In addition, in the programs that did respond, the self-reported method of data collection via the telephone survey did not always provide specific measurable information about the service provided. Therefore, this is considered a limitation of this quality improvement project. Discussion The Therapeutic Effect and Contraindications to Water-Based Exercise There are added immediate benefits of exercising in water, including the positive influence of buoyancy, which provides an ideal environment for both rehabilitation and conditioning in individuals with disability. When standing upright in the water, the depth significantly reduces the body weight on the joints with estimates as follows: waist level=50%;; chest level=25%;; neck level=10%.3,6 This allows the exerciser to move joints more freely, increasing their range of motion. Also, when a person is immersed in neck-deep water in an upright position there is an increased external hydrostatic pressure on the body (a 100-cm column of water exerts a pressure of 76 mm Hg on the body surface). This added pressure compresses superficial veins, particularly in the lower extremities and abdomen, resulting in a blood volume shift to the thorax and heart.7-8 In a healthy heart, the associated effect is an increased venous return, which results in a significant increase in stroke volume (approximately 35-45%) due to the Frank Starling mechanism and a corresponding reduction in the exercising heart rate at any given metabolic load (See Figures 2-3).9-10 Baroreceptors located in the aortic arch and carotid arteries detect the increase in stroke volume and respond by decreasing heart rate.7,11 So in essence, you are training with a “slower stronger heart”. In addition, there is evidence of improved endothelial function and the regulation of cerebral blood flow with upright continuous water-based exercise versus land-based continuous exercise.12 However, cardiopulmonary rehabilitation professionals should be cautioned about prescribing unsupervised water-based exercise for individuals with specific heart conditions, including a recent myocardial infarction or a diagnosis of severe heart failure (HF).7,13-14 There may be an adverse effect to neck deep upright water exercise that results from the increased pressure associated with the increased venous return in people with these conditions.12 While there are an increased number of publications on HF and water-based exercise, further research is needed. Therefore, current guidelines have limitations. In the meantime, the following recommendations have been proposed.8,13,15 Conclusions References Individuals with limited mobility are susceptible to cardiorespiratory deconditioning and related medical complications. Water-based exercise may be a low-impact therapeutic option for people with specific types of physical disability. This investigation was conducted to identify and describe the services of medically-directed water therapy (MWT) programs in Arizona. A review of existing state-wide directories (i.e. Arthritis Foundation), an online search and expert opinion were used to identify active programs. Thirty-one MWT clinics were identified within the state. Twenty (65%) completed a standardized telephone survey with questions about the service provided. An updated record through March, 2016 was then compiled. It is recommended that this directory of MWT programs is routinely updated. This will provide a resource for health professionals that treat patients with physical limitations. Abstract 1. Identify and describe medically-directed water therapy programs within Arizona. 2. Understand the feasibility of using water-based continuous exercise to prevent cardiorespiratory deconditioning. 3. Describe the therapeutic physiological effect of water-based exercise on the cardiorespiratory system. Learning Objectives There were 31 MWT clinics identified in Arizona. Only 20 facilities responded to the telephone survey (See Table 1). All programs required a physician referral and MWT was a reimbursable service. Musculoskeletal pain and post-surgical rehabilitation were qualifying diagnoses at all of the facilities. Only four programs (20%) reported that they offered specific therapies for patients with heart and blood vessel conditions. The pool temperature ranged between 83-92 degrees Fahrenheit (considered thermoneutral), the depth was 3.0-6.0 feet and the size ranged between 8 feet X 10 feet in all but one facility. One of the programs was located at a health club facility and used a lap pool. The MWT was delivered by a licensed physical therapist/physical therapy assistant. The therapy was initially one-on-one with a duration time of 30-60 minutes, but there was the option to transition to a small group session. All of the programs reported that the specific number of sessions was dependent on the patient’s insurance coverage. The mode of exercise was individualized to the needs of the patient and consisted of range of motion, water resistance training and aerobic exercise. The proportion of time devoted to each modality was not reported. Results A review of existing state-wide directories (i.e. Arthritis Foundation), an online search and expert opinion were used to identify active MWT programs within Arizona. Programs were classified as medically-directed if there was a physician referral to water therapy delivered by a licensed heath care professional (physical therapist) in a clinical setting. All programs were contacted to confirm they had an active program. An administrative representative from the clinic was asked to complete a standardized telephone survey from an assigned interviewer with questions about eligibility and insurance reimbursement, the process of enrollment and specifics about the pool and services offered. An updated record through March, 2016 was then compiled. Methods Project Limitations © 2016 Mayo Foundation for Medical Education and Research Kyle Menkosky1, B.S., Cengiz Akalan 2, Ph.D. Robert Scales1, Ph.D. •Mayo Clinic-Arizona - USA.,1 Ankara University-Faculty of Sport Sciences - Turkey.2 Background Regular continuous exercise is essential to maintaining health and fitness.1 However, physical deconditioning is common in people with mobility impairment and leads to an increased risk of chronic secondary health complications.2 Land-based weight-bearing continuous exercise may not be suitable for some individuals with specific types of physical disability. Whereas water-based exercise (e.g. swimming and/or shallow or deep water upright continuous exercise with or without a buoyancy aid;; See Figure 1) may be a feasible option to improve cardiorespiratory health and fitness.3-5 Purpose To identify medically-directed water therapy programs in Arizona and describe the services offered. Recommendations • Decompensated heart failure is an absolute contraindication to water immersion and swimming. • Water temperature should be thermoneutral. • Patients with severe HF who tolerate sleeping flat are safe to sit or conduct gentle therapeutic exercise in warm water provided they are safe in an upright position and immersed no deeper than the xiphisternum. • Water based-exercise should only be conducted in the presence of exercise professionals with a sound knowledge of water-dynamics. • Patients require at least a VO2 max of 15 ml/kg/min and anaerobic threshold of >10ml/kg/min during a symptom limited exercise stress test to be considered safe for gentle exercise in water. An inappropriate heart rate response during exercise stress test should highlight added caution. • Patients meeting the above criteria, and especially those with an implantable defibrillator, should be notified of the safety precautions associated with exercise in water and should be advised to never swim alone. • The Borg Rating of Perceived Exertion Scale can be used for self-monitoring during water therapy. Moderate intensity water-based exercise that is continuous (10+ minutes/bout to accumulate 2.5+ hours/week) may be a low-impact therapeutic option to prevent cardiorespiratory deconditioning in people with specific types of physical disability.16 A physician referral to supervision from a licensed physical therapist trained in MWT will help initiate and individualize this type of activity. A safe and effective guideline may then be provided with the long-term goal of transitioning to independent home-based water exercise. It is anticipated that the identification of MWT facilities throughout the state will be a useful resource for healthcare professionals that treat patients with physical limitations. It is recommended that this state-wide directory is routinely updated and expanded as other programs are identified. Future directions should focus on the development of a quality improvement process to streamline the referral process. Continued research is needed to study the effect of strategic modes of water-based exercise therapy on the cardiorespiratory system and its implications for the prevention and management medical conditions.17-18 Future Directions 1. ACSM's guidelines for exercise testing and prescription. (2014). 9th Edition. New York, NY: Lippincott, Williams and Wilkins. 2. Saltin, B., Blomqvist, G., Mitchell, J. H., Johnson, R. L. Jr., Wildenthal, K., Chapman, C. B. (1968). Response to exercise after bed rest and after training: A longitudinal study of adaptive changes in oxygen transport and body composition. Circulation, 38, 5, VII 1-78. 3. Brody, L., Geigle, P. R. (2009). Aquatic exercise for rehabilitation and training. Champaign, Illinois: Human Kinetics. 4. Layne, M. (2015). Water Exercise. Champaign, IL: Human Kinetics. 5. Jones, K. M., Waters, D., Leggec, M., Jones, L. (2011). Upright water-based exercise to improve cardiovascular and metabolic health: A qualitative review. Complementary Therapies in Medicine, 19: 93-103. 6. Konlian, C. (1999). Aquatic Therapy: Making a wave in the treatment of low back injuries. Orthopaedic Nursing, January/February, 11-18. 7. Meyer, K., Bucking, J. (2004). Exercise in heart failure: Should aqua therapy and swimming be allowed? Medicine & Science in Sports & Exercise, 36, 12: 2017- 2023. 8. Schmid, J-P., Noveanu, M., Morger, C. et al. (2007). Influence of water immersion, water gymnastics and swimming on cardiac output in patients with heart failure. Heart, 93: 722-727. 9. Wilder, R. P., Brennan, D. K. (1993). Physiological responses to deep water running in athletes. Sports Medicine, 16: 374-380. 10. Reily, T., Dowzer, C. N., Cable, N. T. (2003). The physiology of deep water running. Journal of Sports Science, 21: 959-972. 11. Akalan, C., Scales, R. (2013). Evaluating the cardiovascular response to deep water running with a timed distance performance test. Medicine and Science in Sports and Exercise, Abstract 536, 45, 5. 12. Pugh, C.J.,Sprung, V.S., Ono, K., Spence, A.L., Thjissen, D.H., Carter, H.H., Green, D.J. (2015). The effect of water immersion during exercise on cerebral blood flow. Medicine & Science in Sports & Exercise, 47, 2: 299-306. 13. Meyer, K. (2006). Left ventricular dysfunction and chronic heart failure: Should aqua therapy and swimming be allowed? British Journal of Sports Medicine, 40: 817-818. 14. Meyer, K., Leblanc, M-C. (2008). Aquatic therapies in patients with compromised left ventricular function and heart failure. Clinical Investigational Medicine, 31, 2: E90- 97. 15. Adsett, J., Mullins, R. (2010). Evidence Based Guidelines for Exercise and Chronic Heart Failure. Pathways Home Project, Queensland Government: Queensland Health. 16. Garber, C. E., Blissmer, B., Deschenes, M. R. et al. (2011). Quantity and quality of exercise developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. American College of Sports Medicine's Position Stand. Medicine & Science in Sports & Exercise, 43, 7: 1334-1359. 17. Akalan, C., Scales, R. (2015). Feasibility of individualized water-based continuous exercise to prevent cardiorespiratory deconditioning in wheelchair users. Proceedings of a conference. 2015 Southwest Conference on Disability, Albuquerque, New Mexico. 18. Scales, R., Wethe, J. (2014). Rationale for cardiology- based exercise therapy in the treatment of post- concussion syndrome. Proceedings of a conference. 2014 Southwest Conference on Disability, Albuquerque, New Mexico. City Location Address Phone number Data Collected Chandler 360 Physical Therapy 1976 W. Chandler Blvd. #103 Chandler, AZ 82224 480-‐821-‐1997 X Flagstaff DeRosa Physical Therapy * 1485 N. Turquoise, #220 Flagstaff, AZ 86001 928-‐774-‐6626 X Fountain Hills 360 Physical Therapy 12545 N. 24th St. #230 Fountain Hills, AZ 85248 480-‐837-‐1530 X Gilbert Carling Therapy * 725 W. Elliot Rd. #103 Gilbert, AZ 85233 480-‐892-‐2428 X Gilbert Aqua Therapy 2571 S. Val Vista Dr. Gilbert, AZ 85295 480-‐773-‐7766 Gilbert Pain Relief & Physical Therapy 3485 S. Mercy Rd. #101 Gilbert, AZ 85297 480-‐963-‐2400 X Glendale Banner Dessert Medical Thunderbird 5555 W. Thunderbird Glendale, AZ 85306 602-‐865-‐5830 X Glendale HealthSouth Valley of the Sun Rehabilitation 13460 W. North 67th Ave. Glendale, AZ 85304 623-‐334-‐5362 X Maricopa 360 Physical Therapy 21083 N. John Wayne Pkwy. #C-‐104 Maricopa, AZ 85139 520-‐233-‐7555 X Marana Maximum Impact Physical Therapy 13395 N. Marana Main St. Marana, AZ 85653 520-‐682-‐9645 Mesa 360 Physical Therapy 4210 E. Baseline Rd. #106 Mesa, AZ 85206 480-‐503-‐2373 X Mesa Desert Pain Institute 6309 E. Baywood Ave. Mesa, AZ 85206 480-‐759-‐5200 Mesa Banner Desert Medical Center 1400 S. Dobson Rd. Mesa, AZ 85202 480-‐412-‐3000 X Mesa STI Physical Therapy 6309 E. Baywood Ave. Mesa, AZ 85206 480-‐759-‐5200 Mesa Kempton Physical Therapy 6960 E. Broadway Rd. Mesa, AZ 85208 480-‐807-‐9000 X Peoria Oakeson Physical Therapy 8240 W. Cactus Rd. Peoria, AZ 85381 623-‐878-‐9696 Phoenix 360 Physical Therapy 3700 N. 24th St. #230 Phoenix, AZ 85016 602-‐903-‐4383 X Phoenix Southwest Therapy Specialists 7540 N. 19th Ave. #101 Phoenix, AZ 85201 602-‐249-‐9129 Phoenix Aspite Therapy * 1016 N. 32nd St. Suite A Phoenix, AZ 85008 602-‐275-‐1899 X Scottsdale 360 Physical Therapy 14203 N. Scottsdale Rd. #169 Scottsdale, AZ 85254 480-‐607-‐9200 X Scottsdale HealthSouth Rehabilitation 9630 E. Shea Blvd. Scottsdale, AZ 85260 480-‐551-‐5423 X Scottsdale Spooner Physical Therapy 9091 E. Desert Cove #110, Scottsdale, AZ 85260 480-‐860-‐4298 X Sun Lakes 360 Physical Therapy 25229 S. Sun Lakes Blvd. #119 Sun Lakes, AZ 85248 480-‐883-‐6734 X Tempe 360 Physical Therapy 1805 N. Scottsdale Rd. Tempe, AZ 85281 480-‐941-‐4169 X Tempe 360 Physical Therapy 1952 E. University Dr. Tempe, AZ 85281 480-‐821-‐1997 X Tucson Tucson Physical Therapy 7315 N. Oracle #101 Tucson, AZ 85704 520-‐293-‐5551 Tucson Tucson Orthopedic Institute E. 2424 N. Wyatt Dr. #130 Tucson, AZ 85712 520-‐784-‐6570 Tucson Maximum Impact Physical Therapy NW 6970 N. Oracle Rd. #130 Tucson, AZ 85704 520-‐219-‐1512 Tucson HealthSouth Rehabilitation Institute 2650 N. Wyatt Dr. Tucson, AZ 85712 520-‐322-‐3663 Youngtown Aspite Therapy * 12600 N. 113th Ave. Building A Youngtown, AZ 85363 623-‐972-‐4033 X Yuma Yuma Rehabilitation Hospital 901 W. 24th St. Yuma, AZ 85364 928-‐314-‐8812 *Cardiac and pulmonary services offered Figure 1. Figure 2. Figure 3.