Aquatic Therapy: Outcomes studies can be hard to find

How can providers reassure payors, referral sources, and patients that this modality delivers results?

Aquatic therapy is a fast-growing area of treatment. One-on-one aquatic therapy protocols provided by physical and occupational therapists are covered in most states by third-party payors, although level and duration of coverage vary widely.

Aquatic programs have multiplied at an extraordinary rate in pain clinics and hospitals. Increasingly, physicians and surgeons refer their patients to water therapy for symptom relief and functional improvement.

“The industry is exploding,” according to Alison Osinski, PhD, owner of Aquatic Consulting Services in San Diego. “There’s a lot of construction. Hospitals or clinics that used to have a couple of hot tubs are now building aquatics complexes.”

“There’s a lot of publicity about aquatic therapy,” said aquatic therapy consultant Charlotte O. Norton, DPT, ATC, of Building Bridges, Ripon, WI. “It’s a nouveau thing to do in the ’90s. With the fitness boom and the aging population, many providers see it as another way to make money.”

However, this boom is likely to be offset by a bust as treatment offered without good medical justification will likely result in resistance from payors about authorizing treatment.

“We have to do a lot of education for insurance companies who are skeptical about the efficacy of aquatic therapy,” Norton said.

Providers delivering aquatic therapy, and those considering adding aquatic therapy services, are beginning to ask, Where is the research? What does it say about the efficacy and efficiency of aquatic therapy? How can providers reassure payors, referral sources, and patients that this is a modality that delivers results?

Where is the research?

“We’re at a point where we need to quantify what we do,” Norton admitted.

Insurance payors expect patients to be evaluated and treated by healthcare providers with a track record of delivering excellent outcomes. Healthcare providers want to provide treatments that will result in recovery and rehabilitation. Authorization to provide treatment is tied to specified outcomes and the expected frequency, amount, and duration of services required to achieve the outcome per diagnosis and level of care. Using good case management principles, payors conduct intervention profiling that identifies the most effective and efficient treatment procedures.

Robert Schrepfer, MS, PT, is clinical supervisor at the Center for Aquatic Rehabilitation at Cherry Hill, in Cherry Hill, NJ. About 150 patients a week receive aquatic therapy in a facility that boasts three in-ground aquatic-therapy pools. Most are referred following orthopedic injuries.

“Existing research is sparse, poorly directed, and poorly focused. We need to do some groundwork research,” he said.

“If you look at it,” Norton said, “a lot of how we justify aquatic therapy is based on the principles and properties of water (buoyancy, resistance, hydrostatic pressure, sensory stimulation, etc.). We see that if patients are in less pain, they do more and feel better about rehabilitation. We tell payors that if we get (patients) in the water, we can cut down time in rehabilitation. We aren’t doing a very good job justifying the effectiveness and clinical outcomes in terms of range-of-motion, strength, walking. If we’re going to thrive, we’ll have to do that.”

“Most (research in aquatic therapy) looks at arthritis, or exercise in older adults,” Norton added, “There’s also a tremendous amount of material on the physiological response to water, but not on clinical results.”

Kravitz and Mayo presented an overview of some pertinent aquatic therapy research, including aquatic exercise and neuromuscular disease, and aquatic exercise and rheumatic disease, to the Aquatic Exercise Association in 1997.1

Andrea Poteat Salzman, MS, PT, disagrees that outcomes research in aquatic therapy is limited. But she admits that the research often isn’t easy to find doing a Medline search. So how should the information be located?

Salzman operates Concepts in Physical Therapy in Amery, WI, and the Aquatic Resources Network (ARN) in Oak Ridge, TN (see sidebar). Salzman’s company prepares and sells bibliographies on aquatic therapy organized by author, topic, date, etc. She also prepares Aqua Bullets, an ongoing review of published outcomes studies in one-page summaries. The ARN Web site offers these summaries for sale, and posts one free research summary monthly.

Research challenges

Salzman is also editor-in-chief of The Journal of Aquatic Physical Therapy, published quarterly by the Aquatic Physical Therapy Section of the American Physical Therapy Association. In the May 1996 issue, Salzman reminded aquatic therapists that evidence of the effectiveness of aquatic therapy must be collected.

For a scientific analysis of treatment, she cites Harris, who lists six characteristics of valid research:

- theories underlying treatment are supported by valid anatomical and physiological evidence;

- treatment is specific to a patient population;

- potential side-effects are discussed;

- studies have validated the efficacy of the treatment;

- research studies are peer-reviewed, well-designed, and either experimental (prospective, randomized, controlled) or single-subject experiments; and

- the proponents of the treatment are willing to discuss its limitations.2

Norton agrees with these criteria, but offers a caveat.

“There’s a catch-22. If you know the aquatic intervention is effective, it’s unethical to deny treatment, and you can’t have a control group. Second, most aquatic interventions are combined with land therapy, because eventually the patient must operate on land. (In discussing outcomes) you can’t isolate aquatic therapy,” she said.

All gains realized in water must be transferable to land. Partly because of reimbursement issues, therapists focus their treatment on helping the patient accomplish functional objectives on land.

“The research planning for therapy, including aquatic therapy, requires a defined land goal,” said Jack Wasserman, PhD, senior vice president for research & development and product integration for HydroForce in Knoxville, TN.

For example, accomplishing a goal of walking 100 yards without resting might be one measure of a patient’s functional improvement required as part of a return-to-work program. Unless the patient’s work setting is underwater, ambulating in a therapy pool would not meet that criterion. Only if the therapist can document that increasing strength, flexibility, and endurance in water will improve the patient’s readiness to walk on land will the payor be comfortable in authorizing aquatic therapy.

Norton points to another challenge for would-be aquatic-therapy researchers.

“There’s the whole problem of physical therapy and rehabilitation in the clinical environment. Therapists can’t control a lot of variables that could confound the research,” she said.

Uncontrollable variables in clinical settings might include the sex, age, preinjury health status, and presenting diagnosis of patients, among others.

The trend in aquatic therapy research is in conducting and documenting individual case studies.

“That’s a useful way to start building a case,” Norton said. “I can take to an insurance company one case study of a successful use of aquatic therapy published in a peer-reviewed journal and demonstrate the probability that the intervention will be an effective use of aquatic therapy with my patient.”

Many clinicians who would like to show that aquatic therapy is effective simply lack the time or administrative support to develop and carry out rigorous research projects. Some therapists feel intimidated by their lack of expertise in statistical analysis.

“As in all clinical studies, the time to collect and process data is not a major purpose of the clinic,” Wasserman said.

Norton encourages providers to team up with academic resources.

“Clinicians can advise graduate students and use university resources to do statistical analysis,” she said.

Schrepfer, who is developing a research program, acknowledges the challenges involved.

“We can work to control a number of variables, but there are always trade-offs with any research. We can control for one thing, but that opens up other arguments,” he said.

Collaborating with vendors

Companies that manufacture or sell therapeutic pools and other equipment used in aquatic therapy are just beginning to conduct their own in-house outcomes research, according to Ruth Sova, executive director of the Aquatic Therapy and Rehab Institute (ATRI) in Chassell, MI.

“As a manufacturer,” Wasserman said, “I find the clinics are interested in cooperating with vendors on research if they can do it in a way that is not too time-intensive for therapists. We are currently working to establish protocols with several clinics.”

Sova and Norton agree that collaborating with vendors has benefits, although Norton cautions providers to be selective.

“Vendors are willing to donate equipment to do studies. But they (the companies) are generally small and don’t have the resources to conduct research. Most vendors are very committed to the industry from both the fitness and the therapeutic perspective,” he said.

“The companies are very credible and seem to have an honest interest in helping the industry—not just their company—move forward,” Sova said.

Boosting outcomes research

The ATRI and the Aquatic Exercise Association (AEA), Petersburg, WV, are promoting research in aquatic therapy. In September, the institute will add a research forum to its annual conference in Washington, DC. The forum will bring together clinicians, academicians, and researchers to share their expertise in a series of 30-minute sessions.

“The goal is to share and compare, and prepare the practitioner,” said Fran Stanat, PhD, chairman of the ATRI research committee. “We want to take research into action, not allow it to collect dust in an obscure journal. Hopefully, over a couple of years practitioners will seek input for doing their own work. Or they’ll network about common concerns: How can I measure change when I have to perform miracles in two weeks?” (For further information contact ATRI at 906/482-9500.)

Stanat also suggests that aquatic therapists might explore a range of sources to help fund research in this area.

“NIH (National Institutes of Health) has been funding research in alternative interventions. Because it’s not drug-based, aquatic therapy is something NIH might fund,” Stanat said.

Samuel H. Joseloff, PhD, information officer at the Center for Scientific Research (formerly the Division of Research Grants) at the NIH said that the range of health-related topics covered by the NIH is broad. NIH specialists are available to give advice and evaluate the relevance of a research topic to various NIH funding sources, and provide assistance to researchers on the NIH grant application process, he said. Joseloff encouraged clinicians interested in getting NIH support for research in aquatic therapy outcomes to contact the NIH (see sidebar).

Although it may be challenging to many clinicians, there are many benefits to collecting and analyzing aquatic therapy outcome data. Norton, Schrepfer, and Salzman, for example, encourage aquatic therapy providers to gather cumulative data so that aquatic therapy statistics reflect accurately its effectiveness. If good research is done and published, Salzman has written, aquatic physical therapists won’t find themselves given impossible cases long after other efforts have failed, only to be told that aquatic PT won’t work because the patients don’t get better.3

Valerie A. Lipow is a freelance medical writer in Grand Junction, CO.



References

1. Kravitz L, Mayo JJ. The physiological effects of aquatic exercise: a brief review. Presented to the Aquatic Exercise Assn 1997.

2. Harris, SR. How should treatments be critiqued for scientific merit? Phys Ther 1996;76(2):175-181. In Salzman, AP. Evidence-based aquatic therapy. J Aquatic Phys Ther 1997;5(2):2.

3. Salzman, AP. Front-line PT. J Aquatic Phys Ther 1997;5(3);2.

Autora

Valerie A. Lipow