Aquatic Therapy: A Viable Therapeutic Recreation Intervention · 2019-05-30 · Aquatic Therapy: A Viable Therapeutic Recreation Intervention Ellen Broach and John Dattilo This paper

Aquatic Therapy: A ViableTherapeutic Recreation Intervention

Ellen Broach and John Dattilo

This paper presents a review of the literature concerning the effects of aquatic therapyutilizing swimming and exercise activity to improve function. Based on the literature, aquatictherapy appears to have numerous psychological and physical benefits. Research studiessupport the belief that participation in an aquatic therapy program can provide individualswith a realistic solution for maintaining physical fitness and continuing to achieve rehabilita-tion goals while engaging in enjoyable leisure pursuits. Implications of aquatic therapy toleisure generally and therapeutic recreation more specifically are highlighted.

KEY WORDS: Aquatic Therapy, Swimming, Water Exercise, Therapeutic Recreation

Aquatic therapy, utilizing swimming and improve functioning of all major muscleexercise activity to improve function, is be- groups without the impact that is unavoid-lieved to have beneficial consequences for able in land based physical exercise (Cam-physiological and psychological well-being pion, 1985).(Campion, 1990; Davis & Harrison, 1988; Physiological improvements achievedHurley & Turner, 1991; Skinner & Thom- through involvement with aquatic therapyson, 1989). Hurley and Turner (1991) sug- have been documented in studies of individ-gested that for many individuals with disabil- uals who have multiple sclerosis (Gehlsen,ities the buoyancy as well as the increased Grigsby, & Winant, 1984), cystic fibrosisresistance and warmth of water creates an (Edlund, 1980), arthritis (Danneskiold-environment for exercise which is more con- Samsoe, Lyngberg, Risum, & Telling, 1987),ducive to achieving treatment goals than ex- orthopedic impairments (Skinner & Thom-ercise conducted on land. In addition, exer- son, 1989), cerebral palsy (Harris, 1978;cise achieved through aquatic therapy may Smith, 1985) and asthma (Haung, Veiga,

Ellen Broach is a doctoral student and John Dattilo is a Professor in the Department ofRecreation and Leisure Studies at the University of Georgia.

Third Quarter 1996 213

Sila, Reed, & Hines, 1989). Furthermore,psychological benefits of participants inaquatic therapy have been identified to in-clude improved mood (Berger & Owen,1992; Berger, Owen, & Man, 1993), en-hanced self-esteem and body image (Bene-dict & Freeman, 1993; Wright & Cowden,1986), and decreased anxiety and depression(Stein & Motta, 1992; Weiss & Jamieson,1989). In addition to physiological and psy-chological benefits, aquatic therapy maypromote the development of swimming as alifetime leisure skill which helps maintainhealth and contributes to happiness (Beau-douin & Keller, 1994; Johnson, 1988; Pega-noff, 1984; Smith, 1992; Tsukahara, Toda,Goto, & Ezawa, 1994).

Although various issues abound in thegeneral area of aquatics, from concerns re-garding water temperature (Campion, 1990;Franchimont, Juchmes, & Leccomte, 1983)to qualifications of practitioners using theaquatic medium in therapy (Campion, 1990;Smith, 1992), the general consensus reportedin the literature is that aquatics is a viablemedium that has potential to enhance qualityof life for people with disabilities. Based onthe findings reported in the literature, aquatictherapy appears to be an intervention thatcan be used by therapeutic recreation spe-cialists to promote psychological and physi-ological improvement while facilitating in-dependence in swimming and water exer-cise.

This paper begins with a definition of"aquatic therapy" and the issue of swim-ming as therapy as discussed in the literature.Subsequently, physiological, psychological,and leisure activity implications are ad-dressed. Implications for aquatic therapy de-livered in community settings by therapeuticrecreation specialists are presented as well.The paper concludes with recommendationsfor the practice of therapeutic recreation.

Description of Aquatic TherapyAquatic therapy has a long-established

and documented history. People have sought

the restorative properties of spas, warm bathsand the sea since the 5th century BC. Greeksand Romans recognized the value of thewarm water as an adjunct to their sportingactivities and aquatic activity for rehabilita-tion of individuals with paralysis (Campion,1990). More recently, aquatic therapy hasbeen provided in the United States in swim-ming pools and therapeutic pools sinceWorld War I (Reynolds, 1976). Aquatic ther-apy has been described as activity in the wa-ter based on hydrodynamic principles fortherapeutic purposes (Campion, 1990). Theliterature concerning use of water as a me-dium for therapy has been written by variousindividuals practicing in aquatics, includingtherapeutic recreation specialists, physicaltherapists, occupational therapists, massagetherapists, physiotherapists, medical doctors,sport psychologists and exercise physiolo-gists.

Aquatic therapy (Johnson, 1988), hydro-therapy (Campion, 1990), water therapy(Smith, 1992), swimming therapy (Campion,1990), water exercise (Danneskiold-Samsoe,Lyngberg, Risum, & Telling, 1987) and wa-ter physiotherapy (Smith, 1992) are some ofthe phrases used in the literature describingthe use of the water for therapeutic benefits.The term "hydrotherapy" is presented pri-marily in literature published in Great Britainand ' 'aquatic therapy'' seems to be the domi-nant phrase used in the United States. For thepurpose of this paper, the phrase "aquatictherapy" is used to include water exerciseand swimming as modes of prescribed activ-ity used as rehabilitation/habitation toachieve goals of improved physiological,psychological, psychosocial and/or life ac-tivity function under the supervision of indi-viduals qualified and competent in its tech-niques and utilization. Therapeutic recre-ation specialists should be familiar withintervention strategies and benefits ofaquatic therapy. An understanding of the po-tential of aquatic therapy to enhance an indi-vidual's leisure lifestyle may be useful injustifying treatment programs.

214 Therapeutic Recreation Journal

The techniques of aquatic therapy vary.Some popular interventions include Bad Ra-gaz (Boyle, 1981) (employing the principlesof proprioceptive neuromuscular facilitationusing active and passive techniques forstrengthening, muscle re-education andtrunk elongation); Watsu (Dull, 1993)(applying the moves of Zen Schiatsu to facil-itate decreased tension and improved psy-chological well being); deep and shallow wa-ter ambulatory exercise and therapeuticswimming commonly implemented usingthe Halliwick Method (Campion, 1985) orSequential Swim Techniques (Carter, LeCo-ney, & Dolan, 1994) which inherently facili-tates normal patterns of movement and pos-ture (Neurodevelopmental Treatment). Theuse of passive or active water exercise andswimming as therapeutic media are technicalprocesses that require the ability to teachswimming as well as understand the hydro-dynamics of the water and the implicationsand contraindications associated with use ofthe water for therapy (Association of Swim-ming Therapy, 1992).

Although swimming is considered to bea component of aquatic therapy in this paper,for some individuals it is seen as a recreationactivity not in the realm of aquatic therapy(Davis & Harrison, 1988). Some prac-titioners consider aquatic therapy as limitedto passive or active exercise techniques inthe water, while Campion (1985) and othersbelieve that swimming is an integral part ofaquatic therapy, and is essential to the over-all rehabilitation of some individuals. Nu-merous examples of the benefits of swim-ming when used in aquatic therapy are pre-sented in the literature (Bar-Or & Inbar,1992; Benedict & Freeman, 1993; Edlund,1980; Haung et al., 1989; Johnson, 1988;Langridge & Phillips, 1988; Peganoff,1984). Thus, as suggested by Campion(1990), swimming is a critical aspect ofaquatic therapy because of its potential tobe adopted as a life-long leisure and fitnessactivity.

Physiological ImplicationsAlthough techniques such as Watzu, and

Bad Ragaz are discussed in the literature,swimming and non-swimming water exer-cise were the only mediums found to be ex-amined in the research literature. The physi-cal benefits of activity performed in the wa-ter may include relief of pain (Guillemin,Constant, Collin & Boulange, 1994; Lan-gridge & Phillips, 1988; Woods, 1989), de-creased spasticity and increased relaxation(Davis & Harrison, 1988), improved bonedensity (Benedict & Freeman, 1993; Tsuka-hara et al., 1994), improved pulmonary func-tion (Haung et al., 1989; Whitley & Schoene,1987), strengthened muscles (Gehlsen, Grig-sby, & Winant, 1984), improved endurance(Burke & Kennan, 1984; Danneskiold-Samsoe, Lyngberg, Risum, & Telling, 1987;Edlund, 1980; Edlund et al., 1986; Routi,Troup, & Berger, 1994; Wright & Cowden,1986), and improved range of motion andincreased circulation (Peganoff, 1984). Thefollowing is a review of articles describingthe physical benefits of aquatic therapy.

Decrease PainAlthough water exercise and swimming

are commonly mentioned as recommendedforms of treatment for lower back pain(Campion, 1990; Johnson, 1989; J^evin,1991; Meyer, 1990; Siracusano, 1984; Skin-ner & Thomson, 1989), it is a treatment mo-dality which has limited scientific researchbasis and reports in the back pain literature.One study conducted by Guillemin, Con-stant, Collin, and Boulange (1994), assessedthe effects of spring water treatment onchronic low-back pain by comparing a ran-domly selected group of 50 people undergo-ing an aquatic therapy program to 52 ran-domly selected people not receiving aquatictherapy. After three weeks (6 X week), thepeople in the aquatic therapy group reporteda reduction in their daily duration of pain,pain intensity and drug consumption, andshowed significant improvement over the


control group in their spine mobility andfunctional score on the Waddell index (Wad-dell & Main, 1984). The Waddell index is aself report questionnaire designed to assessan individual's ability in nine daily life activ-ities including lifting, sitting, traveling,standing, walking, sleeping, social activities,sexual activity, and foot wear. The long termeffect assessed after nine months showedthat, although participants in the aquatictherapy group maintained reduced levels ofpain and drug consumption and an increasein spine mobility over the control group, thefunctional score reported on the Waddell in-dex returned to the original level. The au-thors concluded that aquatic therapy, if usedas a therapeutic medium for people withchronic pain, may have positive short termand moderate long term effects on chroniclower back pain. The authors suggested vari-ous factors that may contribute to the effec-tiveness of the aquatic therapy. First, warmspring water is thought to have therapeuticeffect in hydrotherapy. Second, the authorssuggested the positive effects of the programcould have been because of the change inlifestyle during the program. Finally, the au-thors concluded that aquatic therapy is bene-ficial because it occurs in an environmentthat is physically nonthreatening, thus lead-ing to participants' relaxation and lessguarded movement.

An earlier study by Woods (1989) inves-tigated the use of aquatic therapy using pre-scribed exercise and modified swimmingstrokes to improve strength, range of motionand in the reduction of pain. Eighteen peoplewho sustained a lumbar/sacral strain or hadreceived lumbar laminectomies for ruptureddiscs participated in the study (3 X week atno greater than 1 hour each session) for sixweeks. The mean age was 39 years with twoof the participants being female. Statisticalanalysis to determine whether any changeoccurred in either functional ability or painreports over the course of the treatment wasperformed using a two-by-two chi-squaretest. Each participant was assessed pre- and

post-treatment with participants serving astheir own controls. The Functional AbilityAssessment Checklist indicated an improve-ment in functional ability (p <.O1). TheFunctional Ability Assessment Checklistwas developed for this study to test flexibil-ity and strength of the trunk extensors, trunkflexors and lower extremities. Pain was as-sessed using a portion of the McGill PainQuestionnaire that denotes the intensity ofperceived pain (Melzack, 1983). No changewas noted in the self report pain levels. Thus,no statistical relationship existed betweenself-reports of pain and functional capacityfor the participants. The author stated thatthe findings support a contention that reli-ance upon pain reports alone to determinereadiness for the resumption of occupationalor leisure activities is not judicious. Never-theless, the non-experimental design of thisstudy prevents generalization of results.

To further assess group hydrotherapy forparticipants with chronic back pain Langridgeand Phillips (1988) monitored subjective painlevels and quality of life of 27 participants ina group aquatic therapy program. Ages wereclustered around 41 to 60 years. Attendanceranged from 4 to 33 sessions in a six monthperiod. Prior to and after each session, eachparticipant completed a visual analog painscale expressing pain level. Pre-post question-naires included information on physician vis-its, quality of life, medication use, ease ofwork and general pain level. Overall resultsof the subjective visual analog scores showeda diminution of pain for the participants (p<.OO1) while 11% expressed an increase inpain. Eighty one percent reported an improve-ment in pain before and after each session,while 15% found that pain increased immedi-ately after each aquatic therapy session.Ninety-six percent showed improvement intheir quality of life (p <.001) and sixty-sevenpercent showed a decrease in private medicalcost. None of the participants showed an in-crease in the number of drugs taken for backpain and 44% showed a decrease in theamount of drugs taken. Caution in interpret-


ing these results is advised since only a fewparticipants were used and methodologicalrigor was not employed. However, implica-tions of the study are useful to consider inaquatic therapy interventions for individualswith chronic pain. The authors emphasizedthat the participants derived much enjoymentfrom the sessions, they perceived themselvesto be having positive benefits regarding levelsof pain and expressed a general feeling ofimproved well being which influenced theirquality of life and eased their work capacity.The authors hypothesized that the positive re-sults were due perhaps to the (a) peer supportfound in the group approach and (b) partici-pants ability to take control in helping them-selves through water exercise rather than de-pending on skilled practitioners in a clinic.

Prevent Bone LossBone loss has become a recent topic in

aquatic literature because of its relation toosteoporosis. To examine the impact of wa-ter exercise in a warm pool in preventingbone loss, Tsukahara, Toda, Goto, & Ezawa(1994) conducted a cross-sectional study ofJapanese post menopausal women to deter-mine improvement in bone mineral densities(BMD). In a nonexperimental control grouppost-test only design, the researchers mea-sured the bone density of the lumbar spineof 27 volunteers who had been exercising ina sports club for two or more times a weekfor 35.2 months (veterans), 40 participantswho had been exercising two or more timesa week for three to four weeks (newcomers),and 30 non-exercisers using BD Z-scores.Length of sessions were not disclosed in thearticle. There were no significant differencesin participant's age, height, body weight,body mass index, and body fat percentage.Comparisons were performed by simple lin-ear regression and stepwise multiple regres-sion. Student's Mest found that for the vet-eran group, the BMD scores were signifi-cantly higher than the scores of thenewcomers (p < .05) and the non-exercisers(p < .001). The results of the non-exercisers

group in this study supported previous re-search (e.g., Nilas & Christiansen, 1987) in-dicating a decrease in BMD by 1-2% in post-menopausal women. Although the ongoingwater exercise provided in this study ap-peared to have a suppressive effect on parti-cipants' bone loss, caution is advised wheninterpreting the results due to major limita-tions associated with the study design.

Benedict and Freeman (1993) found simi-lar results to Tsukahara et al. (1994) regard-ing bone densities and swimming. This non-randomized control group study includedtests recorded on 73 volunteer participants(32 men and 42 women) who were regularparticipants in a swimming and aquatic aero-bics program that had met for 6 hours a weekfor 10 years, and two volunteer controlgroups; a group of 73 (15 men and 58women) who attended senior centers for ac-tivity but not swimming and 12 individuals(10 women and 2 men) who neither attendeda senior center nor swam. The bone densitiesof people who exercised in the swimmingand aquatic aerobics program for more thanthree years were compared to those who hadexercised for a shorter period of time and toolder people who had not exercised on aregular basis. Sixty-two of the nonswimmingcenter attendees reported that they exercisedregularly (mostly walking). Bone densitiesof the femoral neck and spine were measuredby dual-energy X-ray absorbtionetry. Two-way analysis of variance and chi square wereused to compare the bone densities of peoplewho exercised in the swimming group formore than three years to those in the othertwo groups. The swimmers' bone densitiesof the hip (p <.01) and spine (p <.O4) werehigher than the senior center attendees whodid not participate in water exercise or swim-ming. Length of participation in the programwas not significant.

Increase StrengthAlthough there is limited empirical evi-

dence on strength benefits for individualswith disabilities, improved strength is often


identified as a benefit of aquatic therapy(Campion; 1990; Davis & Harrison, 1988;Skinner & Thomson, 1989). In an attempt tosubstantiate this contention, Gehlsen, Grig-sby, and Winant (1984) examined the effectsof a 10-week aquatic program (3 X week,60 min sessions) on 10 people (M age =40) with multiple sclerosis (MS). Selectioncriteria required participants to be ambula-tory and in remission. Testing occurred priorto participation, midway into the programand in the week following completion of theprogram. A Cybex II dynamometer was usedto measure components of strength (peaktorque and work) and fatigue in the kneeflexor and extensor muscles, and a swimbench was used to measure components ofmuscular strength (force, work, and power)and fatigue in the upper extremities. Therewas a significant difference of peak torquefor knee extensor muscles for pre-trial tomid-trial (p <.05) with no significant im-provement after mid-trial. For the upper ex-tremities, a significant increase was seenfrom pre-trial to mid-trial to post-tests in allforce measurements accompanied by sig-nificant improvement in power and totalwork (ps <.05). The authors warned that thegreater improvement in the components ofthe swim bench data for the upper extremit-ies may be related to discrepancies in thetesting protocols for the different instru-ments. Gehlsen and colleagues (1984) sug-gested that the lack of improvement in someareas may be attributed to the general muscu-lar weakness and contraction experienced bypeople with MS, as well as the inability oftraining to change previous central nervoussystem damage that occurs with MS. Al-though the results were mixed, Gehlsen andcolleagues indicated that strength was im-proved for the individuals in this study.Thus, according to the authors, a positivechange in strength can be expected throughaquatic exercise. The mixed results and non-experimental design associated with thisstudy and the absence of other investigationassessing the effects of aquatic therapy on

strength indicate a need for further researchin this area.

Increase EnduranceAlthough the efficacy of aquatic therapy

on cardio-vascular endurance has receivedmore attention in the literature than otherphysical implications, there are few studiesexamining benefits specific to individualswith disabilities. For example, Edlund(1980) and Edlund et al. (1986) examinedthe effects of a 12-week swimming therapyprogram (3 X week, 60 min sessions) on thestrength, endurance and pulmonary functionof 12 children with cystic fibrosis to 11 chil-dren who did not receive swimming therapy.Volunteers residing in a children's hospitalwere randomly assigned to an experimentalgroup that consisted of 9 boys and 3 girlsand the control group that consisted of 5boys and 6 girls between the ages of 7 and14. Participants in the swimming therapygroup were required to attain a minimumlevel of their maximum heart rate duringeach swim session set at 60% for the firstfive weeks, building up to 70% in the finalfour weeks of the program. The pre-tests andpost-tests for pulmonary function includedforced expiration volume, forced vital capac-ity, residual volume, residual volume overtotal lung capacity, and diffusion capacity.The pre-test and post-test exercise tolerancewas evaluated by testing the participants'maximum oxygen consumption, time on atreadmill, heart rate blood pressure and mi-nute ventilation. The clinical state of the dis-ease was evaluated according to a Shwach-man score (Shwachman & Kulezycki, 1958).The Shwachman scoring technique scoreshistory, physical evaluation, nutrition, andchest roentgenogram. A single blind tech-nique was used for score determination. Anexperimental design of pre and post-test ex-posure, with one control group with anANCOVA to determine significance, wasused. Although a significant improvementwas found in their clinical state of diseaseas determined by the Shwachman score (p


<.O5) for both studies, the children in boththe 1980 and 1986 swimming therapy pro-gram did not significantly improve their pul-monary function. They did, however, showa statistically significant improvement overthe control group in endurance (p <.01).

Burke and Keenan (1984) examined 5women (M age 36.6) and 5 men (M age 32.8)volunteers using the elementary backstroketo examine energy cost and to determine ifheart rate and perceived exertion are usefulfor monitoring intensity. The volunteersswam at four different intensities, while ve-locity, V02, heart rate and perceived exertionwere monitored. Each dependent variablesignificantly increased with increasing inten-sity. In addition, Burke and Keenan foundthat the average energy cost was acceptablyhigh. The American College of Sports Medi-cine recommended that healthy individualswork at 60% to 90% of their maximal heartrate reserve and a recommendation of 12 to14 on the Borg perceived exertion scale(Borg, 1970). Both of these criteria were metduring the medium and fast intensities. Theauthors concluded that the elementary back-stroke is suitable for an aquatic therapy pro-gram. The elementary backstroke is oftenand comfortably used in instruction withmost individuals with disabilities because itallows easier breathing due to the face beingout of the water (Farrell, 1976; Garvey,1991; Hurley & Turner, 1991; Johnson,1988). Therefore, although this non-experi-mental study consisted of individuals with-out disabilities, this information may be ben-eficial for the therapeutic recreation special-ist using swimming in aquatic therapy.

Endurance was also examined by Wrightand Cowden (1986) who examined the effectof swim training on individuals with mentalretardation in a non-randomized pre-testpost-test control group study with one groupof 25 (M age = 15.5) who participated in a1 hour 10 week (2 X week) training programand a control group of 25 (M age = 15) whoadhered to normal daily living activities. Theparticipants in the two groups were equated

in ages and IQs and were all classified asmildly or moderately mentally retarded inschool evaluations. The researchers used the9-minute Run/Walk test (Governor's Com-mission on Physical Fitness, n. d.) to mea-sure endurance and the Piers and HarrisChildren's Self Concept Scale (Piers & Har-ris, 1964). Using a two way ANOVA withthe Scheffe' test as a subsequent test formean comparison, significant F ratios wereidentified. Results showed that this programcontributed to a significant increase in car-diovascular endurance (p <.05) and self con-cept (p <.05) for participants in the experi-mental group when compared to the controlgroup. A variety of methodological concernsincluding the use of ANOVA rather thanmultivariate procedures for analysis shouldbe considered when interpreting the resultsof this study.

In another study, Routi, Troup, and Be-rger (1994) examined the impact of a waterexercise program on the muscular enduranceand aerobic work capacity of older adults(age >50 years) by comparing the perfor-mance of 12 participants in a water exercisegroup and 10 participants in a control group.The people in the control group reported thatthey were not currently participating in anyorganized exercise or recreational program.Participants were tested before and after a12-week water exercise program (3 X week,30 min sessions) by measuring resting heartrate in a supine position, cardio pulmonaryfunction through maximum oxygen con-sumption (VO2 max), maximum heart rate(HR) on an treadmill, and work capacity inthe water. Two tests of physical performancein the water were employed before and after12 weeks of training, including muscle en-durance of the shoulder and HR response towalking four widths of the pool in the water.The training effects were significantlygreater for the water exercise group as com-pared to the control group on all dependentmeasures. In spite of the use of a small sam-ple size, the water exercises produced physi-ological changes in the cardiovascular sys-


tern reflected in the reduction of resting HRand increase in VO2 and work capacity. Al-though results of increased VO2 were thesame as findings reported by Pollock (1973),who documented the training effects of olderadults in 8 to 42 weeks of running, Routiand colleagues noted that an advantage ofwater exercise was that it resulted in lessjoint stress. The authors contended that indi-viduals recovering from physical injury ormuscular disease may employ water exer-cises with expectations of a training effectin aerobic work capacity and in muscularendurance.

Improve Pulmonary FunctioningThe impact of aquatic therapy on pulmo-

nary functioning has been studied primarilyas it relates to children with asthma. For ex-ample, Haung et al. (1989) examined the ef-fects of swimming training on asthma mor-bidity. Participants included 45 children(ages 6-12) with asthma who were matchedby age, sex and severity of illness and ran-domly assigned to swimming training (3 Xweek, 1 hour sessions) for 12 months or acontrol group. Pulmonary function with apeak flow meter every three months, schoolabsenteeism, emergency room visits, hospi-talizations, days requiring daily medications,and days of wheezing both during the swim-ming sessions and for a period of 12 monthsafter the final swimming session were re-corded. These data were compared to datacollected 12 months prior to the swim classand to the control group. The Student's t-test or the chi square test was used for theanalysis. Between group differences werestatistically significant on each of the depen-dent variables when compared to the controlgroup (p <.O1) and when compared to the12 months prior to the swimming program(p <.O1). Although Haung et al. concludedthat swimming may have therapeutic bene-fits for children with chronic lung disease(including children with asthma or cystic fi-brosis) and that the beneficial effects maylast longer than previously anticipated, the

use of a Student's f-test rather than a multi-variate analysis raises concern when inter-preting these results.

To further examine the effects of swim-ming on children with asthma, Bar-Or andInbar (1992) conducted a comprehensive lit-erature review to explore the benefits and del-eterious effects of swimming on children withasthma. The review of the evidence suggestedthat swimming induces less severe broncho-constriction than other active leisure relatedactivities (e.g., Fitch & Morton, 1971;Holmer, Stein, Saltin, Ekblom & Astrand,1974). Although reasons for this protectiveeffect of swimming are not clear, the authorscited experimental evidence (e.g., Inbar, Do-tan, Dlin, Neuman, & Bar-Or, 1980) implyingthat positive effects may result, in part, fromthe high humidity of inspired air at waterlevel, which reduces respiratory heat loss andpossible absorption of airway mucus.

Deleterious effects of swimming on indi-viduals with asthma, according to Bar-Or andInbar, include the "diving reflex" which is aparasympathetic response to immersion of theface in water, especially colder water. Afterexamining studies by Sturani, Sturani, andTosi (1983) and Mukhtar and Patrick (1984),Bar Or and Inbar speculated that asthmaticresponse of individuals may be enhanced incold water and water containing chlorine andits derivatives, especially when air recirculat-ing occurs. Recirculating the concentration ofchemicals may irritate the airways, as ob-served by Penny (1983), when he reportedincreased complaints of coughing when sucha system was in use. Because participants inPenny's study did not have asthma, more re-search is needed to determine if this airwayirritation response induced asthma responseof swimmers with asthma.

Bar-Or and Inbar also described sevenstudies documenting how aquatic therapy re-sulted in improved fitness effects, most im-portantly, increased pulmonary function andthe reduction of the incidence and severityof exercise induced asthma (Fitch & Morton,1971; Haung et al., 1989; Mitsubayashi,


1984; Schnall, Ford, Gillam, & Landau,1982; Svenonius, Kautto, & Arborelius,1983; Szentagothal, Gyene, Szocska, & Os-vath, 1987; Tanizaki, Komagoe, Sudo, &Morinaga, 1984). Bar-Or and Inbar con-cluded from their review of the literature thatswimming was less asthma inducing thanother physically active leisure activities andfound swimming as the most suitable exer-cise therapy for children with asthma.

In their assessment of the physiologic andclinical effects of exercise in children withcystic fibrosis, Edlund et al. (1986) (detailedin the section of this paper on endurance),found no change in pulmonary function butdid report that the sputum production duringchest physical-therapy decreased when parti-cipants were involved in the program. Theauthors concluded that the exercise associ-ated with the swimming apparently helpedto clear the lungs of sputum, and that a swim-ming program (at least 3 sessions per week)is an excellent way to improve the clinicalstatus and quality of life of a person withcystic fibrosis.

Zach, Purrer, and Oberwaldner (1981)examined the effect of swimming therapy onforced expiration and sputum clearance of11 participants with cystic fibrosis (mean age= 10 years 7 months) who participated inswimming therapy for seven weeks (17 ses-sions of 1 hour each). The f-test and analysisof variance were used for statistical analysis.Ventilatory status, assessed by spirometryone day before the first session and one dayafter the last session showed significant im-provement in forced vital capacity, forcedexpiratory volume and peak expiratory flowrate. The sputum, collected by the childrenwho registered daily volumes in milliliters,was higher on swimming days than on non-swimming days. Ten weeks after the end ofthe training most of the measurements re-turned to their pre-swimming levels. Al-though the authors contended that swimmingas therapy can assist in mucus clearance andimprove ventilatory function in children with

cystic fibrosis, the lack of a control grouplimits interpretation of the results.

Another population that has been exam-ined in relation to pulmonary function ismuscular dystrophy. Adams and Chandler(1974) investigated the effects of swimmingand breathing exercise of three participants(11 years old) for 11 months (30 min X 2wk). Vital capacity measurements weretaken on a wet spirometer three timesweekly. After four months, each participantimproved in vital capacity. During a three-week vacation, two of three participantsshowed marked losses in vital capacity. Con-tinuing the swimming therapy resulted, onceagain, in improvement. When the programwas, again, canceled for two weeks duringvacation, the participants showed a slightloss which was regained after continuing theprogram. The authors stated that a regularprogram of therapy can result in increasedvital capacity with supervised treatment.Further investigation of methods of main-taining vital capacity is needed for childrenwith muscular dystrophy due to the lack ofstudies in general, and more specifically, dueto the non-experimental design and smallnumber of participants used in this study.

Psychological ImplicationsAlthough some psychological benefits of

aquatics are reported in the literature, thereis a lack of literature documenting the psy-chological benefits of aquatic therapy oraquatic activity, in general, for individualswith disabilities. The majority of studieshave been conducted with people withoutnoted disabilities, mostly college studentsand older adults. Information about psycho-logical improvements such as improvedbody image, self concept, mood and de-creased depression can be useful to the thera-peutic recreation specialist and will be de-scribed in the following section.

Improve Body ImageThe impact of aquatic therapy on body

image was noted by Benedict and Freeman


(1993) who observed older adults swim-ming. In this study (detailed in the sectionof this paper on preventing bone loss), theresearchers assessed body image by projec-tive drawings and the use of a semantic dif-ferential survey. Although there was no sig-nificant differences in the projective draw-ings, an improved body image of swimmerswas observed when compared to the controlgroup who did not participate in water exer-cise (p <.O5) as measured by the semanticdifferential.

Decrease DepressionReduction in depression, noted as a bene-

fit in the literature of aquatic therapy (Skin-ner & Thomson, 1989), has mixed support.For example, in the aforementioned nonex-perimental study by Benedict and Freeman(1993), morale and depression scales wereadministered. Although results showed thatswimmers reported higher morale than thecontrol group (p <.O1), there was no sig-nificant difference in the level of depressionbetween swimmers and the control group.

In a related study, Stein and Motta (1992)compared the effects of anaerobic weighttraining to aerobic swimming on depressionand self-concept. This study was conductedto examine the effects of resistive exercisein the water or through an aerobic regimensuch as swimming on chemical changes in-fluencing depression. Participants could nothave had previous training in aerobic or non-aerobic exercise for at least three monthsprior to the initiation of this experiment. The98 volunteers (M age = 20) were assignedrandomly to a 14-week structured swimmingfor fitness aerobic class (2 X week, 50 minsessions), a structured progressive resistanceweight training (2 X week, 50 min sessions),or a control group that did not exercise. De-pendent measures were assessed using theBeck Depression Inventory, Depression Ad-ductive Check Lists, Tennessee Self-conceptScale and Cooper's 12-minute swim. Afterthe ANCOV A indicated a significant interac-tion, the post hoc analysis showed that sig-

nificant improvement occurred in both ex-perimental groups in self concept and de-pression, when compared to the control (p<.001). Stein and Motta concluded that, inthe case of individuals with disabilities whoare unable to withstand land-based weighttraining, water exercise may be a valuableoption for enhancing self esteem and de-creasing depression.

Weiss and Jamieson (1989) conducted aretrospective study to evaluate the effect ofan aquatic exercise on subjective depressionof participants. The length of time in theprogram for the participants was 8 weeks to5 years. The ages of the 88 women rangedfrom 21 to 75 years with the majority clus-tered between 45 and 64. All 21 participantswho reported symptoms of depression whenbeginning the class reported less depressedfeelings with 90.5 percent of these individu-als attributing the aquatic therapy class as acontributing factor to their improved emo-tional state. According to the authors, thefindings suggest that this particular programwas an effective intervention in the dissipa-tion of depression related symptoms of sub-jectively depressed women. The authorsclaimed that the findings add to a growingbody of literature affirming links of exerciseand psychological well-being including thetreatment of mild depression and preventionof major depression. In addition, the authorsstated the study agreed with other researchsuggesting that the positive effects may oc-cur in conjunction with social concomitantsbecause the women (a) viewed the programas a support group, (b) made new friends inthe classes, and (c) found it helpful to con-verse with the others in the group abouthealth, humor and feeling. The subjectivity,lack of information on interview methods,and the retrospective nature of this studyraises concern in interpreting the findingsand suggest a need for further study.

Enhance MoodBerger and Owen (1992) examined

swimming classes and yoga to determine if


aerobic exercise improved mood by em-ploying a pre-post control group design with87 college student volunteers who enrolledin two swimming classes (2 X week, 40 minsessions), a yoga course (1 X week, 80 minsessions) and a lecture control group course(3 X week, 50 min sessions). The initial pre-class mood and anxiety scores of the threegroups were compared to examine variabil-ity of students selecting physical activity ascompared to the more sedentary lectureclass. The three groups were not differentsignificantly in social desirability, gender,state anxiety, tension, depression, fatigueand confusion on the initial pre-class scores,except for differences in age, with the yogagroup being older (M age = 28.4) than theswimming (M age = 20.3) and control group(Af age = 21.1). Participants completed theProfile of Mood States (POMS) inventoryimmediately before and after class on thesecond session, midway through the studyand on the last day of instruction. A signifi-cant reduction in anger, confusion, tensionand depression was reported for the swim-ming and yoga groups when compared tothe control group (p <.0002), indicating thataerobic exercise and exercise below one'starget heart rate may enhance mood. Bergerand Owen suggested that since swimmingand Hatha yoga can facilitate deep, rhythmi-cal diaphragmatic breathing, which is a com-mon element in many stress reductions tech-niques, the rhythmical breathing may facili-tate mood alteration. In addition, Berger andOwen suggested that lap swimming and Ha-tha yoga may influence mood by "stretchingand relaxing large muscle groups in thebody, an internal awareness, finding time foroneself and a focus on the present . . . "(p. 1340). This study has implications forindividuals with disabilities because someindividuals have difficulty performing landbased aerobic activity and the water environ-ment may be one of the few environmentsthat a person could do aerobic activity inde-pendently (Campion, 1985). Because thisstudy was not specific to (re)habilitation,

these speculations call for further examina-tion of the psychological effects of swim-ming in aquatic therapy.

To examine further the complex relation-ship between exercise and mental healthacross cultures, Berger and Owen (1993)studied 15 swimmers and 15 controls fromCzechoslovakia (Czech) for 12 weeks (1 Xweek, 90 min sessions); and 20 swimmersand 28 controls from a large metropolitancollege in the United States (US) for 14weeks (2 X week, 50 min sessions). Partici-pants were involved in either a beginningswimming course or a lecture control course.Although the duration of the swimming ses-sions in the two countries differed, the totaltime participants swam each week was thesame. The POMS was utilized to measuretension, depression, anger, and confusionand an increase in vigor. The POMS wasadministered to all groups before and afterclass on the second session, mid semester,and at the end of the courses. The resultingpre-post and activity interactions were sig-nificant for the Czech (p <.00) and US (p<.00) swimmers. The US. and Czech swim-mers showed a significant mood shift (p<.00) on every scale except fatigue. Allscores were similar except for tension whereCzech swimmers reported a larger reductionthan the US swimmers. Results indicatedthat the students felt better after enrolling inthe swimming course than before they beganthe course. This study provides additionalsupport for the belief that swimming posi-tively influences mood.

Although the aforementioned studies donot include individuals with disabilities, theresults have implications for people with dis-abilities, individuals receiving psychiatricservices, and individuals without a clinicalmental health diagnosis. An acquired physi-cal disability often results in decreased self-esteem, self-determination and consequen-tial mood alterations (Krause & Crew, 1987).Since many individuals with physical disa-bilities are unable to participate actively inland based aerobic activity (Campion, 1985),


it may be useful for therapists to consideradditional benefits from aquatic therapy be-yond physiological ones and examine psy-chological benefits such as improved mood.

Leisure ImplicationsA major advantage of aquatic therapy is

that it may enhance functional ability thatencompasses all areas of life and helps todevelop a life-long leisure activity that canbe enjoyed with other people (Campion,1985; Peganoff, 1984). Specifically, Cam-pion emphasized that once a person is inde-pendent in the water, opportunities for so-cialization are increased. There is, however,limited research on the benefits of aquatictherapy to a person's leisure lifestyle. Never-theless, many authors have emphasized theimportance of transitioning the person with adisability from the clinical environment intorecreational programs in the community toachieve psychosocial and functional benefits(e.g., Duley, 1983; Martin, 1983; Slade &Simmons-Grab, 1987). Although not data-based, there are numerous reports of the ben-efits of using recreational activity, commu-nity re-entry or family training in aquatictherapy to meet goals and to facilitate contin-ued participation (e.g., Duley, 1983; Martin,1983; McNamara, 1994; Melvin, 1976;Priest, 1976; Smith, 1985; Smith, 1992). Thefollowing are examples of two case studiesthat include information relative to the lei-sure experience.

Peganoff (1984) presented a case study toexemplify the use of swimming as a leisureactivity that incorporates therapeutic goalsfor individuals with disabilities. The partici-pant was a 12-year-old girl with spastic righthemiparesis who participated in an 8-weekswimming program (2 X week, 45 min ses-sions). The treatment goals included improv-ing (a) range of motion, (b) functional useand coordination of the right upper extrem-ity, (c) bilateral integration, (d) balance andequilibrium skills, and (e) self image. Theparticipant showed a 15° increase in shoulderflexion and a 10° increase in shoulder abduc-

tion of the right upper extremity. She beganusing her right upper extremity during activi-ties of daily living at home. Although theparticipant refused to swim with others ini-tially, after learning how to swim at the be-ginner level, she continued the activity in herfree time in the presence of family and peers.According to Peganoff, this skill acquisitionalso resulted in an increase in incidence ofsatisfaction and compliance with the pro-gram as compared to her traditional therapy.Thus, for this participant, treatment goalsachieved through instruction in the basicswim strokes were enhanced by incorporat-ing a new leisure skill of interest.

In another case study, Johnson (1988) de-scribed a 62-year old man (Charlie) who wasdiagnosed with amyotrophic lateral sclerosis(ALS) three years prior to this aquatic ther-apy intervention. Upon entering the pro-gram, Charlie had respiratory weakness,trace to poor lower extremity musclestrength and fair to good upper extremitystrength. Aquatic therapy was prescribed forCharlie for 10 weeks (2 X week, 45 minsessions) to facilitate an increase in strength,flexibility, and conditioning, as well as pro-mote recreation and socialization. Charlieimproved from not being able to swim toswimming 26 lengths of a 20-yard pool withan adapted vest and minimal assistance.Johnson concluded that aquatic therapy forCharlie achieved, not only increased endur-ance and strength, but improved reported en-ergy level and happiness in daily activityas a result of utilizing a challenging leisureactivity. According to Johnson, an aquatictherapy program may provide a person whohas ALS with a realistic alternative for main-taining physical fitness or continuing withrehabilitation goals while participating in anaffordable leisure activity.

In further support of aquatic therapy as ameans to independent leisure involvement,Beaudouin and Keller (1994) described aprogram developed by a therapeutic recre-ation practitioner that was designed to im-prove functional abilities, facilitate psy-


chosocial adjustment and ultimately lead oneto independent participation in other com-munity recreation programs. Assessmentswere conducted on participants' psychoso-cial and physical skills (endurance, strengthand flexibility) as well as their personal inter-ests and functional needs. The program usedwater exercises and swimming to meet thetreatment goals, which, generally, includedmoving from individual to group sessions.Although no data were reported on the effec-tiveness of the program, the relevance of thisarticle is its focus on transitioning partici-pants to community programs and the infor-mation presented on the reimbursement rate.Beaudouin and Keller reported that insur-ance companies provided 85% reimburse-ment for treatment which was attributed toorganized and continuous communicationwith physicians and case managers. The au-thors stated that successful intervention anddocumentation strengthened the reputationof the program with physicians and thirdparty payers. Beaudouin and Keller's de-scription, in conjunction with informationfrom the previous articles described in thissection, provide information on how aquatictherapy has been used as a means to promoteindividuals' functioning and leisure partici-pation.

Although a benefit of aquatic therapycould be the potential for independence inthe aquatic activity after functional goalshave been met, there has been little discus-sion concerning the leisure implications ofthe interventions. Therapeutic recreationspecialists can address leisure implicationsby including leisure related dependent vari-ables in aquatic therapy research such as sat-isfaction, enjoyment, intrinsic motivationand self-determination.

Implications of Aquatic Therapyfor Therapeutic Recreation

Aquatic therapy is a viable interventionwhich can be employed by therapeutic recre-ation specialists. The number of physician

referrals for aquatic therapy are increasing(Meyer, 1990; Smith, 1992). In addition,aquatic therapy is being viewed by thirdparty payers as a viable treatment (Beau-douin & Keller, 1994). Therapeutic recre-ation specialists who have the educationaltraining may use aquatic therapy to encour-age participants to achieve independent lei-sure participation while realizing functionalbenefits (Beaudouin & Keller, 1994, Cam-pion, 1988; Johnson, 1988; Peganoff, 1984)and enhancing their life satisfaction and lon-gevity (Krause & Crew, 1987).

To address the demand and the educa-tional training needs in aquatic therapy fortherapeutic recreation specialists, systematicinstructional sessions on aquatic therapy arebeing developed by various organizationsand individuals as seen by a recent increasein aquatic therapy workshops sponsored bythe National Therapeutic Recreation Society(NTRS) and the American Therapeutic Rec-reation Association (ATRA). Both organiza-tions have recognized the importance oftraining for therapeutic recreation specialistsin aquatic therapy and expressed a commit-ment to address this need. Based on senti-ments expressed by Broach (1995a) and La-Tourette (1995) that therapists, at a mini-mum, have an understanding and beproficient in the use of properties of the wa-ter, safety and rescue, swimming methodol-ogy, equipment use, patient indications andcontraindications, handling and therapytechniques, NTRS and ATRA have formedaquatic therapy committees to address issuesand increase networking. The NTRS aquaticcommittee conducted a survey to assess thestatus of aquatic therapy use and needs(Broach, 1995b). In response to the survey,the committee has developed yearly aquatictherapy institutes at the national conference.To address further practitioner concerns, aNTRS aquatic therapy network has been es-tablished. The network disseminates aquatictherapy information through bi-yearly corre-spondence, including an updated list of net-work participants. ATRA has a committee


of experts to serve as resources, advocate forreimbursement and research aquatic therapy.In addition, ATRA sponsors aquatic therapyworkshops throughout the year. These ef-forts demonstrate an increased interest inproviding instruction and disseminating in-formation on aquatic therapy and, thus, in-crease the ability of practitioners to incorpo-rate aquatic therapy into their repertoire ofservices.

Aquatic therapy is delivered in varioussettings. In the past, therapeutic recreationhas been provided most often in residentialcenters as a part of individual rehabilitation.A recent trend showing a reduction in hospi-tal length of stay has resulted in many indi-viduals not having the opportunity to takefull advantage of therapeutic recreation ser-vices during hospitalization (Carter, 1991).Therefore, the range of therapeutic recre-ation services needed in the community isexpanding to include services such as aquatictherapy that are designed to have participantsachieve treatment goals (Beaudouin & Kel-ler, 1994). Further, physicians and insurancecompanies are acknowledging the benefitsof aquatic therapy and referrals to aquaticprograms are increasing (Smith, 1992). Inaddition, some physicians and people in needof treatment are searching for alternatives toexpensive outpatient care due to the decreasein insurance reimbursement and rising healthcare costs (Heyneman & Premo, 1993).Thus, as Johnson (1988), Heyneman andPremo (1993), McHugh (1995), and Sladeand Simmons (1987) stated, much of thelong term process of rehabilitation can occurin aquatic therapy programs within the com-munity. Aquatic therapy provided by thera-peutic recreation specialists in a communitypool can facilitate participants achievementof treatment goals while simultaneously pro-moting inclusion in their communities(Beaudouin & Keller 1994).

Based on the review of the literature,there is some support for the use of aquatictherapy by therapeutic recreation specialistsas a viable intervention to meet the needs of

individuals with disabilities. However, thereis limited documentation on the implicationsof aquatic therapy to therapeutic recreation.Therapeutic recreation specialists can ad-dress these shortcomings through efficacy-based research using various experimentaland non-experimental designs. Areas of re-search could include examining the benefitsof (a) similar exercises on land versus waterand continuation of such programs after clin-ical intervention, (b) effects of combining aleisure education model of cognitive behav-ior therapy with aquatic therapy in relapseprevention after discharge, (c) cost effective-ness of aquatic therapy interventions bycomparing lengths of stay of participants andnon participants, (d) psychological effects ofswimming on individuals with a variety ofdisabling conditions and (e) effects ofaquatic therapy interventions on activities ofdaily living and activity level. Therapeuticrecreation specialists are encouraged to con-duct rigorous studies using efficacy-basedresearch documenting the role therapeuticrecreation practitioners play in improving in-dividuals' functional abilities as well as en-hancing their enjoyment and life satisfactionthrough aquatic therapy interventions.

ConclusionThere is evidence to indicate that aquatic

therapy has numerous psychological andphysical benefits. Furthermore, aquatic ther-apy appears not only to improve physical andpsychological functioning, but also maintainhealth and daily life functioning. In addition,aquatic therapy is valuable because it is con-ducted in water which often improves parti-cipants' comfort and increases their confi-dence in achieving functional independence(Guillemin et al., 1994; Hurley & Turner,1991). The health care trend of shorter hospi-tal stays and an emphasis on outpatient carehas resulted in a need for therapeutic recre-ation interventions to be applied across amyriad of environments. It may be useful fortherapeutic recreation specialists to consideremploying aquatic therapy as a facilitation


technique. The facilitation technique ofaquatic therapy can result in an increase inparticipants' functional ability while theyparticipate in an enjoyable leisure activitywhich encourages inclusion in their commu-nities (Dattilo, 1994).

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