Aquatic Physiotherapy – Australian Guidelines (2015)

This document is the second edition of the “Guidelines for Physiotherapists working in and/or
managing Hydrotherapy Pools”, first published in 2002. It is designed to provide information to
physiotherapists and other aquatic professionals managing or working in hydrotherapy pools. The
material is to serve as a guide to ensure that safety and professional standards are maintained and
that water is used as an effective therapy and exercise medium. The aim of the Guidelines is to
continually improve the quality of care offered to the public.
Recognition has been given to differing opinions on the therapeutic use of water. It is recognised that
individual physiotherapists will work as sole practitioners in community pools and that
physiotherapists will be involved in the management of hydrotherapy pools in the community, in
private practice and in institutions. In many situations other professionals will work in the water or
manage the facility used by the physiotherapist.
Hydrotherapy pool managers owe a duty of care to the service providers who use their facilities and to
consider Federal, State and Council regulations.
They have a duty to provide a facility that meets criteria in safety and design, and infection control and
cleanliness.
The Guidelines are designed to give the physiotherapist and the manager guidance as to what
constitutes acceptable standards regarding safety, infection control and credentials needed by people
using or managing hydrotherapy pools.
All possible types of water exercise and therapeutic aquatic activity including Aquatic Physiotherapy
(Hydrotherapy) were considered including the utilisation of non-purpose built pools, the management
of which is not always controlled by physiotherapists. The document outlines minimum standards that
are achievable in all circumstances.
The Guidelines do not include detail on pool design. They should, however be read in conjunction
with the existing Australian Standards for Hydrotherapy Pools (AS3979-2006).
Furthermore, it is recognised that there are additional standards at state and local government levels,
which relate to infection control and pool sanitization, and these will need to be considered. Other
professional associations may have standards for their members. Links to State Government bodies
and Standards have been included in this document.
Aquatic professionals, including physiotherapists, must recognise that a duty of care is owed to clients
regarding both the selection of appropriate facilities and the form of service offered. In offering a
service, the aquatic professional takes responsibility for the client’s safety.
These Guidelines have been designed utilising available knowledge, best practice and evidence in
the areas of Aquatic Physiotherapy, water exercise and therapeutic swimming. They are
recommended to professionals working in hydrotherapy pools or working with people with special
needs and/or disabilities in a water environment, to physiotherapists including members of the
Australian Physiotherapy Association (APA) and to members of the community who may be involved
in managing hydrotherapy pools. They represent the minimum acceptable standard of professional
practice.

Australian guidelines
for aquatic physiotherapists
working in and/or managing
hydrotherapy pools.
Second edition.
I
Australian Physiotherapy Association
Aquatic Physiotherapy Group
Australian guidelines for aquatic physiotherapists
working in and/or managing hydrotherapy pools
Second edition
Acknowledgements
These guidelines are based on the 2002 Guidelines for Physiotherapists Working in and/or Managing
Hydrotherapy Pools. Thanks go to the following people for their valued time and contributions to the
guidelines:
 Maureen MacMahon (Project Officer)
 Sue Gordon (Delphi Process)
 Rose Horvat (APA Project Coordinator)
 Heather Bond
 Sophie Heywood
 Dianna Howell
 Judy Larsen
 Sarah Milne
 Bronwyn McIlveen
 Ross Piper
 Emily Ramage
 Members of the Aquatic Physiotherapy Group National Committee (2010 – 2015)
 Valued contributions from members of the aquatic physiotherapy community, the general
physiotherapy community and to members of other disciplines throughout Australia
 Where people have made special contributions in their area of expertise, they are
acknowledged within the document.
Copyright  2015 AUSTRALIAN PHYSIOTHERAPY ASSOCIATION.
All rights reserved. No part of this document may be modified, reproduced, copied or used to make any
derivative work, digitally reproduced, stored or communicated except for any use as permitted under the
Copyright Act 1968, without prior written permission from the Australian Physiotherapy Association.
Australian Physiotherapy Association
Level 1, 1175 Toorak Road, Camberwell VIC 3124
PO Box 437, Hawthorn BC VIC 3122
ABN 89 004 265 150
Phone: +61 3 9092 0888
E-mail: info@physiotherapy.asn.au
II
Contents
INTRODUCTION .................................................................................................................. 1
DEVELOPMENT PROCESS, PEER REVIEW AND AGREE INTRUMENT TESTING .......... 2
DISCLAIMER ........................................................................................................................ 2
DEFINITIONS OF ACTIVITIES CARRIED OUT IN A HYDROTHERAPY POOL ................... 3
Hydrotherapy ..................................................................................................................... 3
Aquatic Physiotherapy ....................................................................................................... 3
Water Exercise Services.................................................................................................... 5
Aquatic Fitness Activities ................................................................................................... 5
Swimming Activities ........................................................................................................... 5
1: SAFETY ............................................................................................................................ 6
1.1 Client and Staff Safety ................................................................................................. 6
1.1.1 Staff/Service Provider/Client Ratio ........................................................................ 6
1.1.2 Safety – Screening ................................................................................................ 7
1.1.3 Immersion ............................................................................................................. 7
1.1.4 Emergency Policies and Procedures ..................................................................... 8
1.1.5 Emergency Equipment .......................................................................................... 8
1.1.6 Staff Knowledge of Safety and Emergency Techniques ........................................ 9
1.1.7 Hygiene and Infection Control Procedures ............................................................ 9
1.1.8 Client Records ...................................................................................................... 9
1.1.9 Clients Performing Independent Exercise Programs ........................................... 10
1.1.10 Staff Screening/Personal Management ............................................................. 10
1.1.11 Use of Hydrotherapy Pool by External Hirers .................................................... 10
1.2 Safety of Facilities ......................................................................................................... 11
1.2.1 Pool and Environment Maintenance .................................................................... 11
1.2.2 Access to Hydrotherapy Area and Pool ............................................................... 11
1.2.3 Facilities .............................................................................................................. 12
1.2.4 Design Standards ................................................................................................ 12
1.2.5 Slips and Falls Management in Hydrotherapy Pool Facilities .............................. 12
1.2.6 Equipment Aids ................................................................................................... 13
1.2.7 Signage ............................................................................................................... 14
1.2.8 Footwear ............................................................................................................. 14
2: ACCEPTABLE TRAINING LEVELS OF PEOPLE WHO WORK IN HYDROTHERAPY
POOLS ............................................................................................................................... 15
2.1 Physiotherapists: Aquatic Physiotherapy/Hydrotherapy ............................................ 15
III
2.1.1 Entry-level education in Universities for Physiotherapists courses at Bachelor,
Honours and Graduate Entry Masters level .................................................................. 15
2.1.2 Graduate level skills and knowledge ................................................................... 16
2.1.4 Continuing Professional Development ................................................................. 18
2.2 Standards of training for other hydrotherapy pool workers ......................................... 18
2.2.1 Hydrotherapy Assistants ..................................................................................... 19
2.2.2 Individual Carers ................................................................................................. 19
2.2.3 Volunteers ........................................................................................................... 19
3: RESPONSIBILITIES OF THE PHYSIOTHERAPIST ...................................................... 20
3.1 Professional Conduct................................................................................................. 20
3.2 Clinical Management ................................................................................................. 20
3.2.1 Assessment and reassessment for aquatic physiotherapy .................................. 20
3.2.2 Aquatic Physiotherapy records ............................................................................ 20
3.3 Quality Management Activities ................................................................................... 21
APPENDIX I: SCREENING PRIOR TO ENTERING HYDROTHERAPY POOL ................. 22
Cardiovascular System ................................................................................................ 22
Respiratory System ...................................................................................................... 22
Central Nervous System .............................................................................................. 22
Gastro-Intestinal Tract.................................................................................................. 22
Genito-Urinary Tract .................................................................................................... 22
Infectious Conditions .................................................................................................... 22
Skin .............................................................................................................................. 23
Feet ............................................................................................................................. 23
Eyes and Ears ............................................................................................................. 23
Other Conditions .......................................................................................................... 23
Other information not covered elsewhere in assessment ............................................. 23
APPENDIX II: RISK MANAGEMENT .................................................................................. 24
APPENDIX III: HYGIENE AND INFECTION CONTROL .................................................... 25
Infectious Conditions ....................................................................................................... 26
Pseudomonas Aeruginosa ........................................................................................... 26
Ear Infections ............................................................................................................... 27
Gastrointestinal Illnesses ................................................................................................. 30
Cryptosporidium ........................................................................................................... 30
Noroviruses .................................................................................................................. 31
Blood Borne Infections .................................................................................................... 33
Hepatitis B ................................................................................................................... 33
IV
Hepatitis C ................................................................................................................... 33
HIV/AIDS ..................................................................................................................... 34
Multi-Resistant Organisms ............................................................................................... 37
Methicillin Resistant Staphylococcus Aureus (MRSA) .................................................. 37
Vancomycin Resistant Enterococci (VRE).................................................................... 39
Infectious Skin Conditions ............................................................................................... 41
Tinea Pedis .................................................................................................................. 41
Plantar Warts ............................................................................................................... 42
Herpes Simplex............................................................................................................ 43
Other Infections ............................................................................................................... 44
Hepatitis A ................................................................................................................... 44
Urinary Tract Infections ................................................................................................ 44
Respiratory Infections .................................................................................................. 45
Wounds ........................................................................................................................... 46
Skin Grafts/Donor Sites ................................................................................................ 46
Stomas ........................................................................................................................ 46
External Fixators/Leg Lengthening Devices ................................................................. 46
Infants ............................................................................................................................. 48
Staff Hygiene and Infection Control ................................................................................. 49
Health Screening ......................................................................................................... 49
Skin Conditions ............................................................................................................ 49
Effects of Chloramines and Other Disinfectant By-products ......................................... 49
APPENDIX IV: MANAGEMENT OF SPECIFIC CONDITIONS ........................................... 52
Cardiac Conditions .......................................................................................................... 52
Cardiac Physiology of Immersion for Healthy Subjects ................................................ 52
Specific conditions ....................................................................................................... 54
Contraindications for aquatic exercise in patients with cardiac disease ........................ 55
Diabetes .......................................................................................................................... 57
Clients with Hypoglycaemia ......................................................................................... 57
Clients with Hyperglycaemia ........................................................................................ 58
Respiratory Conditions .................................................................................................... 60
Physiological effects of immersion in neck deep water in healthy subjects ................... 60
Chronic Obstructive Pulmonary Disease (COPD) ........................................................ 60
Asthma ............................................................................................................................ 62
Cystic Fibrosis ................................................................................................................. 65
Renal Conditions ............................................................................................................. 66
V
Renal Physiology for Healthy Subjects ......................................................................... 66
Renal Dialysis Patients ................................................................................................ 66
Continuous Ambulatory Peritoneal Dialysis (CAPD) ..................................................... 67
Urinary Incontinence ........................................................................................................ 69
Autonomic Dysreflexia ..................................................................................................... 70
Epilepsy ........................................................................................................................... 71
Management of a seizure in the Hydrotherapy Pool: .................................................... 71
Oncology / Cancer ........................................................................................................... 73
Radiation...................................................................................................................... 73
Chemotherapy ............................................................................................................. 74
Cytotoxic Agents and Disease Modifying Anti Rheumatic Drugs (DMARD’s) ............... 75
Lymphoedema ................................................................................................................. 77
Pregnancy ....................................................................................................................... 78
APPENDIX V: HYDROTHERAPY POOL WATER MAINTENANCE ................................... 80
Pool and Environmental Cleaning and Maintenance........................................................ 80
Pool Equipment used in Treatment .................................................................................. 82
Pool chemical management: Occupational Health and Safety considerations. ................ 84
Material Safety Data Sheets and Personal Protective Equipment ................................ 84
Chemical Handling ....................................................................................................... 84
Staff training ................................................................................................................. 84
Chemical delivery and storage ..................................................................................... 84
Chemical spills ............................................................................................................. 85
Chemical disposal ........................................................................................................ 85
Faecal Accidents and Blood or Body Fluid Spills ............................................................. 86
Faecal Accidents .......................................................................................................... 86
APPENDIX VI: LITERATURE REVIEW PROCESS ........................................................... 88
Literature Review Process-Safety .................................................................................... 88
APPENDIX VII: RESULTS OF DELPHI PROCESS ........................................................... 94
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 1
INTRODUCTION
This document is the second edition of the “Guidelines for Physiotherapists working in and/or
managing Hydrotherapy Pools”, first published in 2002. It is designed to provide information to
physiotherapists and other aquatic professionals managing or working in hydrotherapy pools. The
material is to serve as a guide to ensure that safety and professional standards are maintained and
that water is used as an effective therapy and exercise medium. The aim of the Guidelines is to
continually improve the quality of care offered to the public.
Recognition has been given to differing opinions on the therapeutic use of water. It is recognised that
individual physiotherapists will work as sole practitioners in community pools and that
physiotherapists will be involved in the management of hydrotherapy pools in the community, in
private practice and in institutions. In many situations other professionals will work in the water or
manage the facility used by the physiotherapist.
Hydrotherapy pool managers owe a duty of care to the service providers who use their facilities and to
consider Federal, State and Council regulations.
They have a duty to provide a facility that meets criteria in safety and design, and infection control and
cleanliness.
The Guidelines are designed to give the physiotherapist and the manager guidance as to what
constitutes acceptable standards regarding safety, infection control and credentials needed by people
using or managing hydrotherapy pools.
All possible types of water exercise and therapeutic aquatic activity including Aquatic Physiotherapy
(Hydrotherapy) were considered including the utilisation of non-purpose built pools, the management
of which is not always controlled by physiotherapists. The document outlines minimum standards that
are achievable in all circumstances.
The Guidelines do not include detail on pool design. They should, however be read in conjunction
with the existing Australian Standards for Hydrotherapy Pools (AS3979-2006).
Furthermore, it is recognised that there are additional standards at state and local government levels,
which relate to infection control and pool sanitization, and these will need to be considered. Other
professional associations may have standards for their members. Links to State Government bodies
and Standards have been included in this document.
Aquatic professionals, including physiotherapists, must recognise that a duty of care is owed to clients
regarding both the selection of appropriate facilities and the form of service offered. In offering a
service, the aquatic professional takes responsibility for the client’s safety.
These Guidelines have been designed utilising available knowledge, best practice and evidence in
the areas of Aquatic Physiotherapy, water exercise and therapeutic swimming. They are
recommended to professionals working in hydrotherapy pools or working with people with special
needs and/or disabilities in a water environment, to physiotherapists including members of the
Australian Physiotherapy Association (APA) and to members of the community who may be involved
in managing hydrotherapy pools. They represent the minimum acceptable standard of professional
practice.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 2
DEVELOPMENT PROCESS, PEER REVIEW AND AGREE
INTRUMENT TESTING
These Guidelines have been developed with a literature review (Appendix V) and where supporting
literature could not be found via a Delphi process (Appendix VI). The Guidelines were peer reviewed
by two physiotherapists working in the field of hydrotherapy but not involved in the working party or
the Delphi process. The guidelines have additionally have been assessed with a tool called the
Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument to assess the
methodological rigour and transparency in which the Guidelines were developed.
DISCLAIMER
The clinical guidelines have been prepared having regard to general circumstances, and it is the
responsibility of the practitioner to have express regard to the particular circumstances, and the
application of these guidelines in each case. In particular, clinical management must be responsive to
the needs of individual patients, resources and limitations unique to the institutions or type of practice.
The clinical guidelines have been prepared having regard to the information available at the time of
their preparation, and the practitioner should therefore have regard to any information, research or
material which may have been published or become available subsequently. While the APA
endeavours to ensure that clinical guidelines are as current as possible at the time of their
preparation, it takes no responsibility for matters arising from changed circumstances or information
or material which may have become available subsequently.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 3
DEFINITIONS OF ACTIVITIES CARRIED OUT IN A HYDROTHERAPY
POOL
Hydrotherapy
Hydrotherapy has been used to describe a wide range of activities, of which most pertain to
therapeutic and exercise activities carried out in heated pools. More recently, health funds and
traditional medicine have recognised hydrotherapy as a physiotherapy treatment carried out in water
where the properties of water are utilised to achieve specific, therapeutic goals. There is much
confusion at a public level, however, with many different professionals using the term
hydrotherapy. The word is also used to represent a range of alternative therapies including colonic
washouts. It is recommended that “hydrotherapy” be used as the generic label for the many activities
that occur in a hydrotherapy pool and that providers of aquatic services further define their specific
roles. The most common activities coming under this banner and usually co-ordinated by
hydrotherapy pool managers include:
 Aquatic Physiotherapy Services
- Individual
- Group
- Classes
- Physiotherapy prescribed exercise programs
 Water Exercise Services
- Individual
- Classes
- Aquatic personal training
 Aquatic Fitness Activities
- Aqua aerobics
- Deep water activities
 Swimming activities
- Learn to Swim
- Swimming for people with disabilities
- Therapeutic swimming
Aquatic Physiotherapy
To assist with defining the roles of aquatic professionals and to avoid confusion with compensable
bodies, medical professionals and the general public, the Australian Physiotherapy Association has
defined the specific practice of physiotherapy in water as “aquatic physiotherapy”. It is carried out by a
physiotherapist.
Aquatic physiotherapy treatment (individually or in groups) incorporates individual assessment,
diagnosis and the use of clinical reasoning skills to formulate a treatment program appropriate to the
client. Reassessment is undertaken at the appropriate time by the physiotherapist, with outcome
measures recorded in keeping with evidence-based practice.
The aim of aquatic physiotherapy is to assist with the rehabilitation of neurological, musculoskeletal,
cardiopulmonary and psychological function of the individual. In some cases it will also assist in
maintaining the client’s level of function or prevent deterioration (eg balance and falls prevention) or
prevent injury (eg aid in recovery in a preventative sports medicine program). Aquatic physiotherapy
may involve individual treatment in a one to one situation or may be undertaken in groups or classes.
It may be used alone or in conjunction with other rehabilitation practices.
Individual Aquatic Physiotherapy: This form of treatment may utilise manual skills, demonstration
and correction of exercise or facilitation of desired movement patterns and motor relearning.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 4
Aquatic physiotherapy can also incorporate the development of independent movement in water and
the prescription of modified swimming activities, taking into account pathological changes seen in
neurological and orthopaedic/musculoskeletal conditions.
The level of disability or water competence of the client may necessitate individual treatment.
Water safety and independent movement in water may also be taught or assessed.
Fee structures for individual aquatic physiotherapy are similar to that for land physiotherapy.
If a physiotherapist does not offer aquatic physiotherapy, referral to a physiotherapist with skills in
aquatic physiotherapy is recommended.
Aquatic Physiotherapy Group Programs: These may be individually tailored yet supervised in
clinical groups where individuals follow specific exercise programs designed according to their own
pathology, rehabilitation or recovery requirements.
The client may be supervised/assisted during the exercise component of their management by
hydrotherapy/physiotherapy assistants. Minimum standards of training apply (refer to Guideline 2.2).
Aquatic Physiotherapy Classes: Clients may participate as part of a class designed to meet specific
needs such as those associated with pregnancy, general fitness, mobility for the older adult and
people with arthritis.
It is recommended that simple outcome measures be used to ensure that loss of function and
deterioration in mobility is readily identified. When deteriorating outcomes are identified it is strongly
recommended that the participant be referred for individual evaluation where the physiotherapist can
perform a comprehensive assessment to identify future management requirements.
Independent and/or home programs may be prescribed. The client’s water safety and ability to carry
out aquatic exercises independently must be ascertained (refer to Guideline 1.1.9). The client should
carry out these exercises (a physiotherapy prescribed exercise program) in a pool that is safe and
accessible.
Physiotherapy Prescribed Exercise Programs: Following assessment, treatment and instruction in
selected aquatic activities, the physiotherapist may advise clients on a program that the client can
perform independently. Exercises should be reviewed at appropriate intervals while the client is being
managed by the physiotherapist. This will depend on the client’s condition and rate of progress, and
the program should be modified and/or progressed as required with outcomes measured regularly.
In many cases, a client’s aquatic physiotherapy management will be integrated with land
physiotherapy management. It is the responsibility of all physiotherapists involved in the client’s care
to consider all appropriate modalities.
A physiotherapy prescribed exercise program may be selected as the appropriate mode of aquatic
physiotherapy intervention for many reasons. It may be the best way of progressing rehabilitation and
promoting independence, there may be limited access to an appropriate pool or pool sessions by both
the client and the physiotherapist, or it may be more cost efficient for the client or compensable
bodies.
In some situations, referral to other aquatic professionals will be appropriate, eg exercise physiologist,
aquatic fitness instructor or swimming teacher/coach. Appropriate documentation detailing the
reasons for clinical decisions is recommended.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 5
Water Exercise Services
Water exercise is an exercise conducted in water to maintain and upgrade body strength, flexibility,
conditioning and general fitness and to promote a sense of wellbeing, and is usually performed or
instructed by exercise professionals (refer to Guideline 2.2). Water exercise can enhance the
progress of many rehabilitation and recovery programs and can be offered independently or to
complement existing therapies.
Individual Water Exercise: Clients are assessed and instructed in a program to suit individual needs.
It is recommended that the instructor teach individuals from within the pool.
Water Exercise Classes: Water exercises may be offered in classes with each individual following a
personally prescribed program that has been individually taught or with the class following a program
of exercises designed with a general goal.
Aquatic Personal Training: Water exercise can enhance training and fitness regimens for many
individuals.
Aquatic Fitness Activities
Aquatic fitness activities can be conducted under many titles (eg aqua fitness, aqua-aerobics, water
workout, water callisthenics, deep water running) by a range of exercise professionals including
exercise physiologists and aquatic fitness leaders who should have appropriate aquatic training (refer
to Guideline 2.2).
Swimming Activities
There is a wide range of swimming activities that may be offered in a hydrotherapy pool, including:
Learn to Swim: Swimming lessons may be offered for all ages and abilities, (eg, infants, older adults
and people with disabilities). Often the hydrotherapy pool is used with these populations because of
pool design, temperature considerations and economic use of resources. Infection control and
screening procedures must be implemented in this population, as with all hydrotherapy pool users, to
minimise risk to others.
Therapeutic Swimming: This may be used by physiotherapists or other exercise professionals as
part of rehabilitation programs for strength and conditioning, fitness, weight loss and pain
management. Water safety/confidence is a component of any swimming program but will vary
according to ability of client and may need to be taught.
Swimming for People with Disabilities: In many areas of disability, the teaching of formal strokes
may not be appropriate but individuals can still be taught independent movement in water.
Physiotherapists may be involved in swimming for people with disabilities and teaching independent
movement in water to ensure a therapeutic benefit for the client. This can be done by the modification
of strokes, positioning, tone reduction and facilitating appropriate patterns of movement to maximise
function and movement in a population of people with disabilities. Physiotherapists may also prescribe
appropriate equipment including flotation devices.
Communication between professionals is encouraged at all times, particularly when working with
clients who have pathologies or physical impairments and who undertake swimming activities.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 6
1: SAFETY
Hydrotherapy pool services (including aquatic physiotherapy, water exercise and swimming
activities) shall be organised and administered in accordance with acceptable standards for
clients, staff and the working environment to provide optimum quality of care.
1.1 Client and Staff Safety
During aquatic physiotherapy, water exercise programs and swimming activities, the safety of clients
and service providers must be ensured at all times.
1.1.1 Staff/Service Provider/Client Ratio
When determining the ratio of clients to staff in the pool environment the following factors should be
considered:
a) Pool features including pool access, type of client transfers and the type of hoists available.
b) The size of the pool.
c) Level of disability or impairment of the client including physical, vision, hearing, intellectual,
cognitive and psychological problems.
d) The independent ability of the client/s in the water.
e) The type of therapeutic technique to be used.
An in-pool assistant or external supervisor or assistant is required in any circumstances where safety
would be compromised if something were to happen to the physiotherapist.
If one or more clients require assistance exiting the pool an in-pool assistant or external pool assistant
or supervisor is required.
With appropriate risk assessment, screening, pool orientation and education, volunteers and carers
can assist clients during therapist-led or independent aquatic sessions.
When a physiotherapist is working in a pool environment where an external observer is provided by
the facility it is appropriate for the external observer to observe a number of users or groups at the
one time.
When a physiotherapist is working in a pool environment where no external observer is provided by
the facility, staff members, volunteers, carers or support workers may be used as external observers.
When a physiotherapist is working on their own in a pool environment (with no external observer or inpool
assistant) clients should:
a) Have independent gait and mobility with or without a gait aid or with wheelchair mobility.
b) Be able to independently enter and exit the pool via ramp, stairs or hoist.
c) Be able to effectively communicate and follow instructions.
d) Have no significant cognitive or behavioural issues.
e) Have been screened for any precautions or contraindications before commencing aquatic
physiotherapy.
f) Be able to independently evacuate themselves from the pool if something were to happen to
the physiotherapist.
g) Be orientated to the safety and emergency evacuation procedures of the facility.
Staff and volunteers assisting aquatic physiotherapists must:
a) Be physically capable of taking and following instructions from the person in charge of an
emergency situation and assist clients to evacuate the pool.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 7
b) Should have adequate hearing, vision, concentration and reaction times to be able to
understand and follow instructions and react in cases of emergency.
Carers or support workers assisting an aquatic physiotherapist in the water must be physically able to
evacuate their client and themselves from the pool in an emergency involving another client in the
pool complex, or as instructed by the supervising staff member, care and attend to their own client.
If independently responsible for a client in the pool, the carer or support worker should:
a) Have adequate hearing, vision concentration and reaction times to be able to understand and
follow instructions and react in cases of emergency.
b) Demonstrate the ability to keep themselves and the client they are assisting safe in the water
(eg, stay in the appropriate depth, use any equipment safely, and support the client
appropriately for the clients’ condition and safety).
Children of any age who are not competent swimmers, or who are less than five years of age, should
be supervised by staff or a carer or support worker in the pool within arm’s reach of the client and with
face-to-face observation.
1.1.2 Safety – Screening
All clients should have a land based physiotherapy assessment prior to commencing aquatic
physiotherapy.
As part of an aquatic physiotherapy assessment all clients should have a screening health
assessment for potential precautions and/or contraindications for immersion. Screening should
include assessment of:
a) Presence of infectious conditions and related risk for infection such as open skin, active skin
conditions or wound areas.
b) The level of assistance required for transfers in and out of the pool, for mobility in and out of
the pool environment, and for dressing and general mobility.
c) Medical history, current medications and health status with particular regard to the
physiological effects of immersion and exercise.
d) Ability to communicate including adequate vision, hearing, language and verbal skills.
e) Risk related to cognition and behaviour.
f) Risk related to anxiety and fear of water.
g) Assessment of falls risk.
h) Past and current swimming ability or the ability to regain a safe breathing position in water if
safe to do so.
On completion of the pre-aquatic screening assessment, a management plan should be developed
based on the person’s individual capacity and needs.
All clients should be advised that it is their responsibility to notify the physiotherapist of any changes
in their health and/or physical status.
1.1.3 Immersion
Immersion time for staff depends on water temperature, water and air quality, personal medical status
and individual differences in terms of physiological response to immersion and the environment.
Federal workplace laws regarding work breaks should be applied in the aquatic setting.
Staff immersed for extended periods need to ensure adequate hydration.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 8
Immersion time for clients depends on water temperature, water and air chemistry and personal
medical status and individual differences in terms of physiological response to immersion and the
environment.
Immersion time for new, frail or debilitated clients must be based on the physiotherapists’ assessment
of the client and their knowledge of the pool and external environment in which they are working.
Immersion time and revision of immersion time for all clients, including frail and debilitated clients, will
be based on the physiotherapists’ assessment of the individual client’s response to immersion and
exercise.
Clients should be encouraged to rest if needed and re-hydrate after aquatic physiotherapy treatment.
1.1.4 Emergency Policies and Procedures
Each aquatic physiotherapy service must have clear policies and procedures that are reviewed
annually related to:
a) Emergency procedures
b) Staff training and competencies
c) Staff orientation
d) Client screening, written information provided and pool safety explanation or orientation
e) Water quality and testing (if the service is responsible for this)
f) Handling, storage and addition of chemicals (if the service is responsible for this).
It is recommended that each aquatic physiotherapy service provides documented evidence of:
a) Pool rescue training
b) Client screening before commencement of an aquatic program
c) Provision of written information and explanation regarding pool safety to clients and/or their
carer
d) Client and/or carer acknowledgement and understanding of the aquatic safety rules. If the
client is unable to understand or clearly communicate their understanding of the pool
rules/safety instructions, then the aquatic professional must assess the clients ability to be
safely managed in the pool environment.
It is recommended that all aquatic professionals are water safe and able to demonstrate the ability to
rescue someone from the deepest end of the pool in which they work.
1.1.5 Emergency Equipment
Resuscitation equipment appropriate to the client base should be available (eg, face shield, Air-Viva,
Oxy-Viva). This should be in good working order and appropriate staff trained to use it. When the pool
is in use at least one person present should be qualified to use resuscitation equipment.
There should be an adequate system for summoning assistance in an emergency (eg, alarm, mobile
or cordless telephone, personal alarm or whistle). It is highly recommended that some form of device
be reachable by workers in the pool so that a physiotherapist or pool worker can summon help
without exiting the pool. All staff must be familiar with the system.
Where a pool alarm system is in place, this must signal in the pool area and the nearest place for
assistance when activated. Pool alarms must be tested on a regular basis to ensure effective working
order. Where no in-built alarm exists, a personal alert alarm or whistle may be used to summon
assistance.
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Equipment to assist in removing clients from the pool will be necessary. In cases of respiratory or
cardiac emergency hoists are usually not recommended as a means of emergency exit due to their
slowness. Dedicated rescue slings or spinal boards are recommended.
Protocols for resuscitation in a wet environment must be considered (eg, adequate towels to dry
clients in case of defibrillation). A practice drill of the emergency procedures in a wet environment
should be carried out with appropriately qualified staff, for example, ambulance staff, emergency
department staff, or in private practice with an appropriately accredited instructor and documented in
the relevant department or clinic registers.
1.1.6 Staff Knowledge of Safety and Emergency Techniques
It is generally agreed that annual CPR training should be mandatory for aquatic staff. However, if
volunteers are in a position of responsibility, it strongly recommended that they have CPR training
annually.
Pool rescue training must consider the specific needs and conditions of the client population and
cover evacuating conscious, unconscious and spinal injured clients out of the pool, using the
equipment available at their facility.
All CPR and pool rescue training must be documented in the relevant department or clinic registers.
If aquatic staff treat clients with significant cognitive or behavioural issues that may lead to risky
behaviour (ie, running on the pool concourse or diving into the pool) a spinal board with support
straps should be available to evacuate the client from the pool.
If aquatic staff treat clients at risk of complications from a spinal injury, a spinal board with support
straps should be available to evacuate the person from the pool.
It is generally agreed that all aquatic physiotherapy staff should be water safe and able to
demonstrate the ability to rescue someone from the deepest end of the pool in which they work.
1.1.7 Hygiene and Infection Control Procedures
Appropriate infection control/hygiene procedures shall be implemented for all persons entering the
pool and/or pool environment. (Refer to APA position statement on infection control and Appendix III
Hygiene and Infection Control).
Infection control/hygiene procedures will vary, depending on the client type. They may include the
following:
 Client precautions and pre-screening (refer to Appendix I and II)
 Cleaning and disinfection of pool, pool environs and equipment (hosing of floors alone is not
sufficient)
 Pool chemistry and pool testing (refer to Appendix V)
 Use of appropriate clothing
 Showering before and after pool session
 Toileting and bowel regime
 Environmental management (wet and dry zones, shoe and wheelchair free zones)
 Risk management protocols
1.1.8 Client Records
With the increasing ability of older people, people with pathologies and people with disabilities to
access hydrotherapy pools, documentation of client information becomes even more important. There
may be factors such as pool temperature that can have adverse effects on some clients. Important
information includes:
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 Name
 Address
 Telephone number
 Date of birth
 Contact person in case of emergency
 Medical practitioner
 Relevant screening criteria (eg, diabetes).
This information should be provided by all users including carers and aquatic professionals and it
should be readily available while the client is in attendance.
1.1.9 Clients Performing Independent Exercise Programs
Before prescribing an independent exercise program all clients should be assessed for their ability to
move:
a) Around all areas of the pool they would have access to during their independent exercise
program.
b) From the centre of the pool to the edge of the pool at its deepest part.
Before prescribing an independent exercise program for a client who is unable to enter and exit the
pool independently, the client’s carer or support worker must be assessed for their capacity to safely
assist the client.
Some in-pool exercises and hydrotherapy equipment can put clients at increased risk. The effects of
buoyancy, density and resistance will affect exercises performed in the water. It is expected that the
physiotherapist discuss safety risks with clients when prescribing independent exercise programmes.
It is strongly recommended that exercises are demonstrated by the physiotherapist in the pool with
the client.
1.1.10 Staff Screening/Personal Management
All staff and volunteers entering the pool should be screened annually for water safety, health and
infection control issues. If any issues are identified when screening staff or volunteers a management
plan should be developed based on the individual’s needs.
All carers, support workers and external users entering the pool should be screened for water safety,
health and infection control issues.
Health screening for carers, support workers and external users who assist in the pool should be
performed on an annual basis or if their health or physical status changes. If any issues are identified
then a management plan should be developed based on the individual’s needs.
Physiotherapists should take responsibility for their own personal management incorporating selfscreening.
This will include the physiological effects of immersion, for example, the effect of a warm
environment, problems of dehydration and skin care. Physiotherapists may also be responsible for
those working for them (ie, assistants).
Staff should have an initial screening and be educated to the risks of a pool environment so they
understand the importance of reporting physical changes which may affect working in the pool
environment.
1.1.11 Use of Hydrotherapy Pool by External Hirers
There are many scenarios where an institution may decide to use their hydrotherapy pool for other
purposes but it is beyond the scope of these guidelines to go into detail about each one. If an
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institution allows their hydrotherapy pool to be used for other purposes there are many legal and
safety issues that would have to be considered in each situation.
 The institution must very clearly delineate the times for different purposes.
 Legal and insurance implications should be investigated.
 The local Council and State regulations for public pools must be followed.
 Infection control measures must remain stringent to allow the pool standards to be maintained
at the appropriate levels for clients.
 If the institution allows their pool to be used by staff members with or without supervision,
then it is strongly recommended that they have guidelines in place.
 Copies of qualifications, insurance policies, proof of CPR and rescue training should be
provided by external hirers and kept in department or clinic registers.
1.2 Safety of Facilities
It is understood that there is a large variation in design and standards in existing hydrotherapy pools
and that in some cases, ordinary pools are used for clinical practices. Best practice in terms of facility
standards is something that can always be a goal but may not be reasonably achievable with facilities
available. Documentation of processes to ensure client safety and facility standards are encouraged
where these standards cannot reasonably be met.
The aquatic physiotherapy service should consider all Australian Standards, State and Local
Government Acts and Regulations relevant to the running of a hydrotherapy service in the appropriate
State or Territory.
1.2.1 Pool and Environment Maintenance
Relevant State Health Department Regulations shall be adhered to at all times (refer to Appendix V).
These include
 Water Purification Standards for Public Swimming Pools
 Storage and Handling of Chemicals.
It is the physiotherapists’ responsibility to familiarise themselves with the standards relevant to their
State.
Physiotherapists/organisations with purpose built hydrotherapy pools shall also consider Australian
Standards for Hydrotherapy Pools AS3979-2006 and assess local Council/State requirements.
Physiotherapists utilising public pools for aquatic physiotherapy are not ultimately responsible for pool
chemistry. However, they owe a duty of care to their clients when recommending or using a particular
facility for ongoing treatment or management, and therefore must ensure that the pool they are
utilising maintains a standard within their State Health Department guidelines.
Any adverse effects of immersion should be documented and pool managers notified. Most pool
managers are obliged to have a logbook that is accessible to pool hirers. This logbook documents
chemistry and microbiology readings.
1.2.2 Access to Hydrotherapy Area and Pool
Adequate assessment of the client’s abilities and the facilities of the pool will ensure that the pool and
facilities meet client needs and that the necessary assistance is available if required.
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1.2.3 Facilities
Change, shower and toilet facilities shall be appropriate for the client base. The facilities should
conform to Australian Standard for Design for Access and Mobility AS1428.1-2009 where access is
required for wheelchair users and other people with disabilities.
Adequate lighting levels must be maintained at all times, to allow client safety and adequate
supervision. The aquatic professional should be able to see all participants at all times.
1.2.4 Design Standards
The physiotherapist in charge of pool programs shall ensure that the design of the pool and the
equipment being utilised is safe for use by the target population and for the proposed activities to be
undertaken. Equipment should be checked regularly.
Consideration should be given to the following:
 Non-slip surfaces of pool floor surrounds.
 Temperature of pool and surrounds appropriate for population and activity. The temperature
of hydrotherapy pools may vary according to use and funding. Ideal temperatures will vary.
For example, clients with acute pain, arthritic or some neurological conditions will benefit from
a pool at 34-35ºC while clients involved in work-hardening and aerobic programs may prefer a
slightly cooler pool. Physiology literature suggests that a thermo-neutral pool (in which the
body neither gains nor loses temperature) may be the most appropriate for aquatic
physiotherapy techniques. Thermo-neutral is usually recognised as a “window” of temperature
(based on skin temperature) from 33.5-34.5ºC. This temperature range can be recommended
as therapeutically useful for a wide range of conditions treated by physiotherapists in the pool.
 Humidity control.
 Access to pool and environs.
 Change facilities.
 Size and shape of pool.
 Depth.
 Water purification methods.
 In-pool equipment (eg, jets, walking rails, ramps).
 Lighting.
 Flotation and exercise equipment.
 Emergency equipment.
New purpose built hydrotherapy facilities should take into consideration Australian Standard for
Hydrotherapy Pools AS3979-2006 and Australian Standard for Design for Access and Mobility
AS1428.1-2009. Local councils will have their own building requirements and in some places these
standards must be followed.
Documentation of variations from the standards is recommended.
Physiotherapists involved in pool design should ensure these standards are brought to the attention of
appropriate personnel. Individual pool design will depend on a variety of factors including target
population and budget.
1.2.5 Slips and Falls Management in Hydrotherapy Pool Facilities
Pool environments with wet and dry areas can pose an increased falls risk to many clients. Aquatic
physiotherapy services require multiple strategies to reduce the risk of slips and falls. Hydrotherapy
pools have wet areas around the pool deck and in the shower and change room facilities. These
areas may be accessed by people with impaired mobility and balance. Falls minimisation policies
should be venue specific and include risk assessments and management plans, documented records
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of falls and slip/falls audits. Policies and procedures should be updated at accepted defined intervals
and as new procedures are developed.
Each client requires a risk assessment of their level of independence in and around the pool area any
identified risks need to be mitigated through the implementation of appropriate prevention strategies.
Assessment should include
 Weight bearing status
 Gait aids used
 Assistance or supervision required with transfers, including mode of pool entry
 Assistance or supervision required with dressing. Where assistance with dressing is
necessary further consultation with the client/family/carers to define exact needs or an
outward referral for an Occupational Therapy dressing assessment may be warranted.
 Where used, assessment and advice on appropriate footwear
 Falls history in clients with impaired sensation, compromised visual or vestibular function,
balance deficits and limited strength which may impact on transfers or mobility.
All clients should be orientated to the pool areas including:
 Walkways
 Pool access
 Ramps
 Steps
 Hoist
 Change rooms
 Showers
 Handrails
 Pool depth.
No clients should enter the pool area until instructed by staff.
Pool rules should include no running, jumping or diving into the pool.
Flooring should be reviewed for areas that may require anti-slip flooring, non-slip tape or floor mats.
Check mats for trip hazards.
Clients should avoid using talcum powder, shampoo and conditioner in the change rooms as they can
make the floors slippery.
Clients should be advised to take extra care with walking aids on wet surfaces.
Clients should be advised to use handrails when entering or exiting using the steps or ramps.
Clients can be supervised with showering briefly on the pool concourse if possible or showering at
home if the appropriate level of supervision or assistance is not available in the change/ rooms.
1.2.6 Equipment Aids
For clients with impaired balance or a history of falls a shower chair may be used when showering
and dressing.
Rubber stoppers on walking aids should be checked and replaced if required.
For clients that use single point sticks or crutches, it may be useful to have a walking frame available
for them to use in the pool area if required.
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1.2.7 Signage
Signage should be used in change rooms as well as the pool deck. Appropriate signage may include:
 Caution wet floors
 Do not enter the pool area without staff present
Further information and guidance on pool signage can be accessed through the Royal Life Saving
Society or equivalent organisation.
1.2.8 Footwear
Pool hygiene literature and various government codes of practice encourage patrons to wear footwear
at pool facilities. This is as an infection control measure to help prevent tinea and plantar warts.
Clients with some specific conditions are at increased risk of infection and complications from these
infections (refer to Appendix III - Tinea Pedis and Plantar Warts). The literature also suggests that for
older people, barefoot walking has been shown to increase their falls risk.
The use of footwear is a common strategy used in aquatic facilities to minimise the risk of falls events.
When used, footwear should improve gait dynamics and be well managed by the client. The types of
footwear may include plastic shoes or sandals, aqua shoes, grip socks and thongs/flip-flops. When
providing advice on footwear the physiotherapist should consider factors such as:
 Footwear age, cleanliness and fit
 Slips resistance of footwear on the pool concourse and change area floors
 Capability of the client to get their footwear on/off, possibly at the pool edge
 Patient past history eg, bunions, peripheral neuropathy, hemiparesis, etc.
 Subjective comfort and preference
An individual risk assessment and advice on footwear for each client should be completed. If footwear
is worn, they are to be placed tidily away from the entrance to the pool to prevent the possibility of
other clients tripping over them.
Other Footwear
For some high falls risk clients their usual footwear may be the most appropriate option (eg, low
heels, soles with grip). They should be encouraged to use these shoes in the pool facility and only
remove them just prior to entering the pool.
References
Diabetes Australia. National Evidence Based Guidelines for Prevention, Identification and
Management of Foot Complications in Diabetes.
Jessup RL (2007). Foot pathology and inappropriate footwear as risk factors for falls in a sub-acute
aged-care hospital. Journal of the American Podiatric Medical Association. 97(3) 213-217
Menant J, Steele J, Menz H, Munroe B, Lord S (2008) Optimizing footwear for older people at risk of
falls. Journal of Rehabilitation Research and Development. 45(8):1167-1182
Menz H, Hill K (2007) Podiatric involvement in multidisciplinary falls-prevention clinics in Australia.
Journal of American Medical Association. 97(5):377-384
Sherrington C, Menz H (2003) An evaluation of footwear worn at the time of fall-related hip fracture.
Age and Ageing 32(3):310-314
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2: ACCEPTABLE TRAINING LEVELS OF PEOPLE WHO WORK IN
HYDROTHERAPY POOLS
All pool workers shall have adequate education and training to ensure implementation of
high standards and safety of the client at all times.
The following list of pool workers and suggested minimum standards/training is designed to
assist physiotherapists and other professionals who are pool managers to develop
acceptable accreditation and credentialing procedures
2.1 Physiotherapists: Aquatic Physiotherapy/Hydrotherapy
Aquatic physiotherapy is physiotherapy in a specific environment with knowledge of physics,
physiology, assessment or screening and safety, clinical reasoning, evidence based practice and
specific legislative requirements particularly related to water quality and infection control. The key
areas of knowledge relate to managing risks for safe practice and knowledge and skills for effective
practice.
2.1.1 Entry-level education in Universities for Physiotherapists courses at Bachelor,
Honours and Graduate Entry Masters level
The APA Aquatic Physiotherapy group recognises very widely varying entry-level education of direct
teaching in aquatic physiotherapy. Some courses offer up to six hours of theory and some offer up to
14 hours of practical sessions. Some courses offer little or no direct teaching in aquatic
physiotherapy. Graduate physiotherapists are required to work unsupervised in both hospital,
community and private settings in aquatic physiotherapy in Australia. It is, therefore important that
entry-level courses provide the key areas of knowledge and skills for their students.
It is suggested that the following learning outcomes should be included in entry-level physiotherapy
courses to cover safe and effective practice
1. To be able to describe the hydrostatic and hydrodynamic principles related to buoyancy and
drag and give an example of how these influence:
a. weight bearing with standing, closed chain exercise and walking at different depths
b. floating
c. load with open and closed chain exercise in water
2. To outline the major physiological effects of thermo-neutral immersion on the cardio-vascular,
respiratory, thermoregulatory and autonomic nervous systems:
3. To summarise the key principles for reducing risk to the client including
a. screening for co-morbidities
b. infection control
c. falls prevention in the hydrotherapy environment including change rooms and pool
concourse
d. pool rescue and dealing with an emergency
4. Modifying an aquatic physiotherapy session for a person with cardiac and respiratory comorbidities
to reduce the physiological load or stress of the session
5. To outline the evidence for aquatic exercise
6. To design an aquatic physiotherapy treatment plan for a musculoskeletal or neurological case
study
Ideally this training should include both theory and practical sessions.
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2.1.2 Graduate level skills and knowledge
The Australian Standards for Physiotherapy outline safe and effective practice for physiotherapy
interventions. The Hydrotherapy pool is recognised as a high risk environment. There are many
additional considerations related to client or staff safety.
For staff new to working in aquatic physiotherapy, consideration related to their level of skills and
knowledge should be assessed and an appropriate level of support should be provided to ensure they
are able to practice safely, effectively and independently. This can be provided through professional
development courses, mentoring and supervision or in-service training.
All aquatic physiotherapists should be able to identify risks and understand how to manage them.
Risk management considerations relate to the environment or the client and can include:
 Pool water quality and chemical testing, chemical storage and additions
 Infection control and screening of clients
 Orientation of clients
 Monitoring and supervision of clients poolside and in the water
 Intensity of exercise in a heated pool, fatigue and dehydration
 Load with exercise in the pool
 Access to the pool
 Wet environments, showers and changing rooms, slips and falls
 Dealing with a medical emergency
 Equipment
 Skin care
 Security of the pool area
In addition to risk management, key areas of skills and knowledge in aquatic physiotherapy include:
1. Hydrostatics and hydrodynamics relative density
 Buoyancy
 Drag
 Closed chain exercise and weight-bearing load
 Open chain forces on limbs and trunk
 Metacentre
 Rotational movement in water
2. Physiology of immersion
 Cardiovascular, respiratory, thermoregulatory and autonomic implications
 Cardiovascular fitness
3. Handling skills and manual techniques
 Safe support of patient in the water
 Understanding of breathing control
 Effective application of manual techniques in the water
4. Aquatic physiotherapy and exercise
5. Evidence based practice and clinical reasoning
6. Screening, risk management and emergency procedures
 Precautions, contraindications and screening process
 Identification and management of risk in the environment
 Observation and planning
 Pool rescue and emergency situations
7. Pool management
In addition to the previously outlined knowledge and skills, physiotherapists who manage
hydrotherapy pools must also have knowledge of:
 Safety in the pool environment.
 Water balance and sanitisation.
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 Pool cleaning and maintenance.
 Pool plant operations.
 Safe storage and handling of chemicals.
 Occupational health and safety requirements
 Completing and managing risks
 The ability to teach and supervise ancillary staff, volunteers and others
In some workplaces it may be appropriate to identify competencies in aquatic physiotherapy that are
included in a more structured orientation and professional development program including reading,
discussion, in-service training and supervision.
An example of an orientation checklist may include the following:
 Orientation to the area
o Pool alarms, telephones, oxygen and evacuation equipment
o Office, folders, documentation, exercise programs, resources, types of groups and
local pool information
o Staff change room
o Location of equipment room, plant room, MSDS, sick bags, mops, flooring, patient
change rooms, pool chemistry testing kit
 Occupational Health and Safety and Policy and Procedures
o Pool rescue
o Assessment and documentation (forms and recording)
o Screening and Infection control
o Other (including security of the area and key to hydrotherapy area)
 Awareness and understanding of patient orientation to aquatic physiotherapy including:
o Unwell/dizziness, rehydration, skin care, foot care, anxiety / fear of water
 Awareness and understanding of checking (as appropriate) pain, Blood Glucose Levels,
wound dressings, footwear poolside prior to every session
 Awareness and understanding of level of supervision in the pool, staff: patient ratio
 Awareness and understanding of own skin care, rehydration, monitoring fatigue etc.
 Completed pool rescue session
 Completed CPR training in the last 12 months
 Awareness and understanding of pool chemistry
 Awareness and understanding of the manual handling and risks in the Hydrotherapy area
o use of the hoist for transfer of a person in and out of pool
o moving a dependent patient in the pool including higher load treatment techniques
o putting water plinth in and out of pool
 Communication – with other treating staff, progressions, planning discharge, leave cover
An example of a list of competencies may include the following:
 Skills and knowledge
o To be able to list and describe the major physiological principles that influence the
human body on immersion.
o To be able to list and describe the physics related to buoyancy, drag, metacentre,
relative density and hydrostatic pressure.
 Risk management
o To be able to outline procedures relating to screening, precautions, safety of clients
and infection control.
o To be able to demonstrate their understanding of duty of care and be able to list the
safety issues that will directly affect their clinical practice and the safety of their
patient in the aquatic environment.
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o To be able to demonstrate the concepts of varied weight bearing at different depths
and the effect of walking in the pool and closed chain exercises related to restricted
weight bearing
o To be able to describe the importance of breath control and movement control related
to water safety (and when a client is independent in changing position in the water
and with water safety)
 Load and physics
o To be able to demonstrate the concepts of movement facilitation or strengthening
related to the technique or exercise being buoyancy assisted, buoyancy counterbalanced
or buoyancy resisted.
o To be able to demonstrate the concepts of varied weight bearing at different depths
and the effect of walking in the pool and closed chain exercises for strengthening,
endurance or control
o To be able to relate physics/hydrodynamic principles to common stretching
techniques and thus to utilise the properties of water to assist these techniques.
o To be able to practice a number of specific aquatic physiotherapy techniques
including manual strengthening techniques, rotation control and passive joint
mobilisation
 Communication
o Identifying and demonstrating appropriate frequency of communication with treating
land physiotherapist and with leave cover or handovers
 Provision of Care
o To be able to formulate a treatment plan, use appropriate assessment measures and
discharge plan for a variety of patient types.
o To be able to analyse movement and use objective measures in the pool.
o To be able to define movement in the water related to sagittal, transverse,
longitudinal and combined rotations
2.1.4 Continuing Professional Development
All physiotherapists working in any area of hydrotherapy shall take responsibility for their own
postgraduate education and training consistent with the Physiotherapy Board of Australia requirement
on mandatory continuing professional development and be aware of new developments in the area.
2.2 Standards of training for other hydrotherapy pool workers
Accreditation or credentialing process
Physiotherapists (and other professionals) who manage hydrotherapy pools have a responsibility to
ensure that all pool workers have appropriate qualifications and credentials to minimize risks and
legal implications.
Hospitals, institutions and private physiotherapy practices may participate in an accreditation process.
It is recommended that all clinical staff, whether that be aquatic physiotherapists, assistants, carers
and volunteers or exercise physiologists swim teachers and aquatic fitness instructors, become
involved in this process.
Protocols are encouraged that monitor pool workers, ensuring basic training and ongoing professional
development as well as yearly renewable of CPR qualifications, insurance and annual attendance at
appropriate pool rescue in-services.
It is also essential that any person who works in a hydrotherapy pool has adequate insurance cover.
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2.2.1 Hydrotherapy Assistants
Hydrotherapy assistants will often be responsible for supervising clients in a pool during independent
exercise sessions and therefore may be responsible for recognising risk situations and infection
control problems. Knowledge in these areas and in the screening data (refer to Appendix I) is
essential. In some states, training is available for physiotherapy assistants and this training or similar
(eg, AUSTSWIM disabled extension course or equivalent) is recommended if they have no previous
medical or aquatic background. Training in Allied Health Assistant Courses (Certificate 4) may also be
available at some institutions including units on how to deliver and monitor a hydrotherapy program.
In-service training for institution specific needs is recommended (eg, lifting, manual handling, risk
management and screening). The APA has a position statement on working with a physiotherapy
assistant or other support workers. CPR qualification (yearly renewable) and institution specific pool
rescue courses are essential, if working in water. Separate professional indemnity insurance is
usually not necessary if they are employed by the institution.
2.2.2 Individual Carers
It is recommended that when a client requires a carer, each carer should be trained in handling their
own client, have current CPR and be at least a moderate swimmer. It is not adequate for one carer to
teach another carer when they are looking after a totally dependent client. Each new carer should be
taught about their specific client by an appropriately qualified aquatic professional. With many
disabilities, training in client handling and carrying out a prescribed exercise program is ideally
provided by a physiotherapist who can assess the individual, design a program for their therapeutic
and safety needs and teach the program to the carer. The program should be reviewed at intervals
and upgraded appropriately by the physiotherapist. Where inappropriate handling is observed in the
pool environment, it could be recommended that the carer have further training.
Carers or their organisations would need appropriate insurance.
2.2.3 Volunteers
It is recognised that in some states, systems of volunteer leaders for water exercise classes have
been established (particularly in the areas of arthritis, lymphoedema and asthma). The APA does not
recommend this, as most volunteers do not meet the minimal training standards expected of other
pool professionals. It is recommended that volunteer leader training progress towards participants
having a basic (water) exercise qualification. It is advisable that volunteer leaders should also have
CPR qualifications and attend pool rescue training. Parents and others may work as volunteer carers
in special school programs.
Volunteers may also be involved as pool supervisors and external observers. In this situation
institution specific pool rescue training and a current CPR qualification is strongly recommended. As
volunteers are not exempt from litigation, insurance would need to be reviewed (refer to 1.1).
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3: RESPONSIBILITIES OF THE PHYSIOTHERAPIST
Physiotherapists conducting aquatic physiotherapy/water exercise/therapeutic swimming
shall comply with all APA ethical principles, policies and standards, and the relevant
regulations and requirements of statutory authorities.
3.1 Professional Conduct
All physiotherapists shall abide by the Physiotherapy Board of Australia Code of Conduct and be
aware of the legal and ethical responsibilities relating to working in a hydrotherapy pool.
3.2 Clinical Management
3.2.1 Assessment and reassessment for aquatic physiotherapy
In addition to basic screening, all potential clients must have a land based physiotherapy assessment
prior to entering the water. Some referring agencies/persons may not be familiar with the benefits of,
and precautions for, activities in a hydrotherapy pool. It is therefore the physiotherapist’s responsibility
to ascertain client suitability. For some clients, it will be necessary to assess water safety and the
ability to regain a safe breathing position. This can only be carried out in the water (refer to Guideline
1.1.9). It is not sufficient that a client tell the physiotherapist that they are water safe, and practical
observation of this minimises possible risks. Both land and water assessments are necessary to
ensure appropriate decisions are made regarding:
 Diagnosis
 Treatment
 Outcome measures
 Reassessment/program review
 Exercise prescription/swimming
 Suitability for independent water exercise.
Some reassessment will occur every session but the type and frequency of measures will be
dependent on the client’s condition and progress and will include both land and water assessment
techniques. All assessment, reassessment and screening data must be recorded.
3.2.2 Aquatic Physiotherapy records
Documentation should include
 Contact details
 Next of kin
 Source of referral
 Screening data (refer to Appendix I) and initial assessment
 Specific intervention, treatment and outcomes
 Swimmer, non-swimmer, water confidence
 Special precautions (eg, flaccidity, painful joints, weight- bearing status)
 Assistance required on land including transfers, dressing and general mobility
 Selected mode of entry/exit to and from pool.
Client confidentiality is essential, including specifics of medical condition and intervention. Completion
of a client record for pool management contains only information relevant to safety of the client. (refer
to Guidelines 1.1.2 and 1.1.8 and Appendix I).
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
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3.3 Quality Management Activities
Quality management activities should be implemented in accordance with accepted clinical practice.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
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APPENDIX I: SCREENING PRIOR TO ENTERING HYDROTHERAPY
POOL
With the continuing advancement of knowledge in hydrotherapy, infection control and specific benefits
of aquatic physiotherapy and water exercise, some persons previously considered contraindicated to
pool therapy can now be treated safely. The following areas should be reviewed if appropriate to the
client group:
Cardiovascular System
 Cardiac conditions
 Blood pressure
 Peripheral vascular disease.
Respiratory System
 Chronic and acute diseases
 Shortness of breath at rest or on exertion
 Vital capacity
 Tracheostomy
 Respiratory tract infections
 Pseudomonas aeruginosa.
Central Nervous System
 Epilepsy/fitting/history of seizures
 Swallowing defects, abnormal movements
 Fluctuating tone
 High dependency clients.
Gastro-Intestinal Tract
 Faecal incontinence
 Diarrhoea, gastroenteritis
 Cryptosporidium
 Colostomies
 Noroviruses.
Genito-Urinary Tract
 Urinary incontinence
 Infection
 Discharges
 Menstruation
 Pregnancy.
Infectious Conditions
 Airborne infections
 Herpes simplex
 AIDS, Hepatitis
 Methicillin-resistant Staphylococcus aureus
 Vancomycin-resistant Enterococcus
 Hepatitis A
 Blood Borne infections:
o Hepatitis B
o Hepatitis C
o HIV/AIDS/
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
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Skin
 Surgical wounds, open wounds
 Tracking bone sinus
 External fixators
 Altered sensation
 Rashes
 Chemical sensitivity.
Feet
 Tinea
 Plantar warts.
Eyes and Ears
 Visual impairment
 Contact lenses
 Hearing impairment
 Infections
 Tubal implants/Grommets
Other Conditions
 Acute inflammatory conditions
 Heat sensitive conditions (multiple sclerosis, lymphoedema)
 Radiotherapy
 Morbid obesity
 Fear of water
 Clients who are intoxicated
 Clients who have psychiatric problems
 Behavioural/cognitive problems
 Spinal cord injury (especially T6 and above).
Other information not covered elsewhere in assessment
 Swimmer, non-swimmer, water confidence
 Special precautions (eg, painful joints, weight bearing status)
 General mobility on land, assistance required for dressing or transfers
 Mode of entry to pool
 Diabetes
 Lymphoedema.
However, each potential client must be individually assessed. Then, taking the person’s condition and
the physiological effects of immersion into consideration, an informed decision can be made as to
whether hydrotherapy treatment/activity is contraindicated or whether adequate precautions can be
taken to allow the client to be safely and effectively managed in the aquatic environment.
Where a high risk for the client and/or other pool users exists, consultation with other informed
professionals may be required. In particular, regarding infection control, staff and medical
practitioners/specialists may be consulted. Consultation with peers working with similar clients can
also be of value where uncertainty exists. If unsure, never put yourself or the client at risk.
Email info@physiotherapy.asn.au for a copy of the Aquatic Physiotherapy Assessment and Aquatic
Physiotherapy Screen Forms.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 24
APPENDIX II: RISK MANAGEMENT
All aquatic physiotherapists should be able to identify risks and understand how to manage them.
Risk management considerations relate to the environment, staff or the client and can include:
• Pool water quality and chemical testing, chemical storage and additions
• Infection control and screening of clients
• Orientation of clients
• Monitoring and supervision of clients poolside and in the water
• Intensity of exercise in a heated pool, fatigue and dehydration
• Load with exercise in the pool
• Access to the pool
• Wet environments, showers and changing rooms, slips and falls
• Dealing with a medical emergency
• Equipment
• Skin care
• Security of the pool area
Each workplace will require different risk identification and management. The risk management
process starts with a structured format of risk or hazard identification, consideration of how the risk
could be eliminated, managed or controlled implementation of these strategies and then
reassessment to see how successful these strategies have been. Reporting and review of incidents
in the Hydrotherapy environment forms part of managing risk as does the annual review of policy and
procedures.
Useful References
Australian Government, National Health and Medical Research Council. Australian Guidelines for the
Prevention and Control of Infection in the Healthcare Setting (2010). Overview of risk management in
infection prevention and control
The Australian/New Zealand Standard on Risk Management AS/NZS ISO 31000:2009
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 25
APPENDIX III: HYGIENE AND INFECTION CONTROL
All physiotherapists should take stringent precautions against infection, to protect their clients, their
staff and themselves. It is important that physiotherapists keep up to date with national infection
control guidelines and implement them in their practice.
Infection control procedures should be developed using the Australian Guidelines for the Prevention
and Control of Infection in Healthcare (National Health and Medical Research Council, 2010). The
information in this document has been developed based on these guidelines, as well as other relevant
guidelines including the World Health Organisation-Guidelines for Safe Recreational Waters (2006)
and information from the Centres for Disease Control and Prevention (CDC). Australian State
Government pool management codes of practice have also been included. Where possible, literature
that supports the recommendations has been used. Where there is a lack of evidence, peer advice
and consensus by expert aquatic physiotherapists and other health practitioners has been sought.
Appropriate infection control procedures should be implemented for all persons entering the pool
and/or pool environment. Infection control procedures include:
 Standard and transmission-based infection prevention and control strategies as part of dayto-
day practice such as following basic hand hygiene, respiratory hygiene and cough etiquette
 Pre-screening of pool participants and implementation of any precautions or special strategies
relevant to their conditions
 Regular cleaning of pool, pool environs and equipment
 Management of pool chemistry and pool testing
 Microbiological testing
 Adequate water filtration
 Adequate air ventilation
 Policies for faecal accidents and blood or body fluid spills
 Use of appropriate equipment and clothing
 Showering before pool sessions
 Environmental management
 Training of staff and accurate documentation
 Education of people entering the pool and/or pool environment
 Relevant signage
 Risk management protocols.
(also refer to Appendix V)
References
Australian Government, National Health and Medical Research Council. Australian Guidelines for the
Prevention and Control of Infection in the Healthcare Setting
World Health Organisation. Water Sanitation and Health (WSH) - Guidelines for safe recreational
waters. Volume 2 - Swimming pools and other similar recreational water environments (2006)
Centres for Disease Control and Prevention
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 26
Infectious Conditions
Pseudomonas Aeruginosa
Pseudomonas Aeruginosa (PA) is an important opportunistic pathogen. It is found in water, soil and
other places that contain moisture and also in hospital and medical environments (eg in respiratory
devices/equipment, oxygen masks, catheters and dialysis tubing). It can cause a wide variety of
infections. PA tends to accumulate in biofilms which is more difficult for chlorine to act on due to its
protective outer layer. This is often identified as a scum line on the pool sides or slimy feel of
equipment. (refer to Appendix V: Pool equipment used in treatment).
Symptoms
PA can affect any part of the body. Common infections include:
 Folliculitis (Pustular rash), Otitis Externa (Swimmers Ear), urinary and respiratory tract
infections, wound and cornea (eye) infections, burning eyes and fever
 In immunosuppressed patients and Cystic Fibrosis patients it can cause much more
serious illnesses.
Transmission
 Contact or droplet transmission
 Biofilms created by infected persons skin shedding and sweat secretions
 Staff and clients may carry organisms on their hands and feet
 Warm/damp environments i.e. decks, drains, floors, pool walls
 May develop in biofilms in equipment (ie, in filters that are inadequately maintained)
 High bather loads can reduce the level of residual pool disinfectant and increase the risk
of organism infection and growth.
Recommendations
 Shower prior to pool entry
 Maintain appropriate levels of pool disinfection
 Frequently monitor and adjust for varying bather loads
 Ensure regular, thorough cleaning of pool equipment and environment including pool
surfaces, surrounds, railings and drains and pipework (refer to Appendix V: Pool and
Environmental Cleaning and Maintenance and Pool Equipment use in Treatment).
 Dry out pool equipment after use and store in a dry environment.
Discussion
The international literature shows variations in the rates of PA found in different pools. This probably
reflects different standards and practices in relation to pool chemistry, environmental management,
client pre-screening and monitoring and adjustment to bather loads. Well operated pools should
normally not contain Pseudomonas aeruginosa,
References
Barben J, Hafen G, Schmid J; Swiss Paediatric Respiratory Research Group (2005) Pseudomonas
aeruginosa in public swimming pools and bathroom water of patients with cystic fibrosis. Journal of
Cystic Fibrosis. December; 4(4):227-31
Government of Western Australia, Department of Health. Facts about Pseudomonas aeruginosa in
Swimming and Spa Pools (2006)
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 27
Lutz J, Lee J (2011) Prevalence and Antimicrobial-Resistance of Pseudomonas aeruginosa in
Swimming Pools and Hot Tubs. International Journal of Environmental Research and Public Health
v8(2): 554-564
Moore J, Heaney N, Millar B, Crowe M, Elborn J (2002) Incidence of Pseudomonas aeruginosa in
recreational and hydrotherapy pools. Communicable Disease and Public Health. 5(1): 23-6
Tirodimos I, Arvanitidou M, Dardavessis T, Bisiklis A, Alexiou-Daniil (2010) Prevalence and antibiotic
resistance of Pseudomonas aeruginosa isolated from swimming pools in northern Greece. Eastern
Mediterranean Health Journal. 16 (7):783-88
World Health Organisation. Water Sanitation and Health (WSH) - Guidelines for safe recreational
waters. Volume 2 - Swimming pools and other similar recreational water environments (2006).
Chapter 3, Microbial Hazards. 3.4.2 Pseudomonas aeruginosa
Ear Infections
Otitis Externa - Swimmer’s Ear
Otitis Externa (OE) is an infection or inflammation of the canal between the ear drum and the outer
ear. The inflammation can be secondary to eczema with no infection, or can be caused by an active
bacterial or fungal infection. Acute OE is predominantly a microbiological infection that occurs
suddenly, rapidly worsens and becomes very painful. The most common bacterial pathogens that
cause OE are pseudomonas aeruginosa and Staphylococcus Aureus (SA).
Symptoms
 Pain which may be worsened by tugging the ear or turning the head, itchiness of the
external canal, redness and swelling of the ear, discharge from the ear, reduced hearing
or a buzzing or humming sensation.
Potential Complications
 Chronic OE, narrowing of the ear canal, reduced hearing or facial infection
 Malignant Otitis Externa (MOE) – this uncommon condition should be regarded as a
medical emergency. It is most likely to occur in elderly diabetic or immunosuppressed
patients. MOE is the spread of infection to the bones of the ear canal and lower part of
the skull. Without treatment it may reach the brain or the cranial nerves. Patients may
complain of symptoms such as dizziness, muscle facial weakness, hoarseness, swelling
around the ear.
Transmission
 Water can carry bacteria and fungi into the ear canal. Water remaining in the ear can
create an ideal environment for organism growth. Infection can also be introduced by
putting fingers/cotton buds in the ear.
Causes
 Eczema of the ear canal can cause splits or cracks and that may allow organisms to enter
 Mechanical damage can be created by ear cleaning with cotton buds and finger nails,
causing damage to the delicate ear canal tissue
 Chemical irritation of the ear canal can occur with hairsprays, shampoos and hair dyes
 Middle ear infections can trigger inflammation/infection in the ear canal
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
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 Diabetic patients are more prone to OE due to more alkaline conditions in their ear canals
 Those with narrow ear canals are more prone to OE as it is harder for their ears to dry out
 Swimming, hair washing, perspiration and high humidity can lead to excessive moisture
that elevates the pH and removes the cerumen (ear wax). Once the protective cerumen is
removed, keratin debris absorbs the water creating a medium for bacterial or fungal
growth
 Individuals that spend a lot of time in the water (ie, competitive swimmers, regular pool
users, surfers) are prone to OE.
Recommendations
 Dry ears thoroughly after swimming or bathing-small battery ear dryers are available,
alternatively use a hair dryer set on cool/low
 For clients with current or recurrent problems, earplugs, ear bands, swimming caps may
be used if immersing the head eg swimming, although evidence suggests that wearing
head apparel may be no more protective than wearing no apparel. With head out of water
activities simple measures to stop splash, such as a head band, shower cap or scarf may
be appropriate
 Avoid inserting anything in the ear canal
 Ensure pools have adequate disinfectant and PH levels.
Commercial ear drying agents may be useful but advice should be sought from a medical professional
to ensure a solution of the correct PH is used. Some studies suggest drops may make the situation
worse.
 Use appropriately prescribed medications/preparations
 Once over the acute stage hydrotherapy need not be avoided if a client has OE. The
majority of hydrotherapy is head out of water and even in children with disabilities very
effective treatment can be performed without immersion of the ears. Swimming and diving
may be avoided for longer. Documented risks are associated with head under water
swimming and other activities involving water entering the ear (eg, showering and hair
washing). In the majority of cases hydrotherapy is a head out of water activity and as
such appears to pose little or no risk
 Any clients including those with diabetes or immunosuppressed clients who complain of
earache or swelling in the ear canal should immediately seek medical advice.
Serous Otitis Media – Glue Ear
Serous Otitis Media (SOM) usually develops after an infection in the middle ear which leads to a
build-up of fluid and pus in the middle ear. Children are particularly prone to these ear infections due
to recurrent colds and blocked Eustachian tubes.
Recommendations
 Exclude from pool while unwell, febrile or if any discharge.
 There are varying opinions on whether a child with grommets can swim, but there is
evidence to support swimming as an option, if the correct protective apparel is worn (eg,
ear plugs, swimming cap or ear bands) though evidence for the benefit of headwear
varies also. Liaise with the treating doctor for appropriate management.
 Swimming would not usually be recommended until after the first week post operatively.
This should be discussed with the treating doctor. Diving is usually not allowed after the
insertion of grommets.
 For aquatic physiotherapy treatment it is usually unnecessary to immerse the head so
treatment can continue but it may still be prudent to wear protective splash resistant
apparel.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 29
Additional Information
 State Government Victoria. Better Health Channel. Ear Infections.
 State Government Victoria. Better Health Channel. Swimmer’s Ear
 The Children’s Hospital at Westmead. Glue Ear and Grommets
References
Giannoni C (2000) Swimming With Tympanostomy Tubes. Arch Otolaryngol Head Neck
Surg.126(12):1507-1508
Rosenfeld R, Shiffman R, Stinnett S, Witsell D, Brown L, Cannon R (2006) Clinical practice guideline:
acute otitis externa. Otolaryngology–Head and Neck Surgery 134, S4-S23
Wang M, Liu C, Shiao A, Wang T (2005) Ear problems in swimmers. Journal of Chinese Medicine
Association 68(8):347-52
Wang M, Liu C, Shiao A (2009) Water Penetration into Middle Ear Through Ventilation Tubes in
Children While Swimming. Journal of Chinese Medicine Association 72(2):72–75
Centers for Disease Control and Prevention. Swimmer’s Ear (Otitis Externa)
State Government Victoria. Better Health Channel. Ear Infections
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 30
Gastrointestinal Illnesses
Cryptosporidium
Cryptosporidium is a gastrointestinal illness caused by parasites. Unlike bacterial pathogens
cryptosporidium oocysts are resistant to chlorine disinfection and can survive for days in appropriately
maintained swimming pools. In immunosuppressed patients such as HIV/AIDS, cryptosporidium can
lead to prolonged illness and can be life threatening.
Symptoms
 Watery diarrhoea, cramping abdominal pain, bloating, vomiting, fever.
Transmission
 Transmission occurs via faecal-oral route (ie, person-to-person contact or via ingestion of
contaminated foods and water). Oocysts excretion may persist for several weeks after
symptoms have resolved.
Environmental Treatment
 The Environmental Health Department of the Victorian Government has produced a
useful document for the prevention and management of cryptosporidium outbreaks
(2010). It includes definitions, prevention strategies, outbreak measures and managing
pools with non-toilet trained infants
 Cryptosporidium and Cryptosporidiosis-Information for swimming pool managers.
Infants and Toddlers
 Non-toilet trained infants pose an increased risk of pool contamination. There is limited
evidence that shows swimming nappies can prevent faeces from entering the pool. The
Pool Operators Handbook, Health and Hygiene chapter has specific recommendations on
management of non-toilet trained infants and children’s pool design and filtration.
Recommendations
 A multifaceted approach for prevention of Cryptosporidium must include pre-swim
showering for all persons entering the pool, client screening, adequate pool disinfection,
maintenance of pool operations, behavioural factors, faecal accident policies, infants to
wear tight fitting swim nappies, exclusion period of two weeks after diarrhoea ceases and
appropriate signage. If watery diarrhoea lasts for more than a few days advise patients to
contact their doctor.
Additional Information
 Victorian Department of Health. Infectious Diseases Epidemiology and Surveillance. Blue
book – Guidelines for the control of infectious diseases
References
Dale K, Kirk M, Sinclair M, Hall R, Leder K (2010) Reported waterborne outbreaks of gastrointestinal
disease in Australia are predominantly associated with recreational exposure. Australian and New
Zealand Journal of Public Health 34:527-30
Maas R, Patch S, Berkowitz J, Johnson H (2004) Determination of the Solids Retainment
Effectiveness of Disposable Swim Diapers. Journal of Environmental Health 66:(10)16-20
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 31
Puech MC, McAnulty JM, Lesjak M, Shaw N, Heron L, Watson JM (2001) A state-wide outbreak of
cryptosporidiosis in New South Wales associated with swimming at public pools. Epidemiology and
Infection 126: 389–396
Centers for Disease Control and Prevention. Cryptosporidiosis Outbreaks Associated with
Recreational Water Use – Five States (2006). Morbidity and Mortality Weekly Report. July 27,
2007/56(29);729-732
Centers for Disease Control and Prevention. Healthy Swimming/Recreational Water
New South Wales Government, Department of Health. Cryptosporidium Risk Management
New South Wales Government, Department of Health. Cryptospridium Contamination Response Plan
(2007)
Queensland Government, Department of Health. Swimming and Spa Pool Water Quality and
Operational Guidelines (2004) Appendix 14 Control of Cryptosporidium and Giardia in swimming
pools, leisure pools, spas and hydrotherapy pools
Government of South Australia, Department of Health. Minimising the risk of cryptosporidium in
public swimming pools and spa pools – for pool operators (fact sheet)
Department of Health, Victoria. Cryptosporidium and Cryptosporidiosis - Information for swimming
pool managers
Department of Health, Victoria. Pool operators’ handbook
Department of Health, Victoria. Infectious Diseases Epidemiology and Surveillance. Blue book –
Guidelines for the control of infectious diseases (Cryptosporidiosis)
World Health Organisation. Water Sanitation and Health (WSH) - Guidelines for safe recreational
waters. Volume 2 - Swimming pools and other similar recreational water environments (2006).
Chapter 3 Microbial Hazards. 3.3 Faecally-derived protozoa
Noroviruses
Noroviruses are a group of highly contagious viruses that cause gastroenteritis, an inflammation of
the lining of the stomach and intestines. Illness is often characterised by sudden onset of vomiting
and/or diarrhoea and can lead to dehydration. The acute phase usually lasts 1-3 days. Young
children, the elderly and people who have other medical problems are most at risk for more severe
infection. Diarrhoea is more common in children and vomiting is more common in adults. Noroviruses
are more resistant to chlorine than bacteria.
Transmission
 Contaminated food
 Person-to-person contact
 Contaminated environmental surfaces
 Airborne droplets of vomitus
 Contaminated recreational water – bathers may continue to shed infectious pathogens (in
skin, sweat and saliva) for days or weeks after their symptoms have ceased.
Recommendations
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 32
 A person with diarrhoea should be excluded from the pool for at least two weeks after
their symptoms have ceased
 Ensure thorough showering with soap/skin wash prior to entering the pool
 During outbreaks of gastrointestinal illness in the community, extra signage may be
required to offer advice to pool users including exclusion period, pre-swim showering
using soap/skin wash, hand washing after using the toilet and using appropriate nappy
changing facilities. Nappies are not to be changed beside the pool.
 Ensure well maintained and cleaned environment and pool chemistry.
References
Podewils L J, Zanardi Blevins L, Hagenbuch M, Itani D, Burns A, Otto C, Blanton L, Adams S, Monroe
S, Beach M J and Widdowson M (2007) Outbreak of norovirus illness associated with a swimming
pool. Epidemiology and Infection July; 135(5): 827-833
Department of Health, Victoria. Pool operators’ handbook
Centers for Disease Control and Prevention. Norovirus in Healthcare Settings
World Health Organisation. Water Sanitation and Health (WSH) - Guidelines for safe recreational
waters. Volume 2 - Swimming pools and other similar recreational water environments (2006).
Chapter 3 Microbial Hazards (Faecally-derived viruses)
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 33
Blood Borne Infections
Hepatitis B
Hepatitis B is caused by the HBV virus. Severity of symptoms can vary significantly with each
individual. Hepatitis B is a major cause of chronic hepatitis, cirrhosis and hepatocellular cancer.
Transmission
 Hepatitis B can be found in blood and almost all body secretions and fluids. Hepatitis B is
most commonly spread by; sexual contact, sharing needles, needle stick injury, reuse of
unsterilized equipment, sharing personal items such as razors.
 Hepatitis B is NOT spread by contaminated food and water and cannot be spread through
casual or social contact such as sneezing or coughing.
 These patients are infective for the period of the acute infection and during the chronic
carrier state which may persist for life (chronic hepatitis B).
Symptoms
 For some individuals there are very few symptoms and many individuals are unaware that
they have Hepatitis B. For others with Hepatitis B they can become seriously ill. Children
tend to have milder symptoms.
Recommendations
 Monitor and manage any side effects from Hepatitis B treatment.
 Completely cover all wounds with a water proof dressing.
 Encourage staff and others (see additional information below) to be vaccinated against
Hepatitis B
 All females utilising the pool, irrespective of known blood borne virus status, should use
internal protection (ie, tampons) during menstruation.
 Develop and implement blood and body fluid spill policies.
 Maintain appropriate pool chemistry.
References
Centers for Disease Control and Prevention. Hepatitis in Healthcare Settings
Alfred Health. HIV, Hepatitis and STI Education and Resource Centre
Hepatitis Australia. About the Hep B Virus
Department of Health, Victoria. Infectious Diseases Epidemiology and Surveillance. Blue book –
Guidelines for the control of infectious diseases (Hepatitis B)
Department of Health, Victoria. Infectious Diseases Epidemiology and Surveillance. (Hepatitis B – the
facts)
Hepatitis C
Hepatitis C is caused by the HCV virus which causes inflammation of the liver and liver disease. Most
infections of HCV are asymptomatic. If symptoms are present they are usually mild such as dark
urine, jaundice, flu-like illness. After six months if HCV is still present the condition is referred to as
chronic hepatitis C.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
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Transmission
 Hepatitis C is transmitted by blood-to-blood contact (ie, IV drug users, tattooing, ear and
body piercing with non-sterile equipment, needle stick injuries).
Symptoms
 Symptoms of chronic Hepatitis C may include; lethargy, nausea and vomiting, flu-like
symptoms, pain in joints.
Recommendations
 Monitor and manage any side effects from Hepatitis C treatment
 Completely cover all wounds with a water proof dressing (refer to Appendix III: Wounds)
 All females utilizing the pool, irrespective of known blood borne virus status, should use
internal protection (ie, tampons) during menstruation.
 Develop and implement blood and body fluid spill policies.
 Maintain appropriate pool chemistry.
 At present there is no vaccine available for Hepatitis C
Additional Information
 Department of Health, Victoria. Infectious Diseases Epidemiology and Surveillance. Blue
book – Guidelines for the control of infectious diseases (Hepatitis C – the facts).
 Department of Health, Victoria. Infectious Diseases Epidemiology and Surveillance. Blue
book – Guidelines for the control of infectious diseases (Hepatitis C)
References
Centers for Disease Control and Prevention. Hepatitis in Healthcare Settings
Alfred Health. HIV, Hepatitis and STI Education and Resource Centre
Hepatitis Australia. About Hepatitis C
Department of Health, Victoria. Infectious Diseases Epidemiology and Surveillance. Blue book –
Guidelines for the control of infectious diseases (Human immunodeficiency virus or acquired
immunodeficiency syndrome)
HIV/AIDS
Human immunodeficiency virus (HIV) is the chronic virus that can lead to acquired immune deficiency
syndrome (AIDS). HIV destroys the blood cells that help the body fight disease, adversely affecting
the immune system. Persons with HIV/AIDS are therefore at risk from many types of infections and
illnesses. AIDS is a severe life-threatening disorder that represents the late clinical stage of infection
with HIV. Diseases that can occur in the AIDS stage include; cryptosporidiosis, chronic herpes
simplex infection, Kaposi’s sarcoma, pneumocystis jiroveci pneumonia.
Mode of Transmission
Blood-to-blood contact and via infected body fluids such as:
 Sexual exposure via infected body fluids, infected blood products, breastfeeding by HIV
positive mother, sharps injury
 HIV is not transmitted via swimming pools.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
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Symptoms
 Symptoms of HIV are similar to a variety of other illnesses and infections. Individuals that
have been put at risk of getting HIV should consult with their doctor.
Further information: AIDSinfo fact sheets and the Alfred Health, HIV, Hepatitis and STI
Education and Resource Centre.
Recommendations
 In a well maintained pool with usual precautions for wounds and infection control, the
literature indicates that there is no restriction for HIV clients utilizing pools.
 People with HIV/AIDS are highly vulnerable to infection. Consideration should be given to the
most appropriate treatment options for these clients. If aquatic physiotherapy is deemed
suitable, then a number of strategies can be used to maximise the benefits.
 Liaise with the treating specialist to check that the client’s current health status is appropriate
for aquatic therapy treatment.
 Advise patients with severe immunosuppression (CD4 lymphocyte counts less than
100/mm3) of the risk of contracting water-borne parasites in pools.
 Closely monitor and manage health status i.e. condition of skin, episodes of
diarrhoea/nausea. Patients with gastrointestinal symptoms, open wounds or infective skin
conditions are encouraged to obtain a medical clearance on resolution of their symptoms
before re-commencing pool treatment.
 Ensure all wounds are covered with a waterproof dressing (refer to Appendix III: Wounds)
 Ensure pool chemistry is at its optimum level.
 All females utilizing the pool, irrespective of known blood borne virus status, should use
internal protection (ie, tampons) during menstruation.
 Some patients may develop chronic cryptosporidiosis and herpes simplex infection and
exclusion from the pool will be required.
 Develop and implement Blood and Body Fluids Spill policies (There is no evidence found in
the literature of any HIV/AIDS infection occurring in any pool water environment).
Additional Information
 State Government Victoria. Better Health Channel:
o HIV and AIDS
o HIV, hepatitis and sport
 Department of Health, Victoria. Infectious Diseases Epidemiology and Surveillance. Blue
book – Guidelines for the control of infectious diseases (Human immunodeficiency virus or
acquired immunodeficiency syndrome)
References
Australian Society for HIV Medicine. HIV Guidelines, Policy and Strategies
AIDSinfo
Centers for Disease Control and Prevention. (2009) Guidelines for Prevention and Treatment of
Opportunistic Infections in HIV-Infected Adults and Adolescents. 58 (No. RR-4) 14-19, 61
Centers for Disease Control and Prevention (2009) Guidelines for the Prevention and Treatment of
Opportunistic Infections among HIV-Exposed and HIV-Infected Children. 58 (No. RR-11)
Centers for Disease Control and Prevention. Human Immunodeficiency Virus (HIV) in Healthcare
Settings
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 36
Centres for Disease Control and Prevention. Vomit and Blood Contamination of Pool Water. (Blood in
Pool Water)
Alfred Health. HIV, Hepatitis and STI Education and Resource Centre
Hivpolicy.org. Ministerial Advisory Committee on AIDS, Sexual Health and Hepatitis (MACASHH)
South Australian Health Commission Code. Standard for the Operation of Swimming Pools and Spa
Pools in South Australia. Supplement B Hydrotherapy Pools. The Use of Hydrotherapy Pools by
HIV/AIDS Patients
Victorian AIDS Council
Acknowledgement
Amanda Marriot. The Alfred Hospital, Melbourne Australia
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 37
Multi-Resistant Organisms
Methicillin Resistant Staphylococcus Aureus (MRSA)
Staphylococcus Aureus (S.Aureus) is a common bacterium. One in three people in the community will
be colonized with these bacteria. Usually it does not cause significant infections, however
occasionally it can cause serious health problems.
MRSA is a type of S.Aureus that has become resistant to some Antibiotics (AB’S). The symptoms of
MRSA infection will vary depending on where in the body the infection is.
Colonisation refers to a microbe that establishes itself in a particular environment, such as a body
surface, however does not produce disease. Colonisation with MRSA is often found in the nose,
throat, groin and axilla.
Infection refers to a microbe that enters the body and multiplies within the tissues resulting in disease.
Infection with MRSA can occur anywhere in the body. Most commonly it occurs in skin and soft tissue,
wounds, the urinary tract, the respiratory tract or less commonly in the bloodstream.
Transmission
 Contact with colonised or infected patients or residents.
 Contact with colonised body sites of the staff themselves.
 Contact with devices, items or environmental surfaces contaminated with MRSA.
 Airborne transmission of MRSA may occur, but usually only when infected persons are large
disseminators of the organism e.g. pneumonia, large infected burns, infective exfoliative
dermatitis.
Pool Environment
 S. Aureus can occur in pool environments. It is particularly found on the surface of the water
in skin flakes and nasal secretions. These particles can stay on the surface of the water for
extended periods due to the surface tension, preventing oxidizers from immediately acting on
these particles. Surface water removal by skimmers, spill gutters, filtration and chemical
treatment helps remove S.Aureus from the pool environment.
Recommendations
 Contact the infection control officer of your facility and discuss management options for each
client.
 Clients with MRSA colonisation may be permitted to attend the pool using standard and
transmission based precautions providing they comply with cough etiquette and hand hygiene
and do not have wounds that cannot be contained by a waterproof dressing.
 Prior to pool session the patient should wash their hands thoroughly with soap and water or
apply alcohol-based hand rub.
 Patients should not share towels.
 All equipment used by the patient (including the hoist) should be cleaned immediately post
treatment by 10% bleach solution or facility specific cleaning product. Some facilities may
prefer to isolate equipment used by individuals with MRSA and apply terminal cleaning to the
equipment after discharge of the patient (refer to Appendix V: Pool equipment used in
treatment).
 Personal protective equipment (PPE) (ie, gloves, gown) should be used by staff performing
the cleaning. Cleaning must be thorough. Saturate cleaning cloths with solution and ensure all
surfaces are wiped thoroughly.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 38
 Patients with MRSA are often treated in the last pool session of the day to allow for the extra
time required for additional cleaning.
 For pools without a wet deck ensure regular scrubbing of pool walls at and above surface
water level.
 Staff with active exfoliative skin conditions such as eczema, dermatitis and psoriasis should
not be allocated to care for MRSA patients.
Additional Information
 Department of Health, Victoria. Infectious Diseases Epidemiology and Surveillance. Blue
book – Guidelines for the control of infectious diseases (Staphylococcal infections)
 Centers for Disease Control and Prevention. Prevention of MRSA Infections in Athletic
Facilities
 Centers for Disease Control and Prevention. FAQ’s about MRSA
 Australian Government, National Health and Medical Research Council. Methicillin Resistant
Staphylococcus aureus (MRSA) Consumer factsheet (2010)
 Department of Health, Victoria. Pool operators’ handbook
References
Centers for Disease Control and Prevention. Management of Multidrug-Resistant Organisms in Non-
Hospital Healthcare Settings (2010)
Centers for Disease Control and Prevention. Guidelines for Environmental Infection Control in
Healthcare Facilities
Gregg M, Lacroix RL (2010) Survival of community-associated methicillin-resistant Staphylococcus
aureus in 3 different swimming pool environments (chlorinated, saltwater, and biguanide
nonchlorinated). Clinical Pediatrics Vol. 49 (7), pp.635-7
Meldrum R (2001) Survey of Staphylococcus aureus contamination in a hospital’s spa and
hydrotherapy pools. Communicable Disease in Public Health 4(3): 205-208
Australian Government, National Health and Medical Research Council. Australian Guidelines for the
Prevention and Control of Infection in the Healthcare Setting (2010). Management of Multi-Resistant
organisms and Outbreak Situations
Tolba O, Loughrey A, Goldsmith CE, Millar BC, Rooney PJ, Moore JE (2008) Survival of epidemic
strains of healthcare (HA-MRSA) and community-associated (CA-MRSA) methicillin-resistant
Staphylococcus aureus (MRSA) in river, sea and swimming pool water. International Journal of
Hygiene and Environmental Health 211(3-4):398-402
Tasmanian Government, Department of Health and Human Services (2010) Methicillin Resistant
Staphylococcus aureus (MRSA) in Tasmanian Rural hospitals and non-acute health settings.
Guidance for the management of patients with MRSA in Tasmanian rural hospitals and non-acute
settings V1.1
Victorian Rural Infection Control Practice Group (RICPRAC.) Infection Prevention and Control Manual
(2008). 4.1 Methicillin Resistant Staphylococcus aureus (MRSA)
World Health Organisation. Water Sanitation and Health (WSH) - Guidelines for safe recreational
waters. Volume 2 - Swimming pools and other similar recreational water environments (2006).
Chapter 3 Microbial Hazards 3.4.4 Staphylococcus aureus
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 39
Vancomycin Resistant Enterococci (VRE)
VRE are specific types of antimicrobial resistant bacteria that are resistant to the antibiotic (AB)
Vancomycin, the drug often used to treat infections caused by enterococci. Enterococci are bacteria
that are normally present in the human intestine and female genital tract. Enterococci can sometimes
invade other parts of the body and cause infection.
Most people with VRE in Australia are colonized not infected. Once colonized or infected, the person
may harbour VRE for years.
Colonisation refers to a microbe that establishes itself in a particular environment, such as a body
surface, however does not produce disease.
Infection refers to a microbe that enters the body and multiplies within the tissues resulting in disease.
Transmission
 Direct contact – contaminated hands of healthcare workers, colonised clients (via faeces,
urine or blood).
 Indirect contact – by contact with contaminated medical and patient care equipment or
environmental surfaces.
 VRE does not usually have airborne transmission.
Pool Environment
 There was no current research found on VRE patients and the pool environment.
Recommendations
 Contact the infection control officer of your facility and discuss management options for each
client.
 Clients with VRE colonisation may be permitted to attend the pool using standard and
transmission based precautions providing they have no diarrhoea, uncontrolled faecal
incontinence, or wounds that cannot be contained by a waterproof dressing.
 Prior to pool session the client should wash their hands thoroughly with soap and water (if
visibly soiled) or apply alcohol-based hand rub.
 All equipment used by the client (including the hoist) should be cleaned immediately post
treatment by 10% bleach solution or facility specific cleaning product. Some facilities may
prefer to isolate equipment used by individuals with VRE and apply terminal cleaning to the
equipment after discharge of the patient (refer to Appendix V: Pool Equipment used in
treatment).
 Personal protective equipment (PPE) (ie, gloves, gown) should be used by staff performing
the cleaning. Cleaning must be thorough. Saturate cleaning cloths with solution and ensure all
surfaces are wiped thoroughly.
 Clients with VRE are often treated in the last pool session of the day to allow for the extra
time required for additional cleaning.
 Clients should inform the facility if they have had loose bowel motions or been unwell. A
period of exclusion may be required.
 Staff with active exfoliative skin conditions such as eczema, dermatitis and psoriasis should
not be allocated to care for VRE clients.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 40
Additional Information
 Australian Government, National Health and Medical Research Council. Vancomycin
Resistant Enterococci (VRE) Consumer factsheet (2010)
References
Centers for Disease Control and Prevention. Multidrug-Resistant Organisms in Non-Hospital
Healthcare Settings (2010)
Eckstein B, Adams D, Eckstein E, Rao A, Sethi A, Yadavalli G, Donskey C (2007) Reduction of
Clostridium Difficile and vancomycin-resistant Enterococcus contamination of environmental surfaces
after an intervention to improve cleaning methods. BMC Infectious Diseases 7:61 PMCID: PMC
1906786
Australian Government, National Health and Medical Research Council. Australian Guidelines for the
Prevention and Control of Infection in the Healthcare Setting (2010). Management of Multi-Resistant
organisms and Outbreak Situations
Queensland Government, Department of Health. Protocol for the Management of Patients with
Vancomycin Resistant Enterococcus (VRE) 2011
Government of South Australia, Health Department. Management of Multi-Resistant Organisms.
Guidelines for the Management of Patients with Vancomycin –resistant Enterococcus (VRE)
Colonisation/Infection (2011)
Tasmania Government, Department of Health and Human Services. Vancomycin- resistant
Enterococci (VRE) in Tasmanian rural hospitals and non-acute settings (2010). Guidance for the
management of patients with VRE in Tasmanian rural hospitals and non-acute settings V1.0
Victorian Rural Infection Control Practice Group (RICPRAC.) Infection Prevention and Control Manual
(2008). 4.2 Vancomycin-resistant Enterococci (VRE)
Government of Western Australia, Department of Health. Guidelines for the Management of
Residents with Vancomycin-resistant Enterococci (VRE) in Residential Care Facilities (2004)
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 41
Infectious Skin Conditions
Tinea Pedis
Tinea is a highly contagious fungal infection of the skin. It can be spread by skin-to-skin contact,
shared towels and wet floors. Tinea pedis is the condition which specifically affects the foot. Tinea can
be found throughout the general population.
Population studies show tinea pedis prevalence in general populations varies, with some studies
showing rates as high as 20% and 37%. Studies have reported increased prevalence of tinea pedis in
athletes compared with the general population. It is also more common in males than females. It is
estimated that 70% of the population will be affected by tinea pedis at some stage.
Symptoms
 Can include itching, blisters, cracking, splitting and peeling in the toe web spaces and under
the foot.
 There can also be yellow or white discolouration of the nails.
Treatment
 Anti-fungal preparations.
 It is recommended that patients seek advice from a doctor or pharmacist as to the most
appropriate treatment for their condition. Prompt diagnosis, education and treatment helps to
minimise the spread of infection.
 Patients should immediately commence treatment once tinea pedis is detected.
 They should continue treatment until all symptoms have resolved to prevent recurrence of the
condition.
 Studies in athletes have shown that the recurrence rate is high (59% in swimmers, 61% in
soccer players, 60.7% in runners) when treatment is ceased prematurely. Some infections
can prove difficult to treat.
 Encourage clients to seek further advice if required.
Precautions
 Clients should seek advice from a doctor or pharmacist if they are taking any other
medications as some anti-fungal preparations may affect the way these medicines work.
Risk Factors
 Patients with some specific conditions are at increased risk of infection and complications
from these infections. They include; diabetes, lymphoedema, recurrent cellulitis,
immunosuppression, obesity, eczema, dermatitis, dermatitis, the elderly.
Recommendations
 Wearing appropriate footwear in the pool area, change rooms and showers may reduce
transmission, particularly for those with tinea and those at risk.
 Athletes may be encouraged to wear footwear such as thongs due to the higher incidence of
tinea pedis in this population.
 Those patients with tinea pedis should be advised to wear some form of foot covering
(thongs, slip on shoes, overshoes).
 For those clients with increased risk of tinea pedis and complications, advice should be
provided as to the most appropriate form of footwear and management for each client.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 42
 The wearing of thongs, slip-on shoes and overshoes may increase the falls risk in some
individuals, particularly the frail aged, orthopaedic and disabled population. These risks must
be considered when deciding on appropriate footwear (refer to Guideline 1.2.5 Slips and Falls
Management in Hydrotherapy Pool Facilities).
 Dry skin thoroughly, particularly between the toes.
 Ensure hand washing after touching the affected area.
 Do not share towels. Encourage clients to bring a bathmat to use in the change rooms.
 Expose the skin to air.
 When wearing socks change them frequently (new brands of synthetic socks are made of
hydrophilic fibres which wick moisture away from the feet).
 Ensure regular cleaning of floors on the pool deck, change rooms and showers.
 At home clean the shower or bath after use to avoid re-infection or infecting family members.
Exclusion Period
 Unless an open wound is present, exclusion from the pool is not required, but active
management strategies should be implemented (see above)
Additional Information
 State Government Victoria. Better Health Channel. Tinea
References
Al Hasan M, Fitzgerald S, Saoudian M, Krishnaswamy G (2004) Dermatology for the practicing
allergist: Tinea Pedis and its complications. Clinical and Molecular Allergy 2: 5
Centers for Disease Control and Prevention. Hygiene-related Diseases. Athletes Foot (tinea pedis).
Field LA, Adams BB (2008) Tinea pedis in athletes. International Journal of Dermatology 47(5):485-
92
Mayo Clinic. Athletes Foot
Noble L, Pharm D, Forbes R (1998). Diagnosis and Management of Common Tinea Infections.
American Family Physician, July 1; 58(1): 163-174.
New South Wales Government, Department of Health. Public Swimming Pool and Spa Code of
Practice (May 2010). 2.2.4 Fungal Pathogens
Tiffany L MD, MA; Adams, Brian B MD, MPH (2007) Prevalence of Tinea Pedis in Professional and
College Soccer Players versus Non-Athletes. Clinical Journal of Sport Medicine; January 17(1), pp
52-54
World Health Organisation. Water Sanitation and Health (WSH) - Guidelines for safe recreational
waters. Volume 2 - Swimming pools and other similar recreational water environments (2006).
Chapter 3 Microbial Hazards 3.7.1. Trichophyton spp. and Epidermophyton floccosum (Tinea)
Plantar Warts
A plantar wart, also known as a verruca plantaris, occurs on the sole or toes of the foot. It is a wart
caused by the human papillomavirus. They are usually self-limiting, but treatment is generally
recommended to lessen symptoms and reduce transmission.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 43
Transmission
 Transmission is usually via moist floor surfaces such as showers, change rooms or swimming
pool decks.
 Warts may not become visible for weeks or months and are highly contagious.
Prevention
 Ensure regular cleaning of the floors on the pool deck, change rooms and showers.
 Wearing appropriate foot covering in showers and change rooms can prevent infection. For
those clients with plantar warts, appropriate foot covering should be worn while warts are
present.
 Cover plantar warts with occlusive dressing.
Additional Information
 US National Library of Medicine. National Institutes of Health. MedlinePlus. Warts and
Verrucas
References
Bacelieri R, Johnson SM (2005). Cutaneous warts: an evidence-based approach to therapy.
American Family Physician 72 (4): 647-52.
World Health Organisation. Water Sanitation and Health (WSH) - Guidelines for safe recreational
waters. Volume 2 - Swimming pools and other similar recreational water environments (2006).
Chapter 3 Microbial Hazards 3.5.2. Papillomavirus
Herpes Simplex
Cold sores are the most common type of herpetic infection. They are characterised by a localised
primary lesion which can often weep and can become a recurring condition. In some instances
children with atopic dermatitis and immunosuppressed patients may require hospitalization for
treatment. It may become a chronic condition in patients with HIV infection.
Transmission
 The saliva of carriers is the most significant mode of transmission. The secretion of the virus
in the saliva may occur up to seven weeks after the lesion has healed. Those with recurrent
disease are infectious for 4-7 days with each episode.
Prevention
 Exclude from the pool while lesion present.
 Encourage good personal hygiene.
 Encourage hand washing.
Additional Information
Department of Health, Victoria. Infectious Diseases Epidemiology and Surveillance. Blue book –
Guidelines for the control of infectious diseases (Herpes Simplex Infections)
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 44
Other Infections
Hepatitis A
Hepatitis A is a viral infection of the liver.
Transmission
 Transmission is via the faecal-oral route i.e. ingestion via contaminated food or water.
 After contracting the virus it takes approximately 28 days (range 15-50 days) to become ill.
 People with Hepatitis A are infectious to others from two weeks before they show symptoms
to one week after they become jaundiced.
Symptoms
 Acute fever, nausea, abdominal pain, lethargy, weight loss.
 Infants and young children infected with Hepatitis A will rarely show symptoms of infection.
Recommendations
 Exclude patients from pool until they are recovered. A medical certificate of recovery should
be obtained before recommencing pool activities.
 Encourage good hand hygiene practices.
 A Hepatitis A vaccination is available.
Additional Information
 Department of Health, Victoria. Infectious Diseases Epidemiology and Surveillance. Blue
book – Guidelines for the control of infectious diseases (Hepatitis A)
References
Centers for Disease Control and Prevention. Hepatitis in Healthcare Settings
Hepatitis Australia. Hepatitis A
Urinary Tract Infections
Urinary tract infections (UTI’s) include infections of the urethra (urethritis), bladder (cystitis), or kidneys
(pyelonephritis). UTI’s are most common in women, babies and the elderly. People with diabetes,
prostate conditions and urinary catheters are also at increased risk of developing a UTI.
Recurrent UTI’s (RUTI) in healthy non-pregnant women is defined as three or more episodes of UTI
during a twelve month period. Long term antibiotics (6-12 months) are sometimes prescribed as a
prevention strategy for non-pregnant healthy women with RUTI’s.
Symptoms
 Symptoms include; vomiting, fever and tiredness, urgency, burning pain when urinating, blood
in the urine, the sensation that the bladder is still full after urinating.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 45
Transmission
 Usually E. coli that is spread to the urethra from the anus.
 Sexually transmitted micro-organisms.
Recommendations
 Exclude from pool until symptoms have resolved.
 Empty bladder before entering pool.
 For women on long term prophylactic antibiotics for RUTI’s, side effects can include skin
rashes and gastrointestinal symptoms which will require management.
 Women on long term prophylactic antibiotics, whose side effects are managed and are
otherwise well, can attend the pool.
Additional Information
 Kidney Health Australia
 State Government Victoria. Better Health Channel. Urinary Tract Infections
References
Albert X, Huertas I, Pereiro II, Sanfelix J, Gosalbes V, Perrota C (2004). Antibiotics for preventing
recurring urinary tract infection in non-pregnant women. Cochrane Database of Systemic Reviews
(3):CD001209. DOI:10:1002/14651858.CD001209.pub2
World Health Organisation. Water Sanitation and Health (WSH) - Guidelines for safe recreational
waters. Volume 2 - Swimming pools and other similar recreational water environments (2006).
Chapter 3 Microbial Hazards 3.4.4. Page 47
Respiratory Infections
Respiratory infections involve the respiratory tract including lungs, throat and sinuses. There can be
production of mucus and inflammation of the airways and sinuses.
Transmission
 Airborne spread in aerosols.
 Droplet contact.
 Direct contact (hand-to-hand, hand-to-nose).
Recommendations
 Exclusion from pool environment until well.
 Encourage flu vaccinations, particularly in at risk individuals (young children, the elderly,
individuals with medical problems and smokers).
 Encourage hand washing.
References
The Australian Lung Foundation
Department of Health, Victoria. Infectious Diseases Epidemiology and Surveillance. Blue book –
Guidelines for the control of infectious diseases (Influenza)
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 46
Wounds
All wounds including surgical, open and infected wounds and tracking bone sinus should have an
occlusive dressing which can keep the area totally waterproof. Watertight sleeves can also be used
over a dressing. Some dressings require time for maximum effectiveness of the adhesive, so should
be applied well before immersion. Skin should be dry before applying dressing which may be difficult
in a warm humid climate or in a humid pool environment. Skin can be dried with a cool setting hair
dryer/fan.
Skin Grafts/Donor Sites
Check graft and donor sites for healing. If healing is incomplete or skin remains fragile a waterproof
sleeve can be used. Ensure application and use of equipment does not cause friction or trauma to the
site. Use protective clothing (eg, non-slip socks, leggings) to protect grafts from abrasive contact with
the pool surfaces.
Stomas
A stoma is a surgically created opening of the bowel or urinary tract to a body surface. They include
colostomies, gastrostomies (PEG feeding tubes) and supra pubic catheters. After the stoma wound
has healed (usually around six weeks) they are regarded as closed circuits when the bag is attached.
Recommendations
 Liaise with the client’s stoma therapist if required.
 Empty bags prior to entry to the pool.
 Ensure circuit is intact and closed.
 Secure the bag to the client body using tubigrip or strapping.
External Fixators/Leg Lengthening Devices
External fixation allows for alignment and fixed positioning of bones with minimal internal fixation, to
obtain bony union including after traumatic fracture, leg lengthening and after corrective surgery.
Recommendations
 Liaise with the surgeon as required.
 Ensure correct pool chemistry and infection control protocols are adhered to.
 Continually monitor pin sites. Refer to medical staff if there is any sign of redness, swelling or
pain.
 Patients and carers should follow the pin care protocols to ensure optimal pin site
management.
 Patients can enter the pool with or without protective dressings unless there is an area of
compromised skin which will require occlusive covering.
Additional Information
 Australian Council of Stoma Associations Inc
 Bladder and Bowel Foundation. Bladder Treatments – Suprapubic Catheter
 Queensland Government, Department of Health. Queensland Spinal Cord Injuries Service.
Queensland Health. Caring and Changing your Supra-Pubic Catheter (SPC) Fact sheet
 Scope. Gastrostomy Information and Support Service (GISS)
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 47
References
KL Barker, M Burns, S Littler (1999) Physiotherapy for Patients with an Ilizarov External Fixator: A
Survey of current practice. Physiotherapy, 85:8, 426-432.
Liotard JP, Edwards TB, Padey A, Walch G, Boulahia A (2003) Hydrotherapy Rehabilitation after
Shoulder Surgery. Techniques in Shoulder and Elbow Surgery 4(2):44-49
Nazzar T, Fragomen A, Illizarov S, Rozbruch R (2008) Limb Salvage Reconstruction of the Ankle with
Fusion and Simultaneous Tibial Lengthening Using the Illizarov/Taylor Spatial Frame. Hospital for
Special Surgery Journal. February; 4(1): 32-42 PMCID: PMC2504274
Parameswaran AD, Roberts CS, Seligson D, Voor M (2003) Pin tract infection with contemporary
external fixation: how much of a problem? Journal of Orthopedic Trauma 17(7): 503-507
Rahmann A, Brauer S and Nitz J (2009) A Specific Inpatient Aquatic Physiotherapy Program
Improves Strength after Total Hip or Knee Replacement Surgery: A Randomized Controlled Trial.
Archives of Physical Medicine and Rehabilitation 90:745-55
Villalta EM, Peiris CL (2012) Early aquatic physical therapy improves function and does not increase
risk of wound-related adverse events for adults after orthopedic surgery: a systematic review and
meta-analysis. Archives of Physical Medicine and Rehabilitation. 94(1):138-48
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 48
Infants
In Australia there is a comprehensive immunization program offered from birth. There are currently no
recommendations as to what age infants are advised to commence pool activities. However children
who have had health complications such as premature birth, low birth weight, or have had medical or
surgical problems are sometimes advised to delay any pool activities until their naïve immune
systems have matured.
Many physiotherapists do however see infants and toddlers in the hydrotherapy pool for global
developmental delay issues and functional training in early intervention. Neonatal units will often
include hydrotherapy as part of the physiotherapy intervention. It should be noted that these
treatments would generally be head out of water immersion therapy (refer to Appendix IV: Asthma)
Recommendations
 When required liaise with the relevant medical practitioner in regards to management.
 Document and implement any special precautions.
 Encourage parents to keep children’s immunizations up to date.
References
Australian Government, Department of Health. Immunise Australia Program
National Centre for Immunisation Research and Surveillance (NCIRS)
Schoefer Y, Zutavern, Brockow I, Schafer T, Kramer U, Scaaf B, Herbath O, von Berg A, Wichmann
HE, Heinrich J (2008) LISA study group. Health risks of early swimming pool attendance. International
Journal of Hygiene and Environmental Health. Jul; 211(3-4):367-73
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
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Staff Hygiene and Infection Control
Strategies for staff infection prevention and control should include:
 A health screening policy
 Re-assessment on a regular basis
 Vaccination programs
 Risk management
 Documentation of staff health and safety procedures
 Appropriate exclusion periods for illness.
Health Screening
Prior to working in the pool environment all workers should be informed of the requirement for health
screening. This includes students, volunteers and carers. Depending on the results appropriate
advice and counselling should be offered. Specific strategies or precautions will need to be taken if
required. The same screening tool used for clients can be used for staff.
Re-assessment
 Re-assessment should occur on a regular basis (ie, yearly and/or if a staff members health
status changes). Staff members are responsible for informing the appropriate supervisor of a
change in health status.
Skin Conditions
Often pool-staff spend much longer periods of time in the pool compared with clients therefore the risk
of skin problems may be increased. For those staff with pre-existing skin conditions careful
management is required. Skin irritations are often related to pool chemistry and/or length of time
spent in the pool. Many variables including sanitiser levels, pH, and total dissolved solids can affect
the pool chemistry and therefore skin. Staff should have access to pool chemistry readings, be made
aware of the role of pool chemistry in skin management and implement pre and post immersion
management if required.
Recommendations
 For staff with persistent skin conditions a specific management plan should be implemented
and include risk management activities such as increased moisturising and possibly limiting
pool time. Any increase in symptoms should be immediately addressed. Well managed pool
chemistry and appropriate environmental cleaning will minimise problems.
 Staff with active exfoliative skin conditions such as eczema, dermatitis and psoriasis should
not be allocated to care for VRE or MRSA patients.
Effects of Chloramines and Other Disinfectant By-products
Chlorine-based disinfectants react with nitrogenous compounds originating from sweat, saliva, urine
and other waste from swimmers. These may cause combined chlorine by-products including
chloramines in the water and air. The irritants may cause stinging eyes, nasal irritation or respiratory
symptoms. These may be an indication of poor water quality or inadequate ventilation. Regular
exposure to these irritants may cause sensitivity to fungi and bacteria and aggravate asthmatic
symptoms.
Recommendations
 Ensure adequate disinfectant levels and constantly monitor water quality especially during
periods of high use.
 Perform regular super chlorination.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
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 Encourage good swimmer hygiene-toileting and showering before swimming.
 Ensure adequate ventilation, particularly during periods of high use.
 Ensure fresh water is regularly added to the pool.
Risk Management
 If any adverse effects occur to staff they should be assessed, documented and strategies
implemented to prevent a recurrence.
Documentation
 Records of screening, vaccinations, and any adverse effects of immersion need to be
documented. Privacy and security of these documents must be ensured.
Exclusion Periods
 The Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010)
has a helpful table outlining exclusion periods for different conditions. (p 209 Table C.2.3
Staff Exclusion Periods)
Discussion
 Angenent et al
The reference by Angenent et al is cited in the NHMRC Australian Guidelines for the
Prevention and Control of Infection in Healthcare (2010). The article demonstrates the
significant differences between Australian Standards for Hydrotherapy Pools (ASHP) and
standards found overseas, in this instance the USA .
In this article a pool was temporarily closed after members of staff were diagnosed with nontuberculosis
pulmonary hypersensitive pneumonitis and mycobacterium avium infections. On
investigation these organisms were found on the pool walls, water surface (biofilm) and in the
pool air. The results suggested aerosol partitioning (bioaerosols) as a mechanism for disease
transfer in this environment.
There are a number of issues in the way this pool was managed that would not meet the
current Australian Standards for Hydrotherapy Pools.
Ventilation
The air circulation was inadequate as stated in the articles discussion: “The specific
enrichment of the mycobacteria in the pool air suggested that increased air circulation could
reduce the risk of exposure due to inhalation, and since this investigation, the rate of air
exchange has been increased”.
Many cold climate countries use air recycling devices to control heating costs. This can also
lead to poor air turnover as they take in a limited amount of fresh air. Chlorination by-products
in the air can accumulate and reach high levels. It was not stated in the article if these devices
were used at this facility.
Turnover rate
In this study the pool water was cycled only four times daily (six hourly) through the filtration
system. Under the Australian Standards AS 3979-2006 3.1.3 Turnover Rate a turnover rate of
more than two hours would be regarded as inadequate water filtration.
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
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Water Sanitizers
The treatment system used in this particular pool was a UV-peroxide disinfection system. In
the discussion the article states: “the pool samples show inadequacies in the disinfection
system”. This is not the recommended system for UV management systems in Australia (AS
3979-2006 3.2.2 Supplementary Treatments).
Screening and Infection Control
There is no information provided in this article about any patient/staff screening or infection
control guidelines that were in place at this facility.
 Fantuzzi et al
The article by Fantuzzi et al reports pool free chlorine levels between 0.7 to 2.0 mg/L. This is
below the recommended levels under the Australian Standards. There was no description of
the ventilation system used.
Summary
These articles provide a good example of the problems that can arise if a pool is inadequately
maintained and managed. In Australia hydrotherapy management practices include client
screening and infection control strategies and pool and water management based on the
Australian Standards Hydrotherapy Pools (AS 3979-2006). These management practices are
often at a higher standard than those described in overseas articles.
References
Angenent L.T, Kelley S, St. Amand A, Pace N and Hernandez MT (2005) Molecular identification of
potential pathogens in water and air of a hospital therapy pool. Proceedings of the National Academy
of Sciences of the United States of America 102, 13, 4860-4865
Australian Standards - Hydrotherapy Pools AS 3979-2006
Centers for Disease Control and Prevention. Chemical Irritants (Chloramines) and Indoor Pool Quality
Fantuzzi G, Righi E, Predieri G, Giacobazzi P, Mastroianni K, Aggazzotti G (2010) Prevalence of
ocular, respiratory and cutaneous symptoms in indoor swimming pool workers and exposure to
disinfection by-products. International Journal of Environmental Research and Public Health 7, 1379-
1391.
Lazarov A, Nevo K, Pardo A, Froom P (2005) Self-reported skin disease in hydrotherapists working in
swimming pools. Contact Dermatitis 53: 327-331
Australian Government, National Health and Medical Research Council. Australian Guidelines for the
Prevention and Control of Infection in the Healthcare Setting (2010). C2 Staff Health and Safety
Pardo A, Nevo K, Vigiser D, Lazarov (2007) The effect of physical and chemical properties of
swimming pool water and its close environment on the development of contact dermatitis in
hydrotherapists. American Journal of Industrial Medicine 50:122-126
World Health Organisation. Water Sanitation and Health (WSH) - Guidelines for safe recreational
waters. Volume 2 - Swimming pools and other similar recreational water environments (2006).
Chapter 4 Chemical Hazards. 4.5 Dis-infection by-products
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 52
APPENDIX IV: MANAGEMENT OF SPECIFIC CONDITIONS
With the continuing advancement of knowledge in hydrotherapy, infection control and specific benefits
of aquatic physiotherapy and water exercise, some persons previously considered contraindicated to
pool therapy can now be treated safely. The following areas should be reviewed if appropriate to the
client group.
Cardiac Conditions
Cardiac Physiology of Immersion for Healthy Subjects
During head out of water (HOW) immersion, hydrostatic pressure compresses the superficial veins of
the lower extremities, pelvis and abdomen, resulting in a shift of blood volume to the thorax and heart.
On immersion up to the neck the central blood volume increases by approximately 700mls. On
average, heart size increases to 30% and stroke volume increases 35-45%.
HOW immersion in thermo-neutral water (34-35 degrees) has also been shown to be accompanied by
stimulation of the cardiopulmonary arterial baroreceptors. Sympathetic nervous system activation,
systemic vascular resistance and pulmonary vascular resistance are all decreased.
As the depth of the water decreases, these effects decrease. When water depth is below the iliac
crests the blood volume shift is minimal.
During swimming, the horizontal body position, hydrostatic pressure and muscular activity, can
produce a higher cardiovascular load than that experienced when exercising in an upright vertical
position.
Historically, aquatic exercise has been recommended with caution for clients with cardiac disease.
Whilst these physiological changes are well tolerated by healthy individuals, early investigators
hypothesised that increasing cardiac preload would significantly compromise cardiac function in those
with pre-existing disease. This was particularly of concern for those with chronic heart failure, with the
assumption that the haemodynamic changes would worsen symptoms and progress the disease.
More recently however, studies have demonstrated aquatic exercise to be well tolerated in
appropriately selected patients. Current theories hypothesise that the reduction in afterload that
occurs with peripheral vasodilation, likely offsets the potentially detrimental effects of increased
preload.
Physiological changes observed in cardiac patients vary depending upon depth of immersion and the
temperature of the water. Responses that occur in thermo-neutral water when immersed to the level
of the xiphisternum are depicted in the table below.
Physiological parameter Physiological Response
HR Decreases
Diastolic BP Decreases
Stroke volume Increases
Cardiac output Increases
Ejection Fraction Increases
Peripheral vascular resistance Decreases
SpO2 Unchanged
ECG changes Unchanged
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 53
When cardiac patients are immersed in cold water, peripheral vascular resistance does not decrease
as occurs with warm water immersion, and the potential for cardiac compromise is increased.
Increased ventricular ectopic beats are also observed on ECG in these patients.
Despite the recent evidence, literature in this field remains sparse and the sample sizes studied have
been small. Of the studies that have been conducted, patients have predominantly been middle aged
men with very stable disease. The frail elderly and in particularly women, who represent a more
realistic heart failure population, have been under-represented.
Assessment
Assessment of cardiac clients should include:
 Cardiac diagnosis
 Relevant investigations (eg, cardiac echo, angiogram, ECG)
 Current symptoms and recent change of symptoms
 Chest pain, SOB, dizziness, peripheral oedema, weight gain (fluid retention)
 Recent changes in medication (eg, increased beta blocker medication may lead to
symptomatic dizziness)
 History of hypertension/hypotension
 History of dizziness/fainting/falls
 Clinical observations
o BP, HR, SpO2
o Weight (for heart failure patients).
Equipment
For facilities that treat higher risk clients, equipment that may be used includes:
 Sphygmomanometer and blood pressure cuffs (small and large)
 Stethoscope
 Weighing scales
 Oxygen therapy
 Defibrillator
 Glucometer.
Recommendations
 Liaise closely with the treating doctor if there are any concerns about the stability or
severity of the clients Cardio Vascular (CV) condition.
 Any relevant medications should be available poolside.
 Utilize positioning to minimise CV effects of immersion (depth, body position).
 Initially clients may commence treatment in shallower water and progress to deeper
water.
 Exercise intensity levels should be monitored using tools such as the Borg Scale.
 Ensure adequate rest periods throughout treatment.
 Supervise clients on exiting the pool and during showering if they are at risk of
hypotensive episodes.
 Advise clients to inform staff if they feel unwell or have any new or changing
symptoms (eg, chest pain, dizziness, shortness of breath, nausea, cold sweats).
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
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Management of adverse events
Angina may present in numerous ways including:
 Central chest pain (often described as heaviness, crushing, or tightness)
 Neck pain
 Jaw pain, tooth ache
 Interscapular pain
 Shoulder pain or radiation of pain/ heaviness down one or both arms.
If the client experiences any adverse symptoms, cease the activity immediately. In the event of
angina, the patient should be encouraged to take their usual medication (GTN spray or tablet) and
monitor symptoms (BP, HR, SpO2). If pain persists, medication should be repeated at five mins and
again at 10 minutes if still continues. An ambulance should be called if symptoms persist at 10
minutes. The Heart Foundation has Heart Attack Action Plans.
Clients with cardiac conditions are often prescribed beta blocker medication to decrease the work of
the heart. These clients will traditionally present with low blood pressure and a slow HR. Provided the
patient is asymptomatic, there is usually no cause for concern. If the client experiences dizziness
during the exercise session, this may be secondary to a drop in cardiac output (particularly heart
failure patients), dehydration or other causes. The client should be removed from the pool and
positioned in sitting or lying. Blood pressure should be monitored. If the blood pressure does not
return to pre-exercise levels, medical management should be sought.
Specific conditions
Consideration of cardiac disease and accompanying co-morbidities (ie, insulin dependent diabetes,
morbid obesity, severe pulmonary disease, pregnancy) must be given in formulating a management
plan and determining the level of supervision for each client.
Heart Failure
For clients with heart failure, early decompensation may present as:
 Worsening exercise tolerance or dyspnoea at rest over the previous 1-3 days
 Increased in weight by more than 2kg in the previous 1-3 days.
If either of these symptoms occurs, the client should not exercise and should be referred to their
medical practitioner.
Permanent pacemakers (PPM) and implantable defibrillators (AICD)
PPMs and AICDs do not exclude clients from attending aquatic exercise programmes. It is important
however to determine the specific reason for insertion of the device. This may include management
of specific arrhythmias (usually PPMs), prevention of adverse events in clients at risk of fatal
arrhythmias (AICDs) or resynchronisation therapy to increase cardiac output in patients with heart
failure (biventricular AICDs). The reason for the device will determine the risk of undertaking an
aquatic exercise programme and should be discussed with the treating medical specialist. Other
considerations include:
 Avoid aquatic exercise following device insertion until the wound site is fully healed
 Clients should be referred to a medical specialist if the wound at any time appears infected
 Avoid vigorous upper limb activity at extremes of range on the side of the device
 Clients should always seek medical attention if the device fires at any time (during exercise or
external to the exercise programme).
Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing
hydrotherapy pools (second edition) 55
Atrial fibrillation (AF)
AF is associated with heart failure, valvular disease, coronary artery disease, hypertension and
hyperthyroidism. AF (especially AF with rapid ventricular rate) often reduces exercise tolerance and
results in fatigue. Haemodynamic compromise may also predispose the individual to thromboembolic
events. AF may be intermittent. Clients with new AF may report palpitations; worsening SOB and HR
may be irregular. The following considerations should be made for those supervising patients with AF:
 Clients with new symptoms (eg, irregular HR compared to previously regular HR, palpitations)
should seek medical advice
 Ensure AF clients are compliant with all medications, especially those that help control heart
rate
 Heart rate at rest should be adequately controlled (<100 bpm)  Pulse oximetry will be inaccurate in patients with AF. HR should be assessed manually in these patients. Contraindications for aquatic exercise in patients with cardiac disease  Unstable conditions with activity restrictions  Decompensated heart failure  Myocardial infarct less than 6 weeks  Myocarditis less than 6 months  Unstable ischaemia  Uncontrolled arrhythmias  Severe and symptomatic aortic stenosis  Hypertrophic cardiomyopathy  Severe pulmonary hypertension  Active or suspected myocarditis or pericarditis  Suspected or known dissecting aneurysm  Thrombophlebitis  Recent systemic or pulmonary embolism  Resting systolic blood pressure above 200mmHg  Resting diastolic blood pressure above 110 mmHg  Resting heart rate above 100 bpm. References Bailey E, Gangaway J (2007) Aquatic-based exercise effective as land-based exercise in creating a cardio-respiratory effect in normal individuals. Journal of Aquatic Physical Therapy 15 (1): 2-10 Balady G, Chaitman B, Driscoll D, Foster C, Froelicher E, Gordon N, Pate R, Rippe J, Bazzarre T (1998) AHA/ACSM Joint Position Statement: Recommendations for Cardiovascular Screening, Staffing and Emergency Policies at Health/Fitness Facilities. Medicine and Science in Sports Exercise June 30(6); 1009-1018 Carvalho VO, Bocchi EA, Guimaraes GV (2009) Hydrotherapy in Heart Failure: A Case report. Clinics 64(8):824-7 Chen H, Chen Y, Huang C, Lee S, Chen S, Kuo C (2010) Effects of one-year swimming training on blood pressure and insulin sensitivity in mild hypertensive young patients. The Chinese Journal of Physiology June; 53(3): 185-189 Cox K, Burke V, Beilin L, Grove J, Blanksby B Puddey I (2006) Blood pressure rise with swimming versus walking in older women: the Sedentary Women Exercise Adherence Trial 2 (SWEAT 2). Journal of Hypertension February: 25 (2): 307-314 Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing hydrotherapy pools (second edition) 56 Farahani A, Mansournia M, Asheri H, Fotouhi A, Yunesian M, Jamali M, Ziaee V (2010) The Effects of 10-Week Water Aerobic Exercise on the Resting Blood Pressure in Patients with Essential Hypertension. Asian Journal of Sports Medicine September; 1 (3): 159-167 Laurent M, Daline T, Malika B, Fawzi O, Philippe V, Benoit D, Catherine M, Jacques R (2009) Training-induced increase in nitric oxide metabolites in chronic heart failure and coronary artery disease: an extra benefit of water-based exercise? European Journal of Cardiovascular Prevention and Rehabilitation April; 16 (2): 215-221 Meyer K, Leblanc M (2008) Aquatic Therapies in patients with compromised left ventricular function and heart failure. Clinical and Investigative Medicine April: 31(2): 90-97 Nualnim N, Parkhurst K, Dhindsa M, Tarumi Y, Vavrek J, Tanaka H (2012) Effects of swimming training on blood pressure and vascular function in adults greater than 50 years of age. The American Journal of Cardiology April 1: 109(7): 1005-1010 Piepoli M, Conraads V, Corra U, Dickstein K, Francis D, Jaarsma T, McMurray J, Pieske B, Piotrowicz E, Schmid J, Anker S, Solal A, Filippatos G, Hoes A, Gielen S, Giannuzzi P, Ponikowski P (2011) Exercise training in heart failure: from theory to practice. A consensus document of the Heart Failure Association and the European Association for Cardiovascular Prevention and Rehabilitation. European Journal of Heart Failure January (13); 347-357 Robertson J, Brewster E, Factora K (2001) Comparison of heart rates during water running in deep and shallow water at the same rating of perceived exertion. Journal of Aquatic Physical Therapy 9(1): 21-26 Scherr J, Wolfarth B, Christie JW, Pressler A, Wagenpfeil S, Halle M (2012) Associations between Borg’s rating of perceived exertion and physiological measures of exercise intensity. European Journal of Applied Physiology May 22. PMID 226 15009 Schmid, JP., Morger, C., Noveanu, M., Binder, RK., Anderegg, M., Saner, H. (2009) Haemodynamic and Arrhythmic Effects of Moderately Cold (22 Degrees) Water Immersion and swimming in Patients with Stable Coronary artery Disease and Heart Failure. Eur J Heart Fail 11(9):903-909 Schmid JP, Noveanu M, Morger C, Gaillet R, Capoferri M, Anderegg M, Saner H (2007) Influence of water immersion, water gymnastics and swimming on cardiac output in patients with heart failure. Heart 93:722-727 Svealv, BG, Cider, A, Tang, MS, Angwald, E, Kardassis, D, Andersson, B (2009). Benefit of Warm Water Immersion on Biventricular Function in Patients with Chronic Heart Failure. Cardiovasc Ultrasound 7, 33 Tanaka H (2009) Swimming Exercise: Impact of Aquatic Exercise on Cardiovascular Health. Sports Medicine 39 (5): 377-387 Acknowledgment Julie Adsett. Royal Brisbane Hospital, Queensland Australia. Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing hydrotherapy pools (second edition) 57 Diabetes Diabetes has become a widespread epidemic with the increased prevalence and incidence of Type 2 diabetes mellitus (T2DM). T2DM is a metabolic disorder caused by defective insulin secretion and / or defective insulin action. T2DM clients may be prescribed insulin and / or oral medications to improve glycaemic control. Type 1 diabetics require insulin due to an absolute deficiency. Absolute or relative deficiency of insulin results in elevated blood glucose levels and affects the metabolism of fat, protein and carbohydrate. Hyperglycaemia is associated with microvascular dysfunction, macro vascular disease, neuropathy, glycosylation of collagen and impaired immunity. These factors contribute to systemic complications the physiotherapist should be aware of. Clients with diabetes should be screened for:  Cardiac conditions o Cardiovascular autonomic neuropathy (CAN) Clients with CAN should have physician approval prior to commencing exercise. Stress testing is recommended due to the likelihood of silent ischaemia, heart rate and blood pressure abnormalities  Renal Disease  Retinopathy o Physician approval for exercise is recommended prior to starting an aquatic program. Activities that greatly increase intraocular pressure are contraindicated when proliferative retinopathy is active. Jarring activities increase haemorrhage and risk  Peripheral sensory and motor neuropathy o Sensation testing of feet is recommended to determine risk of diabetic foot ulcers (DFU)  Musculoskeletal conditions o Charcot’s foot presents with impaired architecture and pressure loading of the foot. Cheiroarthropathy may decrease ability to independently manage foot care.  The diabetic foot o Ulceration of the high risk diabetic foot is the most common diabetes-related cause of hospitalization and amputations. Peripheral sensory and autonomic neuropathy, vascular impairment, impaired immunity and alterations in foot structure are risk factors. Comprehensive foot care is recommended for prevention and early detection of sores and ulcers. o Feet should be checked prior to entering the pool, with particular attention paid to between the toes. If redness, cracks, swelling, bruising or blisters are evident immediate help should be sort from a doctor or podiatrist. o Feet should be washed and dried gently and thoroughly after immersion. o Patients should avoid going bare footed. The wearing of thick socks and / or wellfitting shoes in the pool may be beneficial.  Wound management guidelines should be followed if the integrity of the skin is compromised. Clients with Hypoglycaemia  Individuals should self-monitor their BGLs before, occasionally during and following exercise to inform modifications of medication and diet to enable good glycaemic control and prevent hypoglycaemia.  Clients with Type 1 on insulin or T2DM on insulin or oral medications may need to alter their dosage and diet dependent on their response to exercise. Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing hydrotherapy pools (second edition) 58  Physiotherapists should ensure the client has a hypoglycaemia action plan, testing kit and fast release glucose available.  Practitioners should have hypo kits and first aid strategies available. Clients with Hyperglycaemia  Clients with Type 1 diabetes with a BGL higher than 15 mmol/L should check their urine for ketones. Moderate physical activity is safe if no ketones are present and the BGL is trending down.  BGLs should be tested every 30 minutes of physical activity. If BGLs are climbing or ketones present physical activity should be stopped. Clients should initiate their hyperglycaemia plan. This may be administration of short acting insulin, low calorie fluids and rest.  Clients with T2DM and a BGL above 16.7 mmol/L can engage in physical activity if ketosis is not present, they are adequately hydrated and they feel well. Recommendations:  Specific screening for Diabetics as listed above  Any patient with poorly controlled hypoglycaemia, recent /frequent periods of drowsiness, unconsciousness, slurred speech or similar signs of a severe hypoglycaemic event should not exercise alone in the aquatic environment. One-on-one supervision with a physiotherapist or suitable responsible person is required.  All patients at risk of hypoglycaemia should have a personal action plan. A personal hypo kit is central to this action plan.  Where appropriate facilities should have a hypo-kit available.  A health service should monitor the need to have on site BGL testing equipment.  All patients at risk of hyperglycaemia should have a personal hyperglycaemia action plan.  Suggest appropriate footwear to protect skin. Additional information:  Diabetes Australia  National Evidence-Based Guideline - Prevention, Identification and Management of Foot Complications in Diabetes (Part of the Guidelines on Management of Type 2 Diabetes)  Chadban S, Howell M, Twigg S, Thomas M, Jerums G, Alan C, Campbell D, Nicholls K, Tong A, Mangos G, Stack A, McIsaac R, Girgis S, Colagiuri R, Colagiuri S, Craig J. (2009) National Evidence Based Guideline for Diagnosis, Prevention and Management of Chronic Kidney Disease in Type 2 Diabetes. Diabetes Australia and the NHMRC, Canberra References ACSM and ADA (2010) Joint Position Statement. Exercise and Type 2 Diabetes. Medicine and Science in Sports and Exercise July 2010: 2282-2303 Australian Institute of Health and Welfare (2009) Diabetes prevalence in Australia: an assessment of national data sources. Diabetes series no.14. Cat. no. CVD 46. Canberra: AIHW Australian Government, Australian Institute of Health and Welfare, Canberra Baker IDI Heart and Diabetes Institute (2012) Diabetes: the silent pandemic and its impact on Australia Colagiuri S, Dickinson S, Girgis S, Colagiuri R. (2009) National Evidence Based Guideline for BloodGlucose Control in Type 2 Diabetes. Diabetes Australia and the NHMRC, Canberra Rabasa-Lhoret R, Bourque J, Ducros R, Chiasson J (2001) Guidelines for Premeal Insulin Dose Reduction for Postprandial Exercise of Different Intensities and Durations in Type 1 Diabetic Subjects Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing hydrotherapy pools (second edition) 59 Treated Intensively With a Basal-Bolus Insulin Regimen (Ultralente-Lispro) Diabetes Care, Vol. 24: 4, 625-630 Thomas D, Elliott EJ, Naughton GA (2006) Exercise for Type 2 diabetes mellitus (Review). The Cochrane Library, Issue 3 Turan Y, Ertugrul BM, Lipsky BA, Bayraktar K (2015) Does physical therapy and rehabilitation improve outcomes for diabetic foot ulcers? World Journal of Experimental Medicine Vol.20: 5(2): 130- 139 World Health Organization (2006) Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia : report of a WHO/IDF consultation. Acknowledgment Kathryn Devereux. Coordinator Community Physiotherapy Services at Department of Health (WA Health) Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing hydrotherapy pools (second edition) 60 Respiratory Conditions Physiological effects of immersion in neck deep water in healthy subjects Hydrostatic Pressure increases with increasing depth and;  Causes increased work of inspiratory muscle contraction in chest expansion  Causes compression of the abdomen, resulting in cephalad movement of the diaphragm, reducing space in the thoracic cavity  Causes re-distribution of the blood flow from peripheries to the cardiothoracic space, resulting in relative central hypervolaemia  All these factors can have an effect on increasing the work of breathing as well as decreasing lung volumes such as; vital capacity, total lung capacity, functional residual capacity and expiratory reserve volume. Chronic Obstructive Pulmonary Disease (COPD) Definition COPD is a long term lung condition commonly known as emphysema and chronic bronchitis. It is characterised by airway narrowing, leading to limitation of airflow in and out of the lungs, causing shortness of breath (SOB). Equipment  Relevant medications and equipment should be available pool side (bronchodilators, spacers, nebulizers).  Nasal prongs and oxygen therapy could be made available pool side in the acute setting.  For patients with a productive cough, tissues and a disposable cup should be available poolside. Oxygen Dependent Clients  Ensure oxygen cylinders are appropriately secured (i.e. on a portable trolley or crate) so that they cannot tip over on the pool deck or fall into the pool.  Oxygen tubing needs to be of sufficient length for the patient to be able to move about the pool (up to 20 metres).  Staff should inspect oxygen tubing for cracking and the regulator function on a weekly basis.  As oxygen tubing can be difficult to see in water, ensure there is sufficient space around the patient so that another swimmer does not pull the tubing.  Pulse oximeters can be used to measure oxygen saturation (heart rate is not a reliable measure of exercise intensity-(refer to Appendix IV – cardiac conditions). Dry the clients finger prior to placing it in the finger probe. Clients with Tracheostomies  Ensure that adequate floatation equipment is available to keep the tracheostomy site out of the water. Recommendations  If clients feel unwell, have a fever, increased SOB or change in the colour of their sputum, they should immediately contact their care manager (ie, Nurse Practitioner, Doctor) and should not attend the pool.  If required, clients’ should use their bronchodilator medication prior to exertion and entering the pool and have it available poolside. Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing hydrotherapy pools (second edition) 61  Advise clients that SOB may initially increase when entering the pool as their chest becomes submerged and this can be relieved by elevating their chest out of the water.  Clients may initially commence treatment at the shallow end of the pool and slowly progress in depth or level/type of exercise (eg, where variations in depth are not available, squatting to immerse will increase respiratory load, as will progressively adding in upper/lower limb exercise).  Treatment sessions may initially be of a short duration. The amount of time required needs to be assessed on an individual basis (may be as limited as a few minutes).  Ensure adequate rest periods for shortness of breath management.  Allow clients to choose the position most comfortable for them to recover their breath i.e. elevating their chest out of water, leaning on the poolside, sitting on the steps, sitting on the hoist in the water.  Assessment of COPD clients should include the level of SOB at rest and on exertion. Scales for rating the level of breathlessness can be useful in checking that these individuals are working at an appropriate and safe level of exercise intensity. Subjective rating scales which can be used include; the Modified BORG Dyspnoea Scale or the Modified Research Council Dyspnoea Scale. References Anste K, Roskell C (2000) Hydrotherapy - Detrimental or beneficial to the respiratory system? Physiotherapy 86:5-13 Lotshaw A, Thompson M, Sadowsky S, Hart M, Millard M (2007) Quality of life and physical performance in land and water-based pulmonary rehabilitation. Journal of Cardiopulmonary Rehabilitation and Prevention 27:275-51 McNamara R, Alison J, McKeough Z (2011) Water-based exercise in chronic obstructive pulmonary disease. Physical Therapy Review 16(1): 25-30 Ozdemir E, Solak O, Fidan F, Demirdal U, Evcik D, Unlu M, Kavuncu V (2010) The Effect of Water- Based Pulmonary Rehabilitation on Anxiety and Quality of Life in Chronic Pulmonary Obstructive Disease Patients. Turkiye Klinikleri Tip Bilimleri Dergisi 30 (3):880-887 Rae S, White P (2009) Swimming pool-based exercise as pulmonary rehabilitation for COPD patients in primary care: feasibility and acceptability. Primary Care Respiratory Journal 18:90-4 Roig M, Eng JJ, Road J, Reid WD (2009) Falls in patients with chronic obstructive pulmonary disease: a call for further research. Respiratory Medicine 103(9): 1257-69 Scherr J, Wolfarth B, Christie JW, Pressler A, Wagenpfeil S, Halle M (2012) Associations between Borg’s rating of perceived exertion and physiological measures of exercise intensity. European Journal of Applied Physiology May 22. PMID 226 15009 Wadell K, Sundelin G, Henriksson-Larsen K, Lundgren R (2004) High intensity physical group training in water-an effective training modality for patients with COPD. Respiratory Medicine 98: 428-38 The Australian Lung Foundation Acknowledgment Renae McNamara, Prince of Wales Hospital, Sydney Australia. Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing hydrotherapy pools (second edition) 62 Asthma A respiratory disorder characterised by recurring episodes of paroxysmal dyspnoea, wheezing on expiration and/or inspiration, caused by inflammation and constriction of the bronchi, coughing and viscous mucoid bronchial secretions. Individuals with asthma will often have skin conditions such as atopic dermatitis or eczema. Recommendations Assess whether the clients asthma is well controlled. Refer them to their Medical Practitioner if they complain of:  Waking up at night wheezing, short of breath or coughing  Having difficulty with normal activities  Using their reliever medication more than three times per week  Being unsure about their medication use (Note that some clients will have asthma and COPD and they will need management plans to reflect this) Assessment should also include the client’s triggers for asthma which may include:  Inhalation of allergens, pollutants and irritants (in some poorly managed pools, pool chemistry and air management systems may be factors)  Infections (colds and flu)  Cold air (Some pool change rooms can be unheated and cold. Changing on the poolside with a curtained off area may overcome this issue.)  Changes in air temperature and humidity (such as when moving from the moist, heated pool area to the external environment)  Vigorous exercise  Emotional stress If indicated, monitor asthma symptoms using a peak flow meter or an asthma assessment tool such as Asthma Score. All clients with asthma should have an asthma plan from their doctor which may include:  How to manage their asthma symptoms  How to use their medications  What to do if their asthma gets worse  Trigger avoidance strategies  What to do before exercise (ie, slow warm up, medication)  When to seek medical help  When to implement emergency first aid If during the pool session the patient reports or displays worsening symptoms of asthma (cough, wheeze, breathlessness, blue lips), cease activity and immediately implement their first aid plan. Do not wait until their symptoms are severe. Asthma Australia has advice on management, medications and first aid response. Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing hydrotherapy pools (second edition) 63 Exclusions If a client is having an acute asthma attack they should not be permitted in the pool and their first aid response should be implemented. If a client is undergoing a modification of their asthma management plan to help stabilise their asthma, it may be preferable to delay treatment until their new plan has been agreed and implemented. Equipment Recommendations The client’s Asthma Management Plan should be available in the pool area. Relevant medications and equipment should be available pool side (bronchodilators, spacers, nebulizers). For clients with a productive cough, tissues and a disposable cup should be available poolside. Asthma and Swimming Pools In the last ten years there have been some mixed reports in the literature as to the effect of disinfectant by-products (DBP) of chlorine and a correlation with the development of asthma. A metaanalysis by Goodman and Hays (2008) concluded there is no consistent link in the research between childhood swimming pool use and asthma prevalence. Many cold climate countries use air recycling devices to control heating costs. This increases the amount of DBP that can be built up in the pool environment. Pool water turnover rates and pool chemical levels can vary greatly in European countries which can also lead to higher rates of DBP. (refer to Guideline 1.1.7) In Australia pool environments usually have sources of natural ventilation (doors, windows) as well as extraction systems. Standards Australia has recommendations on ventilation, dis-infection and turnover rates and each state has their own guidelines for pool management. Appropriate management of the pool environment should minimise the amount of DBP in the pool atmosphere. It should also be noted that by far the majority of the studies are related to swimming (assuming head immersion) and not head out of water exercise as occurs in many hydrotherapy pools where asthma may be a co-morbidity of a client and not the condition being treated. For further information go to Asthma Australia. References Bernard A, Voisin C, Sardella A (2011) Con: Respiratory Risks Associated With Chlorinated Swimming Pools: A Complex Pattern of Exposure and Effects. American Journal of Respiratory and Critical Care Medicine March 183(5): 570-572 Downing L (2011) Swimming pools and asthma: A new risk or premature concern. Contemporary Nurse 37(2): 225-226 Ferrari M, Schenk K, Mantovani W, Papadopoulou C, Posenato C, Ferrari P, Poli A, Tardivo S (2011) Attendance at chlorinated indoor pools and risk of asthma in adult recreational swimmers. Journal of Science and Medicine in Sport 14(3): 184-189 Font-Ribera L, Villanueva C, Nieuwenhuijsen M, Zock J, Kogevinas M, Henderson J (2011) Swimming Pool Attendance, Asthma, Allergies, and Lung Function in the Avon Longitudinal Study of Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing hydrotherapy pools (second edition) 64 Parents and Children Cohort. American Journal of Respiratory and Critical Care Medicine March; 183(5):582-588 Goodman M, Hays S (2008) Asthma and Swimming: A Meta-analysis. Journal of Asthma 45(8): 639- 647 Klootwijk T, Krul M, Font-Ribera L, Villanueva C, Nieuwenhuijsen M, Zock J, Kogevinas M, Henderson J (2011) Some Concerns Remain About the Proposed Associations between Swimming and Asthma/From the Authors. American Journal of Respiratory and Critical Care Medicine 184(12): 1419- 20 Nystad W, Haberg S, London S, Nafstad P, Magnus P (2008) Baby swimming and respiratory health. Acta Paediatrica May 97(5): 657-62 Piacentini G, Baraldi E (2011) Pro: Swimming in Chlorinated Pools and Risk of Asthma: We Can Now Carry On Sending Our Children to Swimming Pools! American Journal of Respiratory and Critical Care Medicine March 183(5): 569-70 Voisin C, Sardella A, Marcucci F, Bernard A (2010) Infant swimming in chlorinated pools and the risk of bronchiolitis, asthma and allergy. European Respiratory Journal January 36(1): 41-47 Weisel C, Richardson S, NemeryB, Aggazzotti G, Baraldi E, Blatchley E, Blount B, Carlsen K, Eggleston P, Frimmel F, Goodman M, Gordon G, Grinshpun S, Heederik D, Kogevinas M, LaKind J, Nieuwenhuijsen M, Piper F, Sattar S (2009) Childhood Asthma and Environmental Exposures at Swimming Pools: State of the Science and Research Recommendations. Environmental Health Perspectives April 117(4): 500-507 Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing hydrotherapy pools (second edition) 65 Cystic Fibrosis Cystic fibrosis is an autosomal recessive disorder that can affect the lungs, pancreas, liver kidneys and intestines. Respiratory issues are often the primary problem with frequent chest infections causing lung damage and a shortened life span. Bacterial colonisation can occur and are often resistant to antibiotics and other pharmaceutical management. Cross infection of resistant strains of bacteria can occur between clients with cystic fibrosis. Whereas once group activities of children with similar conditions (land or water) may have been encouraged for social and support purposes, such groups are now generally discouraged. In the past low level evidence existed that poorly designed, filtered and managed pools may have been a source of infection. Modern designed pools that meet regulations have not been linked to cross infections. Recommendations  Children /adults with cystic fibrosis should not attend the same group session in a hydrotherapy pool, or attend the pool at the same time to perform independent exercise  Pools should be monitored according to state, council and health regulatory bodies to ensure adequate disinfection and water quality.  In some children diving should be avoided as it may increase the risk of pneumothorax especially in patients with more severe disease. References Barben J, Hafen G, Schmidt J et al (2005) Pseudomonas aeruginosa in public swimming pools and bathroom water of patients with cystic fibrosis. Journal of Cystic Fibrosis 4(4):227–31 Cystic Fibrosis Australia Hirche T, Bradley J, d’Alquen D et al (2010) Travelling with cystic fibrosis: Recommendations for patients and care team members. Journal of Cystic Fibrosis 9(6):385-99 Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing hydrotherapy pools (second edition) 66 Renal Conditions Renal Physiology for Healthy Subjects In head-out-of-water immersion (HOWI) to the neck there is an increase in central blood volume induced by hydrostatic pressure (refer to Appendix IV - Cardiac Conditions). HOWI in thermo-neutral (34.5-35 degrees) water stimulates the cardiopulmonary and arterial baroreceptors. High pressure baroreceptors detect the pressure of blood flowing through them, and via the central nervous system, can increase or decrease total peripheral resistance and cardiac output. Low pressure baroreceptors are involved in regulation of blood volume. They have a circulatory and renal effect. They produce changes in hormone secretion which effects retention of salt and water. With immersion in thermo neutral water, sympathetic nervous system activity and systemic peripheral resistance are decreased and arginine vasopressin (AVP) and the renin-angiotensin-aldosterone axis are suppressed. This causes a reduction in anti-diuretic hormone (ADH) thereby increasing diuresis (urine output) and a release of Atrial Natriuretic Peptide (ANP), which is a vasodilator hormone and helps elicit natriuresis (excretion of sodium). Some studies have also shown a reduction in proteinuria as a result of normalisation in blood pressure. These effects may be beneficial to clients with renal disease. With immersion there is stimulation of renal blood flow. The decrease in plasma renin activity causes a decrease in renal sympathetic activity which in turn decreases renal vascular pressure and increases urine, sodium and potassium excretion. These effects increase with increased depth and immersion time. It should be noted that in thermo-neutral water glomerular filtration rate (GFR) is altered very little. However in cooler water temperatures the GFR increases, further increasing diuresis, placing greater strain on the kidneys and increasing the risk of dehydration. Recommendations Encourage clients to comply with medications and dietary requirements including those clients on fluid restrictions. Initially treat in shallower depths and limit immersion time. Gradually increase depth and immersion time as tolerated. Clients should inform the physiotherapist if they:  Feel too tired to maintain the level of activity  Have unusual shortness of breath  Have chest pain or pressure  Feel nauseated  Experience irregular or rapid heartbeat during or after treatment  Leg cramps  Dizziness or faintness If a client reports any of these symptoms, activity should be ceased and if they do not resolve immediate medical assistance should be sought. For milder symptoms, clients should be referred to their medical practitioner for review. Renal Dialysis Patients Dialysis is a process for removing waste and excess water from the blood and is used primarily to provide an artificial replacement for lost kidney function in people with renal failure. Australian Physiotherapy Association - Australian guidelines for aquatic physiotherapists working in and/or managing hydrotherapy pools (second edition) 67 In haemodialysis, the client’s blood is pumped through a dialyzer and returned to the body via venous lines. Recommendations  Renal clients may prefer to be treated in pools with thermo-neutral water temperatures due to difficulties with thermoregulation.  For dialysis clients treatment sessions are ideally organised for the day after dialysis.  Stable clients who adhere to diet and fluid regimes can exercise at moderate intensity on dialysis days.  It is preferable to avoid exercise immediately before dialysis.  Cover all dialysis sites with a waterproof dressing.  Day-to-day variations in endurance are normal for dialysis clients and the schedule of treatment activity may need to be adjusted accordingly.  Liaise with the client’s medical practitioner particularly if they are having changes in: o Their dialysis schedule o Medication management o They are feeling unwell Contraindications to treatment  The client is acutely unwell.  The client has missed more than one dialysis session. Continuous Ambulatory Peritoneal Dialysis (CAPD) In peritoneal dialysis wastes and water are removed from the blood inside the body using the peritoneal membrane of the peritoneum. A sterile solution containing glucose is run through a catheter into the peritoneal cavity. After a period of time the fluid is drained out through the catheter and discarded. Recommendations  Preferably drain fluid prior to exercise.  The catheter site should be sealed with an appropriate waterproof dressing and cleaned post treatment. Additional Information  Kidney Health Australia  Renal Resource Centre. Rehabilitation and Exercise for Renal Patients  Kidney Research UK. Continuous Ambulatory Peritoneal Dialysis (CAPD) Factsheet References Kutner NG (2007) How can exercise be incorporated into the routine care of patients on dialysis? International Urology and Nephrology 39(4): 1281-5 Borg G (1982)

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