A qualitative pilot study exploring clients' and health-care professionals' experiences with aquatic therapy post-stroke in Ontario, Canada.

BACKGROUND: Aquatic therapy is beneficial for people post-stroke, as it improves their physical function, well-being, and quality of life. There is a lack of description of users' experiences and perspectives toward aquatic therapy that could elucidate contextual factors for aquatic therapy implementation. OBJECTIVES: To explore participants' experiences with aquatic therapy post-stroke as part of a participatory design project to develop an education tool-kit to address the users' needs for aquatic therapy post-stroke. METHODS: A qualitative descriptive study was employed using a purposive sampling. Letters were sent to stroke and aquatic therapy organizations. Individual interviews were conducted either by phone or Zoom with nine participants in the chronic phase of stroke and 14 health-care professionals. All transcripts were coded and analyzed independently by two researchers. Inductive thematic analysis was used to identify the main themes. RESULTS: Health-care professionals practiced aquatic therapy in rehabilitation hospitals (N = 7), community centers (N = 8) and private clinics (N = 3). From the interviews, two organizing themes were identified: (1) Importance of aquatic therapy (e.g. experiences, benefits, and program approaches); and (2) Aquatic therapy education (e.g. knowledge gaps, sources of learning and communication). CONCLUSIONS: Health-care professionals and clients reported numerous benefits of aquatic therapy post-stroke including, but not limited to, improvements in mobility, balance, wellbeing, and socialization. Lack of formal and informal education and communication as participants' transition from rehab to community were viewed as barriers to aquatic therapy use post-stroke. Developing education material and communication strategies may improve the uptake of aquatic therapy post-stroke.

Impact of Falls and Fear of Falling on Participation, Autonomy and Life Satisfaction in the First Year After Spinal Cord Injury.

Introduction: Individuals with spinal cord injury (SCI) experience reduced participation in meaningful activities, leading to reduced social engagement and negative psychological impact. Two factors that may affect participation post-SCI are fall status (e.g., having experienced a fall) and having a fear of falling. Our objective was to examine if and how fall status and fear of falling impact participation, autonomy and life satisfaction in the first year post-injury. Methods: Adult inpatients of a SCI rehabilitation hospital were recruited. Following discharge, falls were tracked for 6 months and participants who fell at least once were categorized as "fallers". At the end of the 6-month period, the Impact on Participation and Autonomy Questionnaire and Life Satisfaction Questionnaire 9 were administered, and participants were asked if they had a fear of falling (i.e., an ongoing concern about falling leading to the avoidance of activities they are capable of doing). Falls were reported using descriptive statistics. Ordinary least squares regression was used to evaluate the relationships between the independent variables (i.e., fall status and fear of falling) and each dependent variable (i.e., questionnaire scores). Results: Seventy-one individuals were enrolled in the study; however, 11 participants were lost to follow-up. The included participants (n = 60) were 58.4 ± 14.6 years old and 99 ± 60.3 days post-injury. Over one third (38.3%) of participants fell over the 6-month tracking period. Twenty-seven participants (45%) reported a fear of falling and 14 (51.9%) of these participants were fallers. Fear of falling significantly predicted scores of autonomy indoors (ß = 3.38, p = 0.04), autonomy outdoors (ß = 2.62, p = 0.04) and family role (ß = 3.52, p = 0.05). Conclusion: Individuals with subacute SCI and a fear of falling experienced reduced participation and autonomy, but with no differences in life satisfaction compared to those without a fear of falling. In contrast, having experienced a fall did not impact participation, autonomy or life satisfaction. In the first year after SCI, rehabilitation programs should place specific attention on the presence of fear of falling to help individuals with SCI prepare for everyday mobility challenges.

The state of aquatic therapy use for clients with spinal cord injury or disorder: Knowledge and current practice.

CONTEXT/OBJECTIVES: Aquatic therapy (AT) has been reported to be beneficial for individuals with spinal cord injury or disorder (SCI/D); however, AT has also been reported to be underutilized in SCI/D rehabilitation. We aimed to understand the knowledge and current practice of AT for clients with SCI/D by physiotherapists, physiotherapy assistants and kinesiologists across Canada. DESIGN/METHOD: A survey with closed- and open-ended questions was distributed (July-October 2019) to professionals through letters sent by professional associations. Non-parametric analyses were used to compare AT knowledge and practice between AT and non-AT users; content analysis was used to identify the themes from open-ended questions. RESULTS: Seventy-eight respondents from 10 provinces were included in the analysis: 33 physiotherapists, 5 physiotherapy assistants and 40 kinesiologists. Respondents using AT (73%) reported greater knowledge of AT benefits and confidence to apply AT than respondents not using AT (p<0.01). Four themes were identified: 1-Variety of physical and psychosocial benefits of AT for people with SCI/D; 2-Attainment of movement and independence not possible on land; 3-Issues around pool accessibility; and 4-Constraints on AT implementation. CONCLUSIONS: Respondents implemented AT to improve health outcomes for patients with SCI/D, despite facing challenges with pool accessibility and numerous constraints. Respondents who provided AT reported having better knowledge of AT and a supported AT practice in the work environment than respondents not providing AT. This study will inform AT stakeholders and institutions when considering strategies to increase the access to AT after SCI/D.

Effects of water immersion on gait initiation: part II of a case series after incomplete spinal cord injury.

Study design: Case series. Objectives: This case series describes how the aquatic environment influences gait initiation in terms of the center of pressure (COP) excursion, impulses, trunk acceleration, and perceptions of participants with incomplete spinal cord injury (iSCI). Setting: Tertiary Rehabilitation Hospital, Ontario, Canada. Methods: Five individuals with iSCI (four cervical injuries/one thoracic injury, AIS D) participated in the study. Baseline clinical balance was evaluated by Berg Balance Scale and Mini-Balance Evaluation System Test. Participants initiated gait on a waterproof force plate and walked ~4 steps, in water and on land. COP trajectories during anticipatory and execution phases, impulses, and trunk acceleration parameters were investigated. Perceptions of walking in both environments were obtained using an interview. Results: COP trajectory was prominently longer when individuals stepped forward. A decrease in velocity of COP was observed predominantly in the AP direction during stepping. Non-normalized vertical impulses decreased as the AP impulses increased, in water compared to land. Upper to lower trunk acceleration ratios showed how water resistance influenced the lower trunk acceleration. Most of participants reported that walking in water was challenging, but safer than on land. Conclusions: Participants with higher balance function seemed to have more pronounced changes in anticipatory and execution phases' duration, length and velocity of COP. A faster anticipatory phase and a slower execution phase were observed in water than on land. Participants walked in water using a different trunk control strategy than on land and reported no fear of falling when walking in water versus land.

The use of aquatic therapy among rehabilitation professionals for individuals with spinal cord injury or disorder.

Context/Objective: Aquatic therapy (AT) has been used to enhance balance and mobility in people with disabilities; however, AT is reported to be underused among people with spinal cord injury or disorder (SCI/D). We aimed to understand the perceptions of AT use by physical therapists (PT), PT assistants (PTA) and kinesiologists (KIN) across Canada for clients with SCI/D. Design/Methods: Individual semi-structured interviews were completed with PT, PTA and KIN (phone or in-person). PT, PTA and KIN who had used AT with at least one client with SCI/D in the past year were eligible. Interview questions queried each participant's AT setting, AT approaches, and perceived facilitators and barriers to AT implementation for clients with SCI/D. Interviews were audio recorded and transcribed verbatim. Thematic analysis was used to identify themes and subthemes. Results: Six PT (2 male, 4 female), three PTA (female) and 1 KIN (female) participated. The following four themes were identified: (1) multi-system benefits from AT (e.g. from impairment to function, confidence and enjoyment); (2) application of AT (e.g. based on principles of the water); (3) perceived barriers to implementing AT (e.g. pool accessibility, client comorbidities); and (4) water as an enabler to function on land. Conclusions: The participants reported AT was a unique and versatile approach that benefits the multi-dimensional aspects of the health of individuals with SCI/D. They successfully integrated AT into their clinical practice despite the barriers faced by professionals and clients.

Effects of water immersion on quasi-static standing exploring center of pressure sway and trunk acceleration: a case series after incomplete spinal cord injury.

Study design: This work is a case series. Objectives: We assessed the influence of the aquatic environment on quasi-static posture by measuring center of pressure (COP) sway and trunk acceleration parameters after incomplete spinal cord injury (iSCI) in water and on land. Setting: Tertiary Rehabilitation Hospital, Ontario, Canada. Methods: Six adult participants with iSCI (4 cervical/2 thoracic injuries, AIS D) were enrolled. Baseline balance was assessed by the Berg Balance Scale and Mini-Balance Evaluation System Test. Participants stood on a waterproof force plate for one minute per trial on land and in water; participants completed testing with their eyes open or closed in random order over 10 trials. Individuals' perceptions of their standing balance were obtained. COP and trunk acceleration parameters were analyzed in the time-domain. Results: COP sway and upper to lower trunk acceleration ratios in the AP direction increased in water, which was in contrast to standing on land in both visual conditions for 5/6 participants. Three participants (P1, P3 & P4) with greater sensorimotor deficits had larger COP sway in water with the eyes closed. Two (P1 & P4) of six participants reported more discomfort standing in water than standing on land. Conclusions: Increased COP sway seemed to reflect the balance and sensorimotor impairments of the participants, especially when standing with eyes closed in water. Although most participants (4/6) perceived that they swayed more in water in contrast to on land, 5 out of 6 participants reported that water felt like a safer environment in which to stand.

The influence of the aquatic environment on the center of pressure, impulses and upper and lower trunk accelerations during gait initiation.

Gait initiation is defined as the transition from stationary standing to steady-state walking. Despite the frequent use of therapy pools for training walking in early stages of rehabilitation, none have been reported on the effects of immersion on gait initiation. We aimed to analyze the center of pressure (COP) trajectories, the vertical and anteroposterior impulses and upper and lower trunk accelerations during anticipatory (APA) and execution phases of gait initiation. In the COP trajectory, the execution (EXE) phase was further subdivided in two phases: predominantly mediolateral (EXE1), and predominantly anteroposterior (EXE2). Able-bodied participants initiated gait while standing on a force plate and walked approximately 4 steps following a visual cue. The participants were wearing three inertial sensors placed on the lower and upper trunk, and on the stance shank. Individuals performed 10 trials each on land and in water, in two consecutive days. The lengths and velocities of COP trajectories increased in water compared to land during APA, while the COP length increased and the COP velocity reduced in water during EXE2. The anteroposterior impulses increased in water during EXE. Lower trunk acceleration was smaller in water while the upper trunk acceleration did not differ, resulting in the larger ratio of upper to lower trunk acceleration in water during EXE. Overall, immersion in water increases COP length during gait initiation, and reduces COP velocity during EXE2, indicating a new postural strategy in water. The aquatic medium may be favorable for individuals who need weight support, gradual resistance and a longer time to execute gait initiation.

The influence of the aquatic environment on the control of postural sway.

Balance training in the aquatic environment is often used in rehabilitation practice to improve static and dynamic balance. Although aquatic therapy is widely used in clinical practice, we still lack evidence on how immersion in water actually impacts postural control. We examined how postural sway measured using centre of pressure and trunk acceleration parameters are influenced by the aquatic environment along with the effects of visual information. Our results suggest that the aquatic environment increases postural instability, measured by the centre of pressure parameters in the time-domain. The mean velocity and area were more significantly affected when individuals stood with eyes closed in the aquatic environment. In addition, a more forward posture was assumed in water with eyes closed in comparison to standing on land. In water, the low frequencies of sway were more dominant compared to standing on dry land. Trunk acceleration differed in water and dry land only for the larger upper trunk acceleration in mediolateral direction during standing in water. This finding shows that the study participants potentially resorted to using their upper trunk to compensate for postural instability in mediolateral direction. Only the lower trunk seemed to change acceleration pattern in anteroposterior and mediolateral directions when the eyes were closed, and it did so depending on the environment conditions. The increased postural instability and the change in postural control strategies that the aquatic environment offers may be a beneficial stimulus for improving balance control.

The Influence of the Aquatic Environment on Gait Initiation: A Pilot Study.

Aquatic therapies are used to restore step initiation in people with locomotor disabilities. However, there is lack of evidence of underlining mechanisms of gait initiation in water. We investigated center of pressure (CoP), vertical and anterior-posterior impulse forces, and kinematics of the first step performed in water in comparison with overground walking. The peaks of anticipatory postural adjustment (APA) and the sections of CoP trajectories were longer in water than on land. Impulse forces were increased in water compared with land. Range of motion (ROM) of ankle joint increased in water while knee joint ROM did not change. We suggest that the aquatic environment may facilitate gait initiation training by allowing a longer step execution with greater stimuli and imposed resistance for the phases of gait initiation.

The effects of aquatic therapy on mobility of individuals with neurological diseases: a systematic review.

OBJECTIVE: To summarize evidence on the effects of aquatic therapy on mobility in individuals with neurological diseases. DATA SOURCES: MEDLINE, EMBASE, PsycInfo, CENTRAL, CINAHL, SPORTDiscus, PEDro, PsycBITE and OT Seeker were searched from inception to 15 September 2014. Hand-searching of reference lists was performed in the selected studies. REVIEW METHODS: The search included randomized controlled trials and quasi-experimental studies that investigated the use of aquatic therapy and its effect on mobility of adults with neurological diseases. One reviewer screened titles and abstracts of retrieved studies from the search strategy. Two reviewers independently examined the full texts and conducted the study selection, data extraction and quality assessment. A narrative synthesis of data was applied to summarize information from included studies. The Downs and Black Scale was used to assess methodological quality. RESULTS: A total of 116 articles were obtained for full text eligibility. Twenty studies met the specified inclusion criteria: four Randomized Controlled Trials (RCTs), four non-randomized studies and 12 before-and-after tests. Two RCTs (30 patients with stroke in the aquatic therapy groups), three non-randomized studies and three before-and-after studies showed "fair" evidence that aquatic therapy increases dynamic balance in participants with some neurological disorders. One RCT (seven patients with stroke in the aquatic therapy group) and two before-and-after tests (20 patients with multiple sclerosis) demonstrated "fair" evidence on improvement of gait speed after aquatic therapy. CONCLUSION: Our synthesis showed "fair" evidence supporting the use of aquatic therapy to improve dynamic balance and gait speed in adults with certain neurological conditions.