Aquatic Physiotherapy Group Australian guidelines for aquatic physiotherapists working in and/or managing hydrotherapy pools. Second edition. 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: [email protected] I 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 II 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 III 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 IV 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 V 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) 1 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) 2 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) 3 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) 4