Tag Archives: Series

Venezuela’s Economic Crisis Puts Older Populations-At-Risk

This article is the first part of a two-part series on Venezuela’s ongoing economic crisis. Click here to read Part 2.

Photo Credit: Wilfredo Rodríguez
Photo Credit: Wilfredo Rodríguez

Venezuela is in the midst of an economic collapse. Oil prices have plummeted and the bolivar (Venezuelan currency) has dropped in value compared to the U.S. dollar. The situation is rapidly becoming a humanitarian emergency due to inflation and devaluation of the currency, food shortages, and collapse of the healthcare system. Safety threats and violence have also escalated an already unstable event. While news coverage of these incidents focus on the impact on children or young adults, this crisis has serious implications for older adults who are often vulnerable in the face of disaster.

Food Shortage

One of the hallmarks of media coverage are the pictures of long lines at grocery stores and food banks. In response to the food shortage, the Venezuelan government has instituted a rationing system, in which individuals must appear in person to buy food on the day indicated by the last digit on their ID card. For older adults who lose mobility or cannot make it to the grocery store on their designated day, there are few alternative options. Even for individuals who make it to the grocery store, there is often no food available. In a video posted on YouTube, an older woman states that she is hungry and willing to buy anything. She says, “It is sad that at this age [old age] it has come to this”. (English translation)

A writer for Havana Times shared an experience in a Venezuelan grocery store, “I also saw many elderly people waiting for hours to be able to buy something…”. Older adults often support their family by reserving a spot in the long lines which have thousands of people waiting for hours to reach the front. Exposure to the weather alone makes the ordeal of grocery shopping in Venezuela a threat to the health of older adults. In January of 2016, the government decreed that individuals should engage in their own food production, a daunting task for older adults.

Safety has been a pressing concern, especially surrounding grocery stores and food. In August of 2015, Reuters reported the death of an 80-year-old Venezuelan woman in a supermarket, “possibly from trampling”. In addition to riots and stampedes, there are reports of shots fired and frequent assaults in lines at grocery stores. The army and national police have responded by guarding the lines, but it is unclear whether the people are being protected or controlled by security forces.

Conclusion

With recovery a long way off, there have been calls for other nations to come to the aid of Venezuela. Older adults and children can benefit from food and health assistance but President Nicolás Maduro states that the situation is not nearly as bad as portrayed in the media. For instance, Cuban doctors are helping to mitigate the healthcare crisis in Venezuela. The fact is that foreign aid may not even be enough, hence societies should have strong governments with smart fiscal policies to insure safety nets for older individuals.

Grace Mandel is pursuing a Master of Public Health in Health Systems and Policy at the Johns Hopkins University Bloomberg School of Public Health.

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Aquatics Programming

In honor of National Physical Therapy Month, Global Health Aging is presenting a weekly four-part article series on aquatic therapy. This is Part 4 in this series. Part 1 focused on the aquatic therapy marketplace, Part 2 focused on selecting an aquatic practitioner and Part 3 focused on selecting an aquatic facility. Thank you for reading!

Aquatics Programming may be found in a class format or individual, one-on-one, personal training. Variances occur when the instructor is in the water or on the pool deck; the instructor can be demonstrating moves or simply observing.  In one-on-one training, a physical therapist may demonstrate on the pool deck and then oversee land-based exercises to be performed in water. This article will present an overview of just aquatic therapy programming–oftentimes misconstrued by physicians and other healthcare providers as water aerobics, as they have not learned to differentiate between aquatic exercises and therapies.

Photo Credit: Pixabay
Photo Credit: Pixabay

Within aquatic therapies, class formats are usually considered “active” therapies, meaning the therapist is demonstrating moves to be performed by the participants using visualization or verbal cueing to effect the desired movement(s). “Passive” therapies require the therapist to be in the water with the participant, physically manipulating the participant in a one-on-one mode of care.

Active therapies are by far the more commonly observed practices in either class or personal format. In active therapies, the practitioner can be demonstrating the moves whether on the pool deck or in the water. Many participants prefer a practitioner on deck where moves can be easily seen and more closely modeled by the participant.  However, there are unknown advantages to having the practitioner in the water with the participant(s). The practitioner can more concisely cue the participant to specific considerations that may be experienced in water, not commonly observed or experienced when the move is performed out of the water. For instance, a leg lift to the side, when performed on deck, is more easily aligned when the buoyancy and resistance of the water is not altering the form of a truly lateral abduction. When a practitioner instructs from the water, he or she may lift the leg sideways but it may be forward of the midline of the hip joint. By cueing the participant to turn the toes inward, the outside of the ankle leads the abduction, effecting a more true lateral abduction. The slight turn inward of the toes strengthens the leg muscles needed to perform the movement, which then translates to a more stable leg lift on land. This is because the muscles have been trained more strongly against the added resistance of the water.

Physical therapists who do not have aquatic training may never come to understand this variance in experience between land and water. Therefore, they can not ever use the water to its fullest multi-planar or “omni-directional” benefit. To be fair, even people trained in aquatic therapy may not become fully aware of this omni-directional efficacy unless they have spent a lot of time in the water, performing the movements they instruct the participants to carry out.

In class formats, there are many kinds of therapies that can be conducted: Yoga, Aqua Stretch, Aqua Pilates, Ai Chi and Watsu are some examples. While Watsu is a “passive” therapy, meaning the practitioner is usually the one to move the extremities of the participant, a therapist can lead a class of paired participants and cue and observe each pair in their therapy. Likewise, Ai-Chi-Ne is a paired participant therapy class. For the purpose of example, a brief explanation for Ai Chi will be included in this article.

Ai Chi, a Japanese aquatic therapy, is oftentimes confused with the land-based Chinese Martial Art, Tai Chi. In a lot of ways, the practices are similar and the newer Ai Chi is based upon the martial art. However, when done in water, Ai Chi accomplishes different objectives of wellness and mind/body self-care. It has a very restorative, if not healing effect when practiced regularly. Moreover, Ai Chi coordinates controlled fluid movements with deep, diaphragmatic breathing in through the nose, but out through the mouth. Its relaxation effects are bridging the mind’s control of the body through the control of breath. It is said that, “the breath is the bridge between the mind and the body.” When practiced regularly, the healing effects of the therapy can be profound. Ai Chi is a cultivation of the energies in and around the body, drawing in healing energy and expelling toxic or harmful stressors.

In a one-on-one aquatic therapy session, a powerful bond is created between the practitioner and participant when both are in the water. Inexplicably, the shared common experience endears the participant to the practitioner, establishing a stronger trust and respect than when a practitioner stays dressed in street clothes, sits on a chair on the pool deck and perhaps keys entries on their computer, while the participant completes the instructed movement(s) or repetitions of a move.

In sports therapy pools, the trainer is like the therapist on the pool deck, but expensive underwater video and monitor equipment enables the trainer to observe the form and kinesiology of the participant. This insures proper  form and alignment therefore maximum potential for improvement. The trainer is also acutely focused on the athlete whose sole objective is to increase maximal performance. Non-professional athletes do not have the luxury of such intensive observation and performance monitoring…unless, of course, the therapist puts on a dive mask or goggles and watches closely with their head under water. Granted, some observations can be made by either the trainer or therapist from above the water’s surface. However, the added benefit of underwater observation can improve the outcomes. If not, sidewall windows in therapy pools would not be created with outside video cameras transmitting or recording the movements within.

Finding an aquatic therapist who is willing to get into the water and observe under the surface can be one’s best investment in personal aquatic programming as well as possibly insure the best possible outcomes for the participant. In many cases of aquatic therapy, it is not reasonable or justified to have a physical therapist treat patients on the same day he or she works as an aquatic practitioner. After all, their time is billable hours and transitioning from land to pool and back again is valuable billable hours lost. Aquatic therapy associations can do more to benefit participants and promote best possible outcomes by lobbying for changes in both insurance coverage and licensing for their members.

Another consideration for programming is music. In many therapy settings, a background accompaniment of soothing music can enhance the experience, aiding in relaxing the participant and helping to center and focus the mind. Quiet times in natatoriums are a rare occurrence in some facilities hence the use of soothing music necessitates the quiet environment.

Physical therapy practices that have therapy or warm water pools are far more likely to have opportunities for quiet times as well as access to sound systems and music that fit the therapeutic objective. Community pools, YMCAs and other athletic clubs are not likely to provide such experiences, except at some limited or designated times.  However, many physical therapy practices do not have pools, largely because of the expense. They may only offer aquatic therapy using other facilities where the noise must be tolerated, and therefore cannot offer therapies in quiet classroom formats.

When considering aquatic therapy, programming is one component of the total experience that needs consideration. The skills and credentials of the practitioner, along with the features of a facility, make aquatic programming play a significant role in the participant’s decision to pursue one of the most effective means of self-care currently available in 21st century America.

Felecia Fischell is an Aquatic Specialist with twenty-three years experience in aquatics. She leads aquatic classes and consults as an aquatic personal trainer and a swim instructor at the Franklin County Family YMCA in Virginia. Formerly the Founder of FunLife Aquatics Consulting in Maryland, Felecia presents at health fairs and has given aquatic presentations to high schools, Howard County Board of Education, Howard County General Hospital and Howard County Community College.

Selecting an Aquatic Facility

In honor of National Physical Therapy Month, Global Health Aging is presenting a weekly four-part article series on aquatic therapy. This is Part 3 in this series. Part 1 focused on the aquatic therapy marketplace and Part 2 focused on selecting an aquatic practitioner. Click here to read Part 4.


Selecting an aquatic facility may be one of the most personal considerations for a prospective aquatic patron. Depending upon an individual’s circumstances, the choice of which facility is best for each patron may vary. At one extreme, there are classes in a resort location, on the shore of a beach or off the dock of a lake home. However, the most common facility is the community pool.

Different health considerations and performance or functional objectives may be central to any patron’s focus. Therefore, an aquatic consultant may be helpful in isolating a patron’s specific requirements. This article focuses on natatoriums (indoor swimming pools) that are open year round as well as some of the many important features of an indoor facility including Access and Water Temperature/Depth.

Access

  • Zero Depth Entry
  • Wide Stairs with Handrail(s)
  • Chair Lift
  • Pool Ladder

Getting into and out of a pool can be a problem for a large number of people who will benefit from aquatic therapy and exercise. In the bullet list above, Zero Depth Entry is the most desirable way to enter the water gradually. Consider wave pools designed with a wide cement slope into deeper and deeper waters of the pool.

In a cost-effective simulation to the wave pool design, a sloping ramp that may actually contain a turnaround or two is ideal. It is much like wading into the ocean, but without the risk of shells underfoot, jellyfish stings, or waves that knock one off balance. In essence, a patron may walk or move their wheelchair into the water using a gently sloping ramp.

Wide Stairs: Ideally, handrails on both sides are sufficient for at least 90 percent of patrons accessing the pool waters. These standard rise pool steps are very helpful in performing some types of therapeutic exercises; a definite plus for most patrons.

Chair Lift: This is very important to consider as land-based ambulation requires canes, walkers and especially wheelchairs. One note of caution to wheelchair-bound patrons: transition between wheel chair and chair lift can be challenging. In addition to a lifeguard on duty, a patron needs a caregiver to assist and perhaps even accompany the patron into the pool. Skill set, including licensing and certification requirements for practitioners and instructors, is  undefined in this circumstance. In other words, the patron’s aided entrance into the pool cannot be assumed to come from the aquatic practitioner.

Pool Ladder: Despite being the most difficult to use, pool ladders affixed to the poolside and deck can be quick and accessible for patrons with sufficient upper body strength and balance. Safe entry into the pool from a ladder attached to the pool deck requires backwards entry. Patrons should consider placing one foot on each subsequent rung although it is more important to focus on the distance between the bottom last rung and pool floor, especially if the patron is not “water safe” (able to float, swim or otherwise not panic when not grounded to the pool floor).

Emphasis must be restated on the requisite upper-body strength to hoist oneself up each rung of the ladder if no easier exit is available.

Water Temperature/Depth

  • Temperature
  • Depth

Temperature: In most circumstances, temperature and depth are equally important. Patrons can generally tolerate aquatic aerobic exercise at 78 degrees F and up to about 84 degrees F or perhaps 85 degrees F. Therapeutic water temperatures are best between 88 degrees F and 92+ degrees F. However, some medical conditions like multiple sclerosis need cooler temperatures even though temperature considerations can also affect certain people with diabetes and some neurologic or degenerative conditions. Arthritis patients have their own specific condition guidelines: 84-88 degrees F for exercise and 92-100 degrees F for therapy.
Note: Facilities that come close to the temperatures necessary for a patron’s specific use can still be considered when the patron invests in warm-water apparel such as a wet vest or aquatic wetsuit.

Depth: Manufacturers in the personal and therapy pool industry tend to hover around a 4-foot-8 to 5-foot-2 inches maximum depth for vertical exercise applications. These parameters seem to target patrons at or below 6-foot in height, which means that a waist belt or noodle is employed to support patrons adequately to achieve full range of motion (ROM) of extremities when suspended (not touching the pool floor) in water.

Depth, of course, is a specifically personal consideration, especially when a patron may not be “water safe.” Comfort in the water, where a patron is able to relax and not panic, is the ultimate consideration in patrons who are self-described as “afraid of the water.”

The choice of water depth is sometimes also a personal consideration. In therapy, if the focus is rehabilitating a joint on a lower extremity, the patron will begin in deeper water, somewhere between shoulder and chest or sternum depth, and progress to more weight-bearing, shallower water when the muscles and joints are stronger. However, depending upon an individual’s center of buoyancy or COB (as it relates to lean muscle mass), it may be difficult for some patrons to stay grounded on the pool floor. If the patron is not water safe, staying grounded will be necessary for the participant to remain relaxed. Fear induces muscular tension which can be counter-productive in aquatic therapies and exercise. Involuntary or unintentional rigidity of muscles may increase the chance of injury and it will make the patron more likely to sink. At a minimum, the tension may inhibit the participant’s ability to perform the exercises with proper form and control; thus making the time spent working not as effective as it can be.

Deep water exercise tends to encourage the use of flotation devices like noodles, hand buoys, and waist belts. By far, the waist belt is the most effective equipment to use in water when performing vertical workouts like cross-country skiing, deep water running, leaping, jumping jacks and other moves where all limbs may be working concurrently. A noodle may be straddled between the legs or wrapped around the back either at the waist or under the arms. Hence, deep water can be a very rigorous form of aerobic work, targeting not only muscle strength but also endurance. Deep water exercise can also enhance range of motion when performed slowly or with a hold between changes of direction of the limbs. One of the most important considerations about deep water work is that postural alignment is maintained with shoulders back (and down) over the hips. This alignment is critical in maintaining core strength and minimizing back strain.

The task of selecting a facility has so very many different considerations to review in making a choice. Often, an aquatic patron does not have the luxury of a large selection of facilities available to them. When visiting a facility and observing the staff and instructors, all these ideas will prepare the new patron to be watchful of conditions, which can make it necessary to plan and prepare ahead of their first aquatic therapy or exercise experience. A good question to always ask on a site inspection is whether towels are provided.

Water is, for most people, a therapeutic medium when comfort of the patron is properly addressed. Plan to heal, grow stronger and enjoy!

Felecia Fischell is an Aquatic Specialist with twenty-three years experience in aquatics. She leads aquatic classes and consults as an aquatic personal trainer and a swim instructor at the Franklin County Family YMCA in Virginia. Formerly the Founder of FunLife Aquatics Consulting in Maryland, Felecia presents at health fairs and has given aquatic presentations to high schools, Howard County Board of Education, Howard County General Hospital and Howard County Community College.

Selecting an Aquatic Practitioner

In honor of National Physical Therapy Month, Global Health Aging is presenting a weekly four-part article series on aquatic therapy. This is Part 2 in this series. Part 1 focused on the aquatic therapy marketplace. Click here to read Part 3.

Photo Credit: Ann Fisher
Photo Credit: Ann Fisher

Over the last thirty years, the field of aquatic therapy has steadily grown in US allied healthcare. Insurance companies that reimburse for aquatic therapy ONLY reimburse for a licensed physical therapist or maybe a physical therapy assistant. Depending on the state, there are some workarounds like a certified instructor being employed by a physical therapy practice or hospital. All too often, though, the employers err on the side of legal caution, fearful of liabilities which may be inherent in land-based physical therapy but seem almost non-existent in aquatic therapy.

Out of respect for those licensed in physical therapy, Aquatic Therapy Rehab Institute (ATRI) certified instructors, who do not have a degree and license in physical therapy, are discouraged from calling themselves “aquatic therapists”. Physical therapists, however, are not required to have aquatic certification to bill for aquatic therapy. So, if you are in need of aquatic therapy, perhaps as pre-operative conditioning or after your insurance allowable coverage for physical therapy has been exhausted, what can you look for in an aquatic professional?

Many reputable organizations either post or offer access to staff biographies. Like they do in the physician offices, those practicing aquatic therapy should specifically display their credentials. A certificate, license or degree from a bona fide organization can be a first tier requirement. Certifications usually require professionals to obtain continuing education hours to maintain credentials. This must be done every two years or less, and professionals should display the one that is relatively current.

Certifications from organizations like ATRI, Aquatic Exercise Association (AEA) and Aquatic Therapy University (ATU) may give an indication that your practitioner has met certain stringent requirements to authenticate their expertise. ATU has more recently been established specifically to target degreed professionals in both physical and occupational therapy. In some instances, even speech pathologists are obtaining certifications as evidence is now emerging on warm water activities. The soothing effects of such activities can advance progress in remediating stroke, traumatic brain injury (TBI) deficits or other speech pathologies, including some oral cancers.

Across all three certifying organizations, a broad and sometimes intensive proficiency needs to be demonstrated. This includes sufficiently answering test questions governing anatomy, physiology, kinetics and some physics as it pertains to water properties, as well as skill demonstration, especially when performing physical manipulations in the water.

Even when a licensed physical therapist is practicing aquatic therapy, it is important to know what additional training and credentials the aquatic professional may have by a certifying organization. All the knowledge of anatomy, physiology and kinesiology may not be as helpful if the practitioner has not spent a significant amount of time in water experiencing how the body works differently on land and in waist or shoulder deep water. It is more important that the aquatic practitioner have a deep understanding of how the properties of the water can be used to best achieve the functional goals or milestones of the participant.

Thus, beyond finding credentials, seeing is believing. Take time to observe your aquatic practitioner and ask permission to observe – perhaps make a video with your cell phone or take notes. Compare one practitioner to another or better yet several others! Look to find many of the following qualities:

  • Clearly defined milestones and functional goals/expectations of outcome;
  • Workload progression that supports goals: meaning variances in
    • time to accomplish an exercise;
    • range of motion;
    • effort or exertion;
    • depth of water used;
    • length of extremity in activating a particular joint;
    • exercises performed where extremities are operating in different depths;
    • exercises performed where extremities are operating in different planes;
    • use of equipment such as drag and buoyancy equipment;
    • cadence/rhythm/speed;
    • breath cueing and control (when to inhale and exhale; diaphragmatic breath);
  • Attentive observation of and note-taking about the patient (some PTs bring their laptops poolside and pay more attention to their computer than their client);
  • Apparent knowledge of how to make modifications of exercises to insure progress without pain or injury;
  • Cheerful disposition and encouragement based upon progress toward goals.

With all or most of these objectives meeting your approval, ask to speak with the professional and ask for referrals. In some cases, aquatic practitioners are award winners in their fields. They may have published research articles or been written up in a local paper or support group newsletter. Be sure to contact references and add their comments to your observation notes. It is best to have a conversation with a prospective aquatic specialist to make sure you communicate easily and understand their instructions. Sometimes, communication disconnects can derail the most qualified professional’s efforts to guide you toward your functional goals.

This kind of upfront investment in your self care may prove the best return for not just your dollar, but more importantly your well-being. After all, your health is your greatest wealth!

Felecia Fischell is an Aquatic Specialist with twenty-three years experience in aquatics. She leads aquatic classes and consults as an aquatic personal trainer and a swim instructor at the Franklin County Family YMCA in Virginia. Formerly the Founder of FunLife Aquatics Consulting in Maryland, Felecia presents at health fairs and has given aquatic presentations to high schools, Howard County Board of Education, Howard County General Hospital and Howard County Community College.

 

Aquatic Therapy Marketplace

In honor of National Physical Therapy Month, Global Health Aging is presenting a weekly four-part article series on water aerobics. This is Part 1 in this series. Click here to read Part 2.

Welcome to the 21st century and a new American Healthcare System. The advent of the Affordable Care Act (ACA) and its gaining foothold of functional acceptance in America presents an interesting opportunity for citizens who are making a paradigm shift: movement from managed health care to managed self care. Who will be making this shift? Citizens are moving into a realm of do-it-yourself healthcare management through many fields of allied health.

Photo Credit: OakleyOriginals
nPhoto Credit: OakleyOriginals

One such allied healthcare service is becoming more commonly prescribed and sought after: Aquatic Therapy. National collegiate teams and professional franchises have led the way as it is most commonly used in sports medicine. Patrons in private and public clubs, especially non-profits like YMCAs, are blazing new trails in aquatic practices, catching up with other countries around the world.

Whether it is prescribed or not, many patrons now choose to seek services outside the coverage of their insurance. In the 21st century, aquatic exercise and therapies are steadily growing with the aging of the baby boomer population. The trend is growing more rapidly in younger populations where an overuse injury from a favorite sport may occur. The younger “weekend warriors” are aware of the conditioning and rehabilitative outcomes from employing aquatic exercise and therapies in support of their favorite sport.

In today’s aquatic marketplace, how can new patrons, of any generation or experience, determine what is desirable in an aquatic program, facility or instructor? The industry is so new that standardization in practice is far from being established and even farther from being commonly known or accepted. Insurance regulations governing those who may be reimbursed for services are sorely misaligned. This means that many aquatic therapy participants can get insurance coverage for “aquatic therapy” but it may not be the best available instruction and care.

Knowing this about the industry now, three questions come to mind: What do you look for in an aquatic facility or program? And thirdly, who or what kind of person with what skill-set or credentials is most important when becoming a patron of aquatic therapy?

Since university degree programs and licensing in physical therapy do not instruct or test students in this aquatic modality, aquatic patrons need be guarded in their pursuit of care. Water exercise can be performed anywhere between high impact and totally suspended, meaning no contact with the pool floor. This variance assures that there is some effective form of aquatic therapy for all ages, most types of injuries, and almost any physical condition a person may need to address. Even speech pathologists are gaining advancements through aquatic environments.

Water therapies can be passive or active. An active therapy is something the patron does in response to the therapist’s instruction and it may ultimately become an exercise. A passive therapy is a physical maneuver or manipulation that the therapist does to the patron’s trunk, limb or extremity. More often than not, passive therapies are practiced only by those aquatic professionals specifically trained in aquatic therapies. They may or may not hold a degree or license in physical therapy.

As the aquatic industry continues to evolve, it can very well become its own discipline in colleges. Presently, there needs to be a lot more work put toward the effort of standardizing practices, quantifying outcomes and modifying insurance coverages. This will allow certified professionals even without degrees in physical therapy to be compensated or reimbursed for their services.

When practitioners universally understand and consistently use the properties of water to their fullest potential, then best outcomes for patrons will emerge.  Aquatic therapies will then become a first line application for preventative and restorative allied healthcare. For instance, physicians will prescribe pre-operative aquatic conditioning to keep the muscles, ligaments and tendons surrounding a surgical site as strong and healthy as possible. Doctors will also place post-op patients in water before commencing land- or weight-bearing exercises so that the supporting muscles, tendons and ligaments can begin moving sooner and speed the healing and recovery process from the surgery performed. The efficacy of aquatic therapy is growing exponentially, thanks to the wisdom of experience; once relegated to senior citizens. The positive experiences of seniors may now be shared by all ages with varying abilities and health constraints.

Felecia Fischell is an Aquatic Specialist with twenty-three years experience in aquatics. She leads aquatic classes and consults as an aquatic personal trainer and a swim instructor at the Franklin County Family YMCA in Virginia. Formerly the Founder of FunLife Aquatics Consulting in Maryland, Felecia presents at health fairs and has given aquatic presentations to high schools, Howard County Board of Education, Howard County General Hospital and Howard County Community College.