A Splash Of Rehab

While the pool can offer your members a fun environment for exercise, water also has great therapeutic qualities that aid in rehabilitation.

While it's no secret that clubs provide a superb place to stay in shape, not everyone realizes that they also offer a great location to get a little rehab. In fact, there's no place more soothing to work out physical kinks than a club's pool or a pool staffed with a club's professionals.

Why? Because most people lose 60 to 90 percent of their body weight in the water. This makes pools an excellent workout area for people with physical limitations, as there is much less impact on their joints. In addition, the water's hydrostatic pressure (the pressure the water exerts or transmits) helps increase circulation and decrease swelling.

Clubs can benefit from the healing power of pools - even if they don't have wet areas. Strategic partnerships can lead to aquatic programming; demand will handle the rest. And the demand is there. Despite what you may think, your community needs aquatic rehab, according to Ruth Sova, president of the Aquatic Therapy and Rehab Institute (ATRI) in Chassell, Mich.

Ever since managed care has taken hold of the insurance industry, people are being bounced out of primary therapy before they are completely rehabilitated. Often, these people have nowhere to go. So why not make aquatic services available to them?

"These people can't participate in a traditional [fitness] program," notes Sova. "If they do, they are likely to re-injure themselves. But the water offers them an excellent environment to continue their recovery [safely]."

Aquatic rehab is a large umbrella term that can include classes for just about any condition, such as obesity, arthritis, fibromyalgia and total joint replacement. This form of rehab can include small groups and one-on-one therapy.

Before deciding whether to work with individuals or groups, however, you have a lot of thinking to do. First off, what are you going to call your aquatic services? If your answer is aquatic therapy, then you better have a licensed therapist in charge. Without the proper professional, it's illegal to dub a program aquatic therapy. A safer term for this service is aquatic therapeutic exercise, Sova suggests.

Andrea Poteat Salzman, owner and founder of Aquatic Resources Network in Amery, Wis., says the first thing club owners need to do if they are thinking about starting an aquatic rehab program is to get a copy of the 25-step plan available at www.aquaticnet.com/launch.htm. "It helps them think sequentially and they can get the whole picture," states Salzman.

Hot and Cold
Since aquatic therapy can cover a variety of services, how can you determine which ones you should provide? Try taking the temperature of your pool.

The pool's temperature is a big determining factor when it comes to the kind of aquatic rehab you are going to offer, states Salzman. "If your pool is 88 degrees, then you can offer aerobic classes for healthy individuals," she says. "But you can't have stretching classes for patients with arthritis or fibromyalgia because they are going to be miserable because the water is too cold."

If you want to do true one-on-one physical therapy, then, ideally, you need a pool that is thermoneutral. Thermoneutral is a temperature at which you can immerse yourself in water, not move and not have temperature shift from your body to the water and vice versa, explains Salzman.

Since your skin temperature is around 93 to 94 degrees, that is the temperature the water should be for low-activity, one-on-one aquatic therapy. On the other hand, that temperature is too high if people will be doing vigorous exercise in the pool.

Unless you have two pools - one for individual therapy, the other for laps - you'll need to make sacrifices. Kathryn Smathers, aquatic specialist at New Dimensions Physical Therapy in the Hills Fitness Center in Austin, Texas, does just that.

While Smathers would prefer warmer water, she conducts aquatic physical therapy in the same pool where people swim laps. Smathers treats a variety of musculoskeletal and orthopedic problems using the water to facilitate movement in healing.

"There are pros and cons to providing physical therapy in an 84-degree pool," she says. "Many of my clients get cold in that temperature, but it's good for people with orthopedic problems that are inflamed and need to decrease swelling."

Conversely, the cold temperature isn't so good for total relaxation exercises. To compensate, Smathers and some of her clients wear wet suits to help them stay warm.

Staffing Issues
After you decide what kind of aquatic rehab program you are going to offer, you have to choose a staff for it. Although you don't need a licensed therapist to conduct a fitness/rehab class for special populations, the person should have some training in physiology and the condition you wish to treat.

If you decide you want to offer true aquatic therapy at your health facility, then you have to decide if you want to lease out space to a therapist, do a joint venture in which both the therapist and your club have financial gain, or hire a therapist to work for the club.

New Dimensions Physical Therapy, which is located in the Hills Fitness Center, has a lease arrangement with Hills. It pays a base lease plus a percentage of therapy revenues.

New Dimensions has a small clinic with treatment rooms and an office. As part of its agreement with Hills, New Dimensions gets to use the club's gym and pool.

If you decide to hire a therapist to work for your club, your best bet is to advertise in your local paper or on the Web. As you interview the candidates, make sure they are licensed in your state. Inquire about any special certifications they might have. That way you can learn if they are continuing their education to stay up to date on current techniques.

Legal Ease
Again, an aquatic program doesn't necessarily demand a therapist, but keep in mind that there are only certain professionals who can legally provide therapeutic services in a pool. They are physical therapists, occupational therapists, exercise physiologists, athletic trainers, kinesiotherapists and therapeutic recreation specialists. This list also includes some other providers whom you don't often see in a pool, such as physicians and nurses. The exact list varies from state to state, so you'll need to check for your area.

The professionals who can use a billing code and bill Medicare for aquatic therapeutic services make up an even smaller list. The American Medical Association has CPT (current procedural terminology) codes used to describe medical treatment. Physical therapists (PTs) and occupational therapists (OTs) are the only allied medical professionals allowed to use a CPT code to describe aquatic-therapy services.

When you look at the professionals whom Medicare will pay for aquatic therapy, the list gets smaller still. Only PTs fall under this category. But then again, PTs have the broadest scope of practice, which includes massage therapy, manual therapy for joint mobilization, gait training and so on.

While hiring physical therapists can be expensive, PTs can add credibility to a club's aquatic program. To help keep the cost of therapy down, physical therapists have recently started using the concept of cash-based therapy. This makes it easier for PTs to move away from medical facilities to provide therapy.

In the past, it has been rare for people to pay out of pocket for physical therapy, explains Salzman, but since managed care is forcing people to get less therapy, patients are willing to pay for it on their own. This is an ideal situation for fitness clubs because their clientele can access their therapists any time and for as long as they want. And it's great for the therapists because they don't have to wait to get paid from insurance companies.

"At most facilities, you are lucky if you get 30 minutes per patient," says New Dimensions' Smathers. "Our facility is unique. I get an entire hour with my patients, which allows me to address their needs more thoroughly. And our prices are comparable with other facilities."

New Dimensions gets $180 for an evaluation and $150 for a follow-up, one-hour treatment. "Our clients are willing to pay that up front because they are people who've gone to other facilities and haven't gotten the care they needed," notes Smathers. In turn, she provides them with the appropriate paper work they need to request reimbursement from their insurance companies.

Marketing Matters
Once you've decided who is going to provide the therapy and what patient populations you are going to treat, the next job is to market your new aquatic rehab services.

Begin by letting physicians and other allied health professionals in your immediate area know that you now offer aquatic rehab. Send out direct-mail pieces to them, local HMOs and support groups for conditions such as arthritis and fibromyalgia.

If you have a licensed therapist working at your facility, play that up, suggests ATRI's Sova. "Having a licensed therapist gives your program more credibility to doctors looking at your facility," she explains. "But you have to show the benefits of your program because physicians traditionally don't know them unless they are a club member. They don't understand the scope of knowledge that [most] health club employees have."

Johnny Keel, general manager of the Sports Village in Lebanon, Tenn., adds that having a licensed therapist in his program sets his club apart from his competition. "It shows that we are not just a health club," he says. "We are a health and wellness center, and people feel comfortable coming here and getting set up on a program that will meet their needs."

While contacting local health professionals can earn your club referrals, don't forget to market the program to your current members. They have aches and pains, too.

Continuum of Care
People who come into your club solely for aquatic therapy become prospects for other club services. For example, the patients at Hills Fitness Center are encouraged to take part in fitness classes or are put on their own independent fitness program after they are finished with their therapy.

"Our members can get a medical membership for 90 days to continue their rehab on their own," says Terri Mitchell, aquatic specialist at Hills Fitness Center. And many opt to join as full-blown members after their therapy is complete, as they have become comfortable with the club.

"It is a great setup," Mitchell continues. "It provides a continuum of care that is a feeding loop. If members need therapy, they can go to the therapy clinic and get special one-on-one attention. And likewise, people who come in just for physical therapy can be introduced to fitness and general conditioning that may change their lives."

Cover Yourself
A combination of aquatic therapy and traditional services can lead to new profits - which could dwindle quickly if you aren't carrying the right kind of insurance.

There are three issues to consider when protecting your aquatic program. The first is malpractice; if you are using a therapist, then his insurance should cover this.

The second issue is coverage for injuries that may occur during a rehab class, and the third is coverage for an accident that may happen in the facility. It is fairly typical for the facility to provide the latter two coverages. However, this is negotiable.

"If a therapist is leasing the space, then he or she needs to carry the first two insurances," notes Salzman. "But these issues have to be hammered out as to who is going to pay the premiums and make sure all three areas are covered."

While creating an aquatic rehab program may seem like a huge undertaking, it is an endeavor that pays off for all involved. Your members get a service that few facilities offer, you get a bigger bottom line, and therapists get a new place in which to practice their expertise.

So you are interested in offering aquatic therapy at your club, yet you don't even have a swimming pool.

25 Steps Toward Aquatic Rehab

These 25 steps, courtesy of Aquatic Resources Network, will get you moving in the right direction.

Step 1: Hypothesize the need for a new aquatic therapy pool or facility in your area.

Step 2: Begin to determine sources for the financing.

Step 3: Hire a functional design consultant.

Step 4: Examine other pools.

Step 5: Determine if you will purchase a prefabricated pool or have your pool custom-designed.

Step 6: Construct a business plan and functional design description.

Step 7: Hire an architectural design consultant and obtain pertinent codes and standards.

Step 8: Promote the financing in earnest.

Step 9: Select an architect.

Step 10: Select a site.

Step 11: Commission preliminary construction designs and cost estimates.

Step 12: Compromise.

Step 13: Commission construction plans and working documents.

Step 14: Submit plans to health commissioner for review and approval.

Step 15: Submit plans for bidding to contractors.

Step 16: Oversee construction.

Step 17: Create policies and procedures manual.

Step 18: Determine programming.

Step 19: Find aquatic-therapy staff.

Step 20: Execute marketing strategies.

Step 21: Have pool inspected.

Step 22: Train staff.

Step 23: Open facility or pool.

Step 24: Justify aquatic-therapy treatment to payers and referring professionals.

Step 25: Train staff again.

Dive In!

Need a little help? Here are some aquatic rehab/exercise sources that can assist your program.

American Physical Therapy
Association Aquatic Section
1111 N. Fairfax St.
Alexandria, VA 22314-1488
(800) 999-APTA
Fax: (703) 684-7343

Aquatic Consulting Services
4909 Orchard Ave., #104
San Diego, CA 92107
(619) 224-3100
Fax: (619) 224-3165

Aquatic Exercise Association
P.O. Box 1609
Nokomis, FL 34274-1609
(888) AEA-WAVE
Fax: (941) 486-8820

Aquatic Fitness Professionals
Association - International

P.O. Box 1556
Elizabeth, CO 80107
(303) 621-2931
Fax: (419) 735-5216

Aquatic Physical Therapy Resources
P.O. Box 5327
Woodridge, IL 60157
(630) 810-1717
Fax: (630) 810-1736

Aquatic Resources Network
302 160th St., Suite 200
Amery, WI 54001
(715) 248-7258
Fax: (715) 248-3065

The Aquatic Therapy &
Rehab Institute Inc.

Route 1, Box 218
Chassell, MI 49916-9710
(906) 482-9500
Fax: (906) 482-4388

Worldwide Aquatic Bodywork Association
P.O. Box 889
Middletown, CA 95461
(707) 987-3801
Fax: (707) 987-9638

Pooling Resources

Don’t have a pool? Well, don’t count yourself out. If you don’t have the room or the money to renovate and/or put in a prefab pool, then partner up. Talk to a local rec center about sharing its pool for aquatic rehab and let its members participate. Or talk to local hospitals or clinics about using their pools for your members’ aquatic rehab, performed by your therapist.

“This is a great way of letting them [the physicians and other therapists] see your quality and dedication to helping your members,” notes Ruth Sova, president of the Aquatic Therapy and Rehab Institute (ATRI) in Chassell, Mich.

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