the aquatic therapist

How frequently is aquatic therapy billed to Medicare Part B? Answers to statistical questions about aquatic therapy use

Inquiring minds want to know:

• How frequently is aquatic therapy billed under Medicare Part B?
  
• How often do private practice PTs use the code 97113? How about OTs?
  
• What setting is the most likely to bill for aquatic therapy?

Answers to these questions -- straight from CMS (click here for master document). Here are a few of the highlights. (From 2006; published Feb 1, 2008)

[Editor's note: Looking for more recent statistics? You can order the 2008 data from Medicare for $100. Download the BESS file here. Contains private practice data only.]

How big a percentage of Medicare Part B claims does “aquatic therapy” (97113) represent?

In 2006, aquatic therapy comprised approximately .9% of claims. It was the 14^th most frequently billed outpatient code behind:

• 97110 (therapeutic exercise) 33.03%

• 97140 (manual therapy) 11.37%

• 97530 (therapeutic activities) 9.52%

• 97112 (neuromuscular reeducation) 7.51%

• G0283 (electrical stimulation - not wound care) 6.23%

• 97116 (gait training) 6.01%

• 97035 (ultrasound) 5.82%

• 97001 (PT eval) 3.09%

• 97535 (self care management) 2.95%

• 97032 (electric stimulation) 2.23%

• 97526 (treatment of swallowing dysfunction) 1.70%

• 97150 (group therapy) 1.33%

• 97124 (massage) 1.23%
  

Which settings are the most likely to bill for aquatic therapy?

Obviously, therapists/physicians are more likely to use the procedure “aquatic therapy” in a hospital, outpatient rehab facility. or outpatient PT setting than in a SNF or home health setting. So, although the code 97113 represented less than 1% of all claims to Medicare Part B in 2006, it represented over 2% of all claims made by hospitals. More here

How much were providers reimbursed for aquatic therapy?

Although “aquatic therapy” represented less than 1% of all claims to Medicare B, it was responsible for 1.75% of all dollars reimbursed overall and over 2.3% of payments doled out to private practice PTs. Why? CPT code 97113 has a higher relative value (and thus a higher reimbursement rate) than many of the other codes on the list. More here

How frequently do private practice PTs bill for aquatic therapy? How about private practice OT?

In 2006, private practice PTs were over 3x more likely to bill for “aquatic therapy” than private practice OTs. More here

There's tons more info available... including the most commonly used ICD-9 codes, the average number of visits by ICD-9 diagnosis, and more. Click here for CMS outpatient therapy utilization document.

Medicare Part B - Billing Scenarios for PTs and OTs (11 pages of them straight from the CMS!)

Often, when we share information about treating Medicare patients in the pool, we hear "Where does it say that in writing?"

Well, here it is from the horse's mouth. And this document includes information about all kinds of billing snafus -- not just group billing. (Note: Although it was created in 2002, it was reviewed 9/2009).

A little sample from the 11-pg CMS billing tip-sheet...

Supervision: The services of a therapist or therapy assistant cannot be billed for supervising a patient who is independently performing a therapeutic exercise program. Medicare pays only for skilled, medically necessary services delivered by qualified individuals, including therapists or appropriately supervised therapy assistants. Supervising patients who are exercising independently is not a skilled service. See reference numbers 1. and 3. above.

Use of Aides: You cannot bill Medicare for the services of an aide that is supervised by the therapist or therapy assistant. Medicare Part B does not pay for the services provided by aides regardless of the level of supervision. Medicare pays only for skilled, medically necessary services delivered

Team Therapy: Where a physical and occupational therapist both provide services to one patient at the same time, only one therapist can bill for the entire service or the PT and OT can divide the service units.

Group Therapy (sample scenario): In a 45-minute period, a therapist works with 3 patients - A, B, and C - providing therapeutic exercises to each patient with direct one-on-one contact in the following sequence: Patient A receives 8 minutes, patient B receives 8 minutes and patient C receives 8 minutes. After this initial 24-minute period, the therapist returns to work with patient A for 10 more minutes (18 minutes total), then patient B for 5 more minutes (13 minutes total), and finally patient C for 6 additional minutes (14 minutes total). During the times the patients are not receiving direct one-on-one contact with the therapist, they are each exercising independently. The therapist appropriately bills each patient one 15 minute unit of therapeutic exercise (97110) corresponding to the time of the skilled intervention with each patient.

To download the document, click here...

Free research download #5 (2010): Effects of Aquajogging in Obese Adults: A Pilot Study

Download the  | Abstract | Full Text (PDF) |


Reference: Eveline J. M. Wouters, Annemieke M. A. Van Nunen. Effects of Aquajogging in Obese Adults: A Pilot Study. Journal of Obesity. 2010, Article ID 231074, 7 pages. doi:10.1155/2010/231074

Effectiveness of Aquatic Exercise and Balneotherapy: A Summary of Systematic Reviews Based on Randomized Controlled Trials of Water Immersion Therapies

Kamioka H, Tsutani K, Okuizumi H, Mutoh Y, Ohta M, Handa S, Okada S, Kitayuguchi J, Kamada M, Shiozawa N, Honda T. Effectiveness of Aquatic Exercise and Balneotherapy: A Summary of Systematic Reviews Based on Randomized Controlled Trials of Water Immersion Therapies. J Epidemiol. 2009 Oct 31. [Epub ahead of print]

Faculty of Regional Environment Science, Tokyo University of Agriculture.

Background: The objective of this review was to summarize findings on aquatic exercise and balneotherapy and to assess the quality of systematic reviews based on randomized controlled trials.

Methods: Studies were eligible if they were systematic reviews based on randomized clinical trials (with or without a meta-analysis) that included at least 1 treatment group that received aquatic exercise or balneotherapy. We searched the following databases: Cochrane Database Systematic Review, MEDLINE, CINAHL, Web of Science, JDream II, and Ichushi-Web for articles published from the year 1990 to August 17, 2008.

Results: We found evidence that aquatic exercise had small but statistically significant effects on pain relief and related outcome measures of locomotor diseases (eg, arthritis, rheumatoid diseases, and low back pain). However, long-term effectiveness was unclear. Because evidence was lacking due to the poor methodological quality of balneotherapy studies, we were unable to make any conclusions on the effects of intervention. There were frequent flaws regarding the description of excluded RCTs and the assessment of publication bias in several trials. Two of the present authors independently assessed the quality of articles using the AMSTAR checklist.

Conclusions: Aquatic exercise had a small but statistically significant short-term effect on locomotor diseases. However, the effectiveness of balneotherapy in curing disease or improving health remains unclear.

Free research download #4 (2009): Therapeutic aquatic exercise in the treatment of low back pain: a systematic review

DOWNLOAD THE | Abstract/Full Text | PDF

REFERENCE: Waller B, Lambeck J, Daly D. Therapeutic aquatic exercise in the treatment of low back pain: a systematic review. Clin Rehabil. 2009 Jan;23(1):3-14.

Free research download #3 (2009): The Borg scale as an important tool of self-monitoring and self-regulation of exercise prescription in heart failure patients during hydrotherapy

DOWNLOAD THE | Abstract | PDF |

REFERENCE: Carvalho VO, Bocchi EA, Guimarães GV. The Borg scale as an important tool of self-monitoring and self-regulation of exercise prescription in heart failure patients during hydrotherapy. A randomized blinded controlled trial. Circ J. 2009 Oct;73(10):1871-6. Epub 2009 Aug 28.

 

Free research download #2 (2009): Benefit of warm water immersion on biventricular function in patients with chronic heart failure

DOWNLOAD THE | Abstract/Full Text | PDF–699K |

REFERENCE: Benefit of warm water immersion on biventricular function in patients with chronic heart failure. Bente Grüner Sveälv, Åsa Cider, Margareta Scharin Täng, Eva Angwald, Dimitris Kardassis, and Bert Andersson. Cardiovasc Ultrasound. 2009; 7: 33. Published online 2009 July 6. doi: 10.1186/1476-7120-7-33.

PMCID: PMC2713206

Free research download #1 (2009): A comparison of Kneipp hydrotherapy with conventional physiotherapy in the treatment of osteoarthritis of the hip or knee: protocol of a prospective randomised controlled clinical trial

DOWNLOAD THE | Abstract/Full Text | PDF–433K |

REFERENCE: A comparison of Kneipp hydrotherapy with conventional physiotherapy in the treatment of osteoarthritis of the hip or knee: protocol of a prospective randomised controlled clinical trial. Martin Schencking, Adriane Otto, Tobias Deutsch, and Hagen Sandholzer. BMC Musculoskelet Disord. 2009; 10: 104. Published online 2009 August 19. doi: 10.1186/1471-2474-10-104.

Read eSPLASH, the Aquatic Therapy Industry hotsheet

 
Nearly 5000 aquatic therapists get it every week. So why not you?

Here are just a few of the topics you missed...

12 Oct 2009: Billing for groups, WaterWay Babies, Multiple sclerosis and More!

21 Sept 2009: Medicare Denials, Swine Flu, TKR Proof, Adapted Showers and More!

14 Sept 2009: s/p TKR, Free CME, Grants for Pools, Pets vs. People and More!

7 Sept 2009: MRSA transmission, Neonatal hydro, HIV lawsuits and More!

17 Aug 2009: Vomit, Pool Yuck, Baby Asthma and More!

3 Aug 2009: Lower Back Pain, Blind Aquatic Therapy, Preschooler Pool Sessions and More!

Click here to read all the archives... or to sign up to get the hotsheet emailed directly to you every Monday.

Why are Medicare Intermediares giving aquatic therapy the cold shoulder?

As with all Medicare services, aquatic therapy must be medically reasonable and necessary in order for the provider to receive payment. Here are some of the most common reasons intermediares such as Cigna are choosing to deny aquatic therapy.

• Therapy services were provided to beneficiaries with no identified need for the use of this type of therapy. There was little evidence to support the need for use of a water based environment (i.e. buoyancy for un-weighting joints, resistance, and/or loss of motion).
• Services were provided for excessive durations of time per treatment session. In some cases aquatic therapy was rendered in excess of one hour.
• Aquatic therapy services continued for long periods of time (several months) in the absence of documented functional gains.
• Services were repetitive in nature and appeared to be for conditioning and overall fitness or maintenance.
• There was little evidence of transitioning the aquatic exercise program to a land-based exercise program to improve functional performance with every day activities.
• The programs provided in the pool setting were rendered in a group environment yet individual therapy was billed.

Source: Cigna Government Services: Aquatic Therapy

(Editor's Note: I would argue that the first reason is absurd. As long as equivalent or better results have been shown for working in water (and the research is mounting!), there should be no reason to have to forgo the pool for land. If the argument is that working in an "aquatic environment" is not functional, then I'd like to see the payer explain why they willingly reimburse for spinal traction or unweighted treadmill work).

Both Land-Based & Water-Based Therapy Helped After Total Knee Replacement

More good news for therapists who choose to take their s/p Total Knee Arthroplasty patients into the water. Water-based rehab works just as good as land... so it should be up to the therapist and patient to decide.

What is it the insurance companies say? That the research isn't there to support it. Or that the research that is there is weak and inconclusive.

Well, this study scores an 8/10 on the PEDro scale. That's as good as it gets in the PM&R world.

Harmer AR, Naylor JM, Crosbie J, Russell T. Land-based versus water-based rehabilitation following total knee replacement: a randomized, single-blind trial. Arthritis and Rheumatism 2009 Feb 15;61(2):184-191. OBJECTIVE: To compare outcomes between land-based and water-based exercise programs delivered in the early subacute phase up to 6 months after total knee replacement (TKR). METHODS: Two weeks after surgery (baseline), 102 patients were randomized to participate in either land-based (n = 49) or water-based (n = 53) exercise classes. Treatment parameters were guided by current clinical practice protocols. Therefore, each study arm involved 1-hour sessions twice a week for 6 weeks, with patient-determined exercise intensity. Session attendance was recorded. Outcomes were measured at baseline and at 8 and 26 weeks postsurgery. Outcomes included distance on the 6-Minute Walk test, stair climbing power (SCP), the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index (n = 85 English-proficient patients), visual analog scale for joint pain, passive knee range of motion, and knee edema (circumference). Planned orthogonal contrasts, with an intent-to-treat approach, were used to analyze the effects of time and time-group interactions. RESULTS: Compliance in both groups was excellent with 81% attending 8 or more sessions. Loss to followup was 5%. Significant improvements were observed across time in all outcomes at 8 weeks, with further improvements evident in all variables (except WOMAC pain) at 26 weeks. Minor between-group differences were evident for 4 outcomes (SCP, WOMAC stiffness, WOMAC function, and edema) but these appear clinically insignificant. CONCLUSION: A short-term, clinically pragmatic program of either land-based or water-based rehabilitation delivered in the early phase after TKR was associated with comparable outcomes at the end of the program and up to 26 weeks postsurgery.

How do I prepare my therapy pool for Swine Flu (H1N1)?

Yes, human-to-human transmission of H1N1 virus can occur. Even at your pool.

Transmission is thought to occur in the same way as seasonal flu occurs in people, which is mainly person-to-person transmission through coughing or sneezing of people infected with the influenza virus.

From the NSPF: What actions should pool operators take at their aquatic facility?

Currently there is no evidence suggesting inactivating the H1N1 virus would be different than other flu viruses. Therefore, continuing to maintain the pool water within the recommended levels for pH and disinfectants should inactivate the viruses. Vomit incidences should be treated the same as always, follow guidelines on the attachment.
www.nspf.org/Documents/cdcarticles/cdcbloodandvomit.pdf


Viruses are transmitted in areas outside of pool water and other surfaces such as restrooms, door handles, and chairs. Follow CDC recommendations of 10% bleach solution to wipe these and other features down. For guidance on cleaning up bodily fluids on inanimate objects download:
www.nspf.org/Documents/cdcarticles/cdcbodyfluiddeck.pdf

Aquatic Exercise for People with Multiple Sclerosis - Fabulous 15 Page Download

Check out this 15 page Aquatic Exercise for MS download (tab down to the 4th publication on the page). It is part of a series of publications designed to help you help your patients with MS.

MS Practice is an initiative of MS Australia and is a series designed to support allied health professionals in the symptom management of people with multiple sclerosis (MS).

There are 7 fabulous downloads (including aquatics, balance, pain, strengthening, etc)

Total Hip Replacment - Sample Protocol Offered by HydroWorx Pools

Looking for an aquatic rehab progression s/p THR? Read the following Total Hip Replacement protocol suggested by HydroWorx.

(Of course, protocols should never be followed blindly. They should be seen as a starting point for clinical decision making. Still, nice to have a starting point for discussion.)

Free education on aquatic rehab for TKA, Cardiac rehab, Mental health and more

In the mood for a freebie or 2? Attend the following seminars online for free courtesy the National Swimming Pool Foundation!

Health Benefit Track

Cardiorespiratory Fitness and Coronary Heart Disease Risk Factors in Women and Men Swimmers ~ Steven N. Blair, P.E.D., University of South Carolina (view abstract & bio)	Watch this seminar!
Exercising the Mind: How Water-Based Exercise Can Improve Mental Health ~ John "Jack" S. Raglin, Ph.D., Indiana University (view abstract & bio)	Watch this seminar!
Aquatic Exercise for Better Functional Activities on Land ~ Mary E. Sanders, Ph.D., FACSM, University of Nevada – Reno/WaterFit (view abstract & bio)	Watch this seminar!
A Comparison of Water and Land Therapy Versus Land Therapy on the Outcome of Total Knee Arthroplasty ~ Richard McAvoy, PT, DPT, CSCS, Rehab 3 at Marshbrook (view abstract & bio)	Watch this seminar!
Cool, Warm, and Hot Water Immersion Effects on Cardiac and Circulatory Function ~ Bruce Becker, M.D., M.S.; Kasee Hildenbrand, Ph.D., Washington State University (view abstract & bio)	Watch this seminar!

Aquatic therapy: Yes! Recommended for TKA patients...

Every therapist must admit that treating the TKR patient can be tricky.

The combination of pain, limp, swelling, weakness and ROM restrictions is hard to treat... and it only gets harder as the months progress. The answer? Look no further than your local therapy pool says an article due for release this Sept! (read below)



Giaquinto S, Ciotola E, Dall'armi V, Margutti F. Arch Gerontol Geriatr. 2009 Sep 5. [Epub ahead of print]

The study evaluated the subjective functional outcome following total knee arthroplasty (TKA) in participants who underwent hydrotherapy (HT) six months after discharge from a rehabilitation unit.

A total of 70 subjects, 12 of which were lost at follow-up, were randomly assigned to either a conventional gym treatment (N=30) or HT (N=28). A prospective design was performed.

Participants were interviewed with Western-Ontario McMasters Universities Osteoarthritis Index (WOMAC) at admission, at discharge and six months later. Kruskal-Wallis and Wilcoxon tests were applied for statistical analysis.

Both groups improved.

The WOMAC subscales, namely pain, stiffness and function, were all positively affected.

Statistical analysis indicates that scores on all subscales were significantly lower for the HT group. The benefits gained by the time of discharge were still found after six months. HT is recommended after TKA in a geriatric population.

How to Fund your Therapy Pool Projects? Help for Non-Profits who work with the Disabled

At our Aquatic Resources Network offices, we constantly receive requests from therapy pools looking for help in funding some of the larger ticket items, like lifts or platforms.

Well, if your facility is a non-profit and if you serve (any) individuals with paralysis, you should consider applying for a Reeve Foundation grant.

Christopher Reeve did much of his post-SCI rehab in water; in fact, he made some of his only limb movements while in a therapy pool. So, his organization has a special interest in aquatics, especially as it relates to Spinal Cord Injuries.

The Christopher Reeves Foundation has established Quality of Life grants (Max funding $25,000). These are designed to improve the lives of the disabled through judicious infusions of cash, many to therapy pool settings.

Recent grants:

AQUATIC TREADMILL & OTHER EQUIPMENT:
Dr. Dale B. Hull Foundation for Neurological Rehabilitation, Inc.
South Jordan, UT
$15,000
This Health Promotion grant will help to support scholarships and supplemental funding for physical rehabilitation for people with spinal cord injuries at Neuroworx, a facility that employs highly-trained physical therapists who have extensive experience in neurological rehabilitation.  The equipment includes an FES bike, body weight system for locomotor gait training, e-stim machine, specialized aquatic therapy pool with underwater treadmill and camera system, TheraGait walker and wheelchair accessible resistive training devices.  Grant funds will support therapy scholarships.

CHAIR LIFT:
Livonia Family YMCA
(YMCA of Metropolitan Detroit)
Livonia, MI
$3,915
This Quality of Life grant will help to underwrite the purchase of a new chair lift for the aquatics program that provides group aqua therapy sessions for people with multiple sclerosis and may be used by anyone from the community who uses a wheelchair and needs to access the pool.

RAMP:
British Columbia Lions Society for Children with Disabilities
Vancouver, BC, Canada
$5,000
This Quality of Life grant will help to fund the purchase of a swimming pool ramp at the camp in Winfield so that children with disabilities that use wheelchairs can transfer into an aquatic chair and can then be safely rolled into the pool so that they can enjoy aquatic activities at the camp.

ADAPTED AQUATIC PROGRAMMING:
Heart Of Variety Fund
Philadelphia, PA
$5,100
This Health Promotion grant will help to support the Adapted Aquatics Program, which provides children with paralysis therapeutic adaptive swimming sessions year-round and during summer camp sessions.

Pool steps: What kind, where and how many?

Comprehensive article from Pool & Spa News on making pool entry easier.

So, chlorine kills everything in the pool, right? Sure, just give it 10 days!

Sure, free chlorine at neutral pH kills most bacteria such as E. coli 0157:H7 in less than a minute

(if the free chlorine is maintained at proper disinfection levels throughout the pool).

However, a few germs are moderately (Giardia, Hepatitis A) to highly (Cryptosporidium) chlorine-resistant.

The table below shows the approximate disinfection times for these germs in chlorinated water.

Source: www.healthyswimming.com (the CDC's aquatic FAQs website)

Agent	Disinfectant Times for Fecal Contaminants in Chlorinated Water*
E coli 0157:H7 Bacterium	< < 1 minute
Hepatitis A Virus	approximately 16 minutes
Giardia Parasite	approximately 45 minutes
Cryptosporidium Parasite	approximately 15300 minutes (10.6 days)
1 mg/L (1ppm) free chlorine at pH 7.5 and 25o C (77o F) These disinfectant times are only for pools that do not use chlorine stabilizers such as cyanuric acid. Disinfection times would be expected to be longer in the presence of a chlorine stabilizer.

So Your Patient has MRSA: Can it be Transmitted in a Pool?

So, what is the likelihood of transmitting MRSA in pools? It's an ongoing debate.

As a general rule, many schools and public pools now have a policy that individuals with open wounds should not use whirlpools, hydrotherapy pools, cold tubs, swimming pools and other common tubs (sample policy).

This is a common sense nod to the fact that it is possible to transmit MRSA (and other bugs present in an open wound) through improperly disinfected pool water and through sharing items (like towels) or touching common areas (like locker-room floors or benches).

However, unlike cryptosporidium, MRSA is rapidly killed by chlorine, so when a pool is properly disinfected, there appears to be little risk of transmission, especially when there is no open wound or portal. (A recent study showed that MRSA could not survive in swimming pool water which maintained a free chlorine concentration of 2.90 ppm).[1]

To learn more about MRSA transmission in pools, attend the ePro Academy online seminar recorded at the 2009 World Aquatic Health Conference ( Emerging Issues: Methicillin-resistant Staphylococcus aureus (MRSA) infection - Jeffrey C. Hageman, M.H.S.).

FYI: Although there is little evidence to suggest that MRSA transmission can/has occurred in chlorinated swimming pools, there have been several reported instances of MRSA transmission in sports team setting, especially when communal whirlpools were used. 

Whirlpool transmission research:
1. Contaminated whirlpool water has been implicated as the route of transmission of Panton-Valentine leukocidin (PVL)-positive MRSA in the community in a report of MRSA infection in a college football team (Begier et al., 2004).

In this study of a college football team, of the 100 players questioned, 10 were positive for MRSA, of which three of four players with infection at a covered site (hip or thigh) had shaved the affected area, and these infections were also associated with sharing the whirlpool greater than or equal to two times per week.

2. Furthermore, methicillin-sensitive Staphylococcus aureus (MSSA) was isolated in communal whirlpool water associated with a professional football team in the US (Kazakova et al., 2005), where there was an outbreak of skin abscesses due to MRSA infection.

3. A more recent report of MRSA infection in a professional football team in St. Louis, Missouri, USA (Kazakova et al., 2005), suggested that the skipping of showers by players prior to use of communal whirlpools may have promoted MRSA cross-infection between
players.

Conclusion: There appears to be no single broad policy espoused by the CDC or other agencies on whether to limit pool use when an open wound is not present. In general, the Centers for Disease Control (CDC) suggest the following measures for preventing staphylococcal skin infections, including MRSA:

1. Practice good hand hygiene by washing hands frequently and in a thorough fashion with soap and warm water or using an alcohol-based hand sanitizer.

2. Take a shower with hot water and wash with soap (liquid antibacterial soap, not bar soap) following all activities (e.g. strength & conditioning sessions, practices, and competitions).

3. Avoid sharing towels, equipment, razors, soap (use liquid soap instead of bar soap), etc.

4. Use a barrier (e.g. clothing or a towel) between your skin and shared equipment.

5. Wipe surfaces of equipment before and after use with an approved disinfectant.

6. Clean and properly cover any open wounds such as turf burns, abrasions, lacerations, etc. with an appropriate bandage at all times. Avoid contact with other people’s wounds or bandages.

7. Avoid whirlpools, hydrotherapy pools, cold tubs, swimming pools, and other common tubs if you have an open wound.

8. Maintain clean facilities and equipment.

9. Do not ignore skin infections, pimples, pustules, abscesses, etc.

Reference
1. Tolba, O., et al., Survival of epidemic strains of healthcare (HA-MRSA) and community-associated (CA-MRSA) meticillin-resistant Staphylococcus aureus (MRSA) in.... Int. J. Hyg. Environ. Health (2007), doi:10.1016/j.ijheh.2007.06.003

Water-based cardiac rehab... Better than land?

Laurent M, Daline T, Malika B, Fawzi O, Philippe V, Benoit D, Catherine M, Jacques R. Training-induced increase in nitric oxide metabolites in chronic heart failure and coronary artery disease: an extra benefit of water-based exercises? Eur J Cardiovasc Prev Rehabil. 2009 Apr;16(2):215-21.

Université de Franche Comté, IFR 133 EA3920, Physiologie, Faculté de Médecine, Besançon, France. mourotlaurent@hotmail.com

BACKGROUND: Rehabilitation programs involving immersed exercises are more and more frequently used, with severe cardiac patients as well.

DESIGN: This study investigated whether a rehabilitation program including water-based exercises has additional effects on the cardiovascular system compared with a traditional land-based training in heart disease patients.

METHODS: Twenty-four male stable chronic heart failure patients and 24 male coronary artery disease patients with preserved left ventricular function participated in the study. Patients took part in the rehabilitation program performing cycle endurance exercises on land. They also performed gymnastic exercises either on land (first half of the participants) or in water (second half). Resting plasma concentration of nitric oxide metabolites (nitrate and nitrite) and catecholamine were evaluated, and a symptom-limited exercise test on a cycle ergometer was performed before and after the rehabilitation program.

RESULTS: In the groups performing water-based exercises, the plasma concentration of nitrates was significantly increased (P = 0.035 for chronic heart failure and P = 0.042 for coronary artery disease), whereas it did not significantly change in the groups performing gymnastic exercise on land. No changes in plasma catecholamine concentration occurred.

CONCLUSION: In every group, the cardiorespiratory capacity of patients was significantly increased after rehabilitation. The water-based exercises seemed to effectively increase the basal level of plasma nitrates. Such changes may be related to an enhancement of endothelial function and may be of importance for the health of the patients.

Plyometric training in water produces better results... with less stress to the athlete

Triplett NT, Colado JC, Benavent J, Alakhdar Y, Madera J, Gonzalez LM, Tella V. Concentric and impact forces of single-leg jumps in an aquatic environment versus on land. Med Sci Sports Exerc. 2009 Sep;41(9):1790-6.

PURPOSE: This study investigated the kinetic and the kinematic differences in female athletes in single-leg static jumps in an aquatic environment compared with those performed on dry land.

METHODS: Twelve healthy, junior national team handball players participated. Subjects completed a familiarization and a testing session. The subjects performed a series of single-leg jumps, dry land and aquatic with and without devices, which were randomized to avoid fatigue effects. Peak concentric force, rate of force development, impact force, and time of the jumps were determined using a force plate.

RESULTS: Peak concentric force and rate of force development were significantly (P < 0.05) higher in the aquatic jumps, whereas impact force was significantly (P < 0.05) lower. There was a shorter total jump time (P < 0.05) for the aquatic jump without devices, whereas the time required to reach peak force was not significantly different between the two environments, despite the greater resistance to movement in the aquatic medium.

DISCUSSION: Aquatic jump exercises result in greater force production and rate of force development in the same amount of time with less impact and can thus offer a viable alternative to traditional dry-land jump exercises, which may also be beneficial for rehabilitating or aging populations. The benefits of this type of exercise include an exercise mode that can be performed without compromising speed while reducing the potential for joint injury.

Department of Health, Leisure, and Exercise Science, Appalachian State University, Boone, NC, USA. triplttnt@appstate.edu

Want a longer duration between shutdowns? Try daily dilution

It's the standard of care in Europe: Dilute DAILY.

Public pools should drain and replace 30 liters (approximately 8 gallons) of pool water per user per day.

Example: Have an average bather load of 60 people? You should be diluting your pool water daily by draining almost 500 gallons and refilling with fresh water.

SOURCE: German DIN (Deutsch Industrie Normen) Standard 19,643: "Treatment & Disinfection of Swimming & Bathing Pool Water".

The DIN Standard has been adopted by the European Community. It is not mandated in the United States (except for international swimming competitions), but it is considered a "best practice". This practice removes total dissolved solids from your pool and makes it possible to extend the duration the pool can remain open before a "drain and fill" is necessary.

More at: www.alisonosinski.com/pooltips/53.htm

From the CDC: Vomit and Blood Contamination of Pool Water

The most common germs spread through recreational water are germs that cause diarrheal illnesses and skin rashes. These are spread by swallowing water contaminated with feces or by skin exposure to contaminated water. Pool water is unlikely to spread illness.

Vomit in Pool Water

Vomiting while swimming appears to be a common event. Often, vomiting is a result of swallowing too much water and, therefore, the vomit is probably not infectious. However, if the full contents of the stomach are vomited, follow the guidance in these Q & As:

Q: What germs are likely to be spread by vomit?

A: Noroviruses (also known as Norwalk-like viruses)

Q: Assuming that norovirus is in the vomit, what should I do?

A: Respond to the vomit accident as you would respond to a formed fecal accident, using CDC's recommendations. The time and chlorine level combinations needed to kill noroviruses and Giardia are similar. Since killing Giardia is the basis of CDC’s formed fecal accident response recommendations, this protocol should be adequate for disinfecting a potentially infectious vomit accident.

Blood in Pool Water

Germs (e.g., Hepatitis B virus or HIV) found in blood are spread when infected blood or certain body fluids get into the body and bloodstream (e.g., by sharing needles and by sexual contact). CDC is not aware of any of these germs being transmitted to swimmers from a blood spill in a pool.

Q: Does chlorine kill the germs in blood?

A: Yes. These germs do not survive long when diluted into properly chlorinated pool water.

Q: Swimmers want something to be done after a blood spill. Should the pool be closed for a short period of time?

A: There is no public health reason to recommend closing the pool after a blood spill. However, some pool staff choose to do so temporarily to satisfy patrons.

Source: www.healthyswimming.com

Check for existing guidelines from your local or state regulatory agency before use. Healthy Swimming recommendations do not replace existing state or local regulations or guidelines.

Aquatic boot camp... Daily aquatic therapy sessions improve low back pain

 

Low back pain is one of the most expensive non-life-threatening problems treated by the medical community. The medical community loses these individuals to a life of reduced production, economic hardship and pain.

But there is hope on the horizon... take them to the waters!

Dundar U, Solak O, Yigit I, Evcik D, Kavuncu V. Clinical effectiveness of aquatic exercise to treat chronic low back pain: a randomized controlled trial. Spine. 2009 Jun 15;34(14):1436-40.

STUDY DESIGN: This study was a prospective, randomized, controlled study.

OBJECTIVE: To compare the effectiveness of aquatic exercise interventions with land-based exercises in the treatment of chronic low back pain (CLBP).

SUMMARY OF BACKGROUND DATA: Land-based exercise and physiotherapy are the main treatment tools used for CLBP. Clinical experience indicates that aquatic exercise may have advantages for patients with musculoskeletal disorders.

METHODS: A total of 65 patients with CLBP were included in this study. Patients were randomly assigned to receive aquatic exercise or land-based exercise treatment protocol. Aquatic exercise program consisted of 20 sessions, 5 x per week for 4 weeks in a swimming pool at 33 degrees C. Land-based exercise (home-based exercise) program were demonstrated by a physiotherapist on one occasion and then they were given written advice The patients were assessed for spinal mobility, pain, disability, and quality of life. Evaluations were performed before treatment (week 0) and after treatment (week 4 and week 12).

RESULTS: In both groups, statistically significant improvements were detected in all outcome measures (except modified Schober test) compared with baseline. However, improvement in modified Oswestry Low Back Pain Disability questionnaire and physical function and role limitations due to physical functioning subpart of Short-Form 36 Health Survey were better in aquatic exercise group (P < 0.05).

CONCLUSION: It is concluded that a water-based exercises produced better improvement in disability and quality of life of the patients with CLBP than land-based exercise.

Department of Physical Medicine and Rehabilitation, Kocatepe University, Afyonkarahisar, Turkey. umitftr@yahoo.com