Aqua Therapy: Preventative Maintenance to Help Ensure Your Long Term Health and Happiness

Aquatic therapy also known as hydrotherapy is becoming popular as an alternative to traditional land-based therapies. It is suitable for all the fitness levels, for children as well as for adults. Physical and sports therapists are using it as a preventative maintenance tool.

Aqua therapy is a physical therapy performed in water by qualified experts and aquatic trainers. Different types of treatment exercises are involved in the therapy that provides recovery, relaxation, fitness, rehabilitation, and many therapeutic benefits. It is popular for musculoskeletal and neurological problems.

Aqua therapy is performed in warm water. The pool is the safest environment to perform specific exercises. The temperature of the water varies according to the condition of a specific patient.

  1. The temperature for athletes should be in the range from 26 °C to 28 °C
  2. The temperature range for neurological and arthritis patients is 29 °C to 31 °C

When you exercise in water, it provides less physiological resistance as compared to the land.

Natural properties of water beneficial for therapy

To understand how aqua therapy works it is important to understand the natural properties of water.

Water possesses certain natural properties that create an ideal environment to perform therapeutic exercises which are difficult to perform on land. The injured and disabled persons can perform in water with much ease and comfort as compared to land.

The ideal properties of water that help perform exercises when the water is being used as a therapeutic agent are

  • Buoyancy force
  • Hydrostatic pressure
  • Natural viscosity

Buoyancy force

The buoyancy force is also known as the upthrust force. It is an upward force exerted by water when the object is partially or fully immersed in water. It opposes the weight of an object. It resists the motion of objects from the surface and assists the motion of an object towards the surface.

So, when you enter underwater you feel an apparent loss of weight. This buoyant force decompresses every joint. You feel so light and can easily perform vigorous exercises with little impact on joints.

  • This force reduces the pressure on joints and can be beneficial for edema and joint pains.
  • It also helps in reducing the friction between the articular cartilage of joints.

Hydrostatic pressure

Hydrostatic pressure is exerted equally on all parts of the surfaces of an immersed object by the thrust of molecules of a liquid. This pressure increases with the density and depth of liquid.

When the body is immersed in water it produces two effects.

  1. The body fluids would move from the extremities to the central cavity. The blood circulation would first increase in muscles, then in the abdominal cavity, and finally in the heart and chest cavity
  2. The chest wall would be compressed and work of breathing would increase

If you are a heart or lung patient, you should avoid in-depth exercises.

Viscosity of water

The viscosity of water provides resistance that is greater than that experienced on land while movement. This Natural property can be used for muscle strengthening and rehabilitation.

Effect of warm water during therapy

Water can retain heat for a longer period. It can transfer heat easily. These properties of warm water are beneficial for therapy as they produce some physiological effects.

  • Warm water dilates superficial blood vessels, activates sweat glands, and removes toxins from the body.
  • It relaxes the body
  • It helps decrease joint pain
  • Warm water diminishes the sensitivity of sensory nerve endings

Different types of popular aqua therapies

Aqua therapy is performed at health spas, physical therapy clinics and sometimes it can be performed at home as well. Different types of appliances used for therapy are Full body immersion tanks, whirlpool baths, body-specific tubs, cold and hot water compresses.

Popular aqua therapies are:

1. Aquatic exercises

Many different programmed exercises are being performed in a pool of hot water or cold water with the help of a qualified therapist. Underwater exercises provide lesser pressure on joints and help in pain management. Aquatic exercises can be performed before starting a physical land exercise program as they are easy to perform.

2. Balneotherapy

Balneotherapy is being offered in spas, wellness centers, and hot spring resorts. It involves the bath in mineral-rich hot water and is famous to treat numerous health problems such as blood pressure, arthritis, and respiratory disorders.

3. Sitz baths

A plastic large tub filled with warm water is used to treat different conditions such as hemorrhoids, fistulas, and other anorectal conditions.

4. Therapeutic baths

Therapeutic baths involve the use of soaking in hot tubs that contain therapeutic agents like Epsom salt, dead sea salt, herbs, and aromatherapy oils. Mud baths are an example of therapeutic baths. These baths are for treating skin conditions, emotional stress, and joint problems.

5. Watsu

Watsu is also known as water shiatsu. It is hydrotherapy that involves stretching, massages and acupressure while you float in a pool of warm water. It promotes physical relaxation, mental relaxation and has a calming effect on the whole body and organs by generating the energy flow.

6. Whirlpool hydrotherapy

If you need an improvement in circulation, mobility, and comfort after the surgery or an illness. Whirlpool therapy is the answer for you. It uses warm water or sometimes cold water in a tub. You immerse your body or whole body in the bathtub.

Benefits of Aqua therapy 

Aqua therapy provides a lot of benefits. Persons of all ages can benefit from it.

  1. It restores range of motion and flexibility during the early rehabilitation phase.
  2. Once your normal body functions restore followed by the early rehabilitation benefits, it further provides resistance training
  3. Helps in regaining balance and coordination
  4. Edema reduction
  5. pain management
  6. Improved range of motions
  7. Provides relaxation
  8. Improve circulation
  9. Helps in skin diseases
  10.  Helps for strains, sprains, and fatigue
  11.  Arthritis
  12.  Helps in re-educating paralyze muscles


You should avoid aqua therapy if you have

  1. Fever
  2. Open wounds
  3. Pregnant
  4. Seizure issue
  5. Hepatitis
  6. Breathing issues

Aquatherapy allows you to benefit from therapy and to get involved in a recreational activity or enjoying nature at once. People of all age groups can benefit from this therapy.


Communicating with Kids


Children can be scary.

I’m not talking about the teleporting dolls of horror movies – just regular pediatric patients.Some people have the natural ability to relate to children, and others might feel like they’ve been knocked out of their usual rhythm of patient communication. How do you explain pathologies to a 10-year-old? How do you make a personal connection, take an efficient subjective history, and get patient buy-in?

As a PT student during a pandemic, trying to practice pediatrics on baby dolls and my adult classmates, I’m curious. After all, somewhere in the world there is a scientist who has dedicated a significant portion of his life to studying kleptoparasitism in kangaroo rats (Kline et al. 2018). Surely someone in the research community has figured out how to talk to kids?

In their book, The Art and Science of Motivation: A Therapist’s Guide to Working with Children, Ziviani et al. emphasize the importance of empowering children by including their input and values in the therapy plan. Older children and adolescents especially benefit from selecting their own personal goals for therapy.

Here are some general recommendations from the authors for talking with children:

Verbal messages: Use words that the child will understand, depending on their age. Talk about how the child feels about the session and their goals. Use language that is “realistic, empathetic, encouraging and responsive”.
Nonverbal messages: Avoid using a “sing-song” voice, speaking loudly or overbearingly, and interjecting while listening. Instead, make eye contact with the child, and use a calm, positive tone of voice. Use facial expressions and body language to show that you are interested and enthusiastic about the session. Take time to listen to your patient and pause to wait for their responses.

Autonomy: Giving children choices and listening to their perspectives
“There are a few things you’ve mentioned you’d like to do; what do you want to do the most?”
“What do you think might happen if…?”
“How are you going to do it?”

Relatedness: Empathetic listening, feedback
“I understand…”
“It seems like this is hard for you….”
“Let’s see if we can figure this out together”
“Who can help you work on this?”

Competence: Affirm a child’s abilities
“Oops, it didn’t work out. Let’s think about other ways/strategies”
“What skills will help you to do it?”
“What will make you feel you can do it?”

I’ve summarized some general recommendations from Ziviani et al. by age:

Age 4: Try to match the child’s sentence length (avg. 4 words). Listen for descriptive words that the child uses and incorporate them into how you describe the therapy. Respect the child’s desire for independence. Understand that these children will become frustrated easily if they cannot accomplish a goal.

Age 5: Offer choices, and help the child find words for their emotions.

Age 6: Adult expectations influence the child’s self perception. Ask the child for explanations or directions, and ask about their feelings.

Age 7: The child describes personal experiences and understands 5-step directions. Use complex tasks and mirror the child’s developing gestures.

Age 8: The child is beginning to compare themselves to other children and seek social acceptance. Involve child in goal planning discussion and peer engagement.

Age 9-10: Use humor to make therapy more interesting.

Age 11-12: The child is developing responsibility and self-reflection. Encourage them to think about their behavior, thoughts and emotions, and to take more responsibility.  Here are some specific phrases that Ziviani et al. suggest using. They are tailored to three psychological needs of a child: Autonomy, Relatedness and Competence (ARC).

We all want to feel like we are making choices in our care. We want to feel heard, and we need genuine encouragement. Kids need the same. There’s no need to fear.


Kline MP, Alvarez JA, Parizeau N. Kleptoparasitism of Harvester Ants by the Giant Kangaroo Rat (Dipodomys ingens) in the Carrizo Plain, California. Western North American Naturalist. 2018;78(2):208-211. doi:10.3398/064.078.0212.
Cuskelly M, Poulsen AA, Ziviani J. The Art and Science of Motivation: A Therapist’s Guide to Working with Children. Jessica Kingsley Publishers; 2013. pp. 159-182. Accessed October 8, 2020. https://search-ebscohost- direct=true&db=nlebk&AN=509756&site=ehost live&scope=site.

Telehealth during Covid- from a patient’s perspective.


Over the past four months or so I have had the opportunity to see healthcare during the COVID-19 era from the perspective of a patient. This has allowed me to personally feel how the changes we have made to keep providing patient care during a global pandemic have impacted our patients. This opportunity has allowed me the chance to see the good and the bad of telehealth and social distanced health care. To begin I want to start by saying all the health care providers I have worked with have been wonderful and are all phenomenal providers, and second this is only my perspective and is not meant as a fully encompassed view of the current state of health care.

I wanted to start by stating how weird it is to go into potentially life changing appointments while sitting at home and staring at a computer waiting for the doctor in the virtual waiting room. The setup just feels a bit odd, one minute you are sitting there drinking your morning coffee in your PJ pants and then all of a sudden you are in a deep virtual conversation with a provider about information that changes the trajectory of your day to day life. Before you know it the zoom, or google chat room closes and you are left sitting there trying to process the news in your living room. The good news is many doctors have understood this concept and are willing to sit in the virtual chat and discuss details for as long as you need, however the difficulty with this is that there is always an abrupt ending to the call and the patient is still left sitting there with their mind racing and the urge to google what they were just told. One thing I have found that has helped is that when a doctor gives life changing information many of them have allowed me the opportunity to schedule an in person visit after the virtual call to follow-up and do the physical examination. 

Another area that has been interesting to see is that there seems to be no set appointment length with patients during this time. My experience has been that my virtual appointments last anywhere between 6-45 minutes. This has been an adjustment as a patient because many times you go into physical appointments and can expect to be seen for around 20-30 minutes. My best virtual appointments have been with the doctors that take the time that would normally have been filled with physical examination and discussed research and things to try at home and scheduling in person visits as necessary. My less effective virtual appointments were doctors just telling me physical lab results that have already been uploaded to my patient portal and ending the call with no clear conclusion. As many professionals try to navigate this new era of health care one area that can not be lost is bedside manners.

One area that I have enjoyed about being a patient in this time is that it has expanded the network of clinicians I can see. I was able to see my PCP back in Minnesota, while still going to school in New Mexico and then within the same week see a specialist down in New Mexico. This type of care has allowed for a wider variety and a larger network of providers to work together. It makes it feel almost like you have your own personal pick of providers as long as they are covered by your personal insurance. This makes getting second opinions easier and more efficient than before. 

Telehealth has provided many challenges for providers to work through on their end, but one area that can not be forgotten is the patient’s experience. The struggle of having to log into a virtual chat to hear news that could alter an individual’s whole life and having that chat end leaving them sitting in their living room is unprecedented for many individuals. Having had the opportunity to live this reality has made me recognize the struggle our patients are going through. The lack of face to face interaction has taken a piece of the compassion out of a professional field that strives to provide our patients what they need during major life changes. This isn’t to bash on telehealth. I have actually thoroughly enjoyed being able to utilize telehealth as a patient, it is just to remind ourselves that our bedside manners are even more important when social distance creates barriers to the compassion that many of our patients need. Through our own continuing education and experiences I think telehealth can become an important piece of health care going forward. 


What Kind of Excerise is Right For You?

by Hannah Mullaney, SPT

Me: “What kind of exercise should I do?”

Also me: “Mmmm, it’s too complicated.”

“But I know it’s important for me.”

“Probably costs lots of money. I don’t know.”

“Just do anything, some push ups, planks, squats, jumping jacks!”

“Oh look, I’m out of time.”

These internal conversations abound when it comes to exercise. It is easy to become frustrated and overwhelmed. And the question often begins with, “what kind of exercise do I do?”

The simple answer is this: whatever you will actually do!

Strengthening the heart, building up the bones, balancing the chemicals messengers of the body and brain – a few of the direct benefits of exercise – these powerful outcomes blossom for doing things that challenge and move the body. Every person has distinct and individual interests, and effective, sustainable exercise training comes from doing something that matches someone’s interests with movement.

Guidelines start simple – move more! Take the stairs, park far away, stand on one leg while talking of the phone. But many people want to take that next step. Once people have experienced the relief of finishing a workout, the satisfaction of pushing their limits, or the sense of calm from endorphin release, they are ready for more. Officially, adults are recommended to do moderate to vigorous physical activity for 30-60 minutes, 5 days a week (

At this point, the options may feel endless – gym membership, Zumba classes, rock climbing, running, biking, swimming, weight lifting, team sports league, golf….the list goes on an on. The volume of opportunities can be overwhelming. Some of these options are more expensive than others, and people need to think about their priorities and budget. Sometimes there are forms of exercise that may be easily overlooked, like roller blading, coaching a child’s soccer team, fishing (especially fishing someplace that can only be reached by hiking), a quick 10 minute circuit of squats, pushups, and planks, and dancing.

All of these things are valid forms of exercise. The trick is to pick something that is fun and interesting and puts a smile on the exerciser’s face.

“I HATE running!” Common sentiment. Solution…don’t run! Yes, it’s important to push oneself past the comfort zone, but, if it really is such a drag, maybe find something that is more interesting. Would running or biking to the movies to meet with friends make a difference? (Then, don’t eat the entire bag of popcorn.) Maybe if running doesn’t jive well, what about dancing? What about 3 v 3 basketball games on lunch break? All of these activities will still increase the heart rate and help make the body happy and healthy.

People talk about SMART goals, and someone who is motivated to move their body more can use these techniques to make their own game-plan. Here is the breakdown of moving more SMART-ly, using the example of someone who wants to swim 800 meters on an upcoming triathlon relay. For this individual, their spouse is doing running while another friend is doing the biking.


Specific – set a narrow goal. “I will go to West Side Pool.

Measurable – set a goal with something concrete to measure. “I will go to West Side Pool for 45 minutes.”

Achievable – set at goal that can actually be reached. “I will go to West Side Pool for 45 minutes on Wednesday and Friday afternoons, when I have a shorter work day. Also, I own goggles and know a little bit about swimming, so this is a realistic goal.”

Relevant – set a goal that matters to you personally. In this example, the individual is doing swimming, so swimming is the relevant activity.

Time-based – set a goal that has a clear start and end time. “The triathlon is in 6 weeks.”


Therefore, the whole goal is would look like this. “In order to prepared for my part of the triathlon relay, I will go to West Side Pool for 45 minutes on Wednesday and Friday afternoons for the next 6 weeks in order to swim 800 meters without stopping.”

Finally, accountability takes goal-making to goal-attaining. If someone is asking us how we are doing, bugging us about going to the gym, waiting for us at the trailhead at 7am, or trying to workout 5 days a week with us, we are that much more likely to follow through with our good intentions. In the example above, perhaps the spouse can run while the swimmer does laps.

Therefore, if you are thinking about exercising more, my encouragement is to dive right in! Find something enjoyable that you actually want to do. Set a SMART goal. And, very importantly, ask someone to hold you accountable. No need to wait – let’s get moving today!

Falls, Exercise and Evidence in Physical Therapy

Does exercise really help reduce falls? As physical therapists, we educate our clients in the importance of exercise daily.  Of course, we know that exercise truly does reduce fall risk.  Some clients are eager to exercise, experiencing an increase in energy and improved confidence with their mobility and walking. However, others need some convincing to jump on the exercise bandwagon.  As a physical therapist, I love to educate my clients in strategies to keep them as independent and active as possible.  Utilizing medical research studies provides great evidence to support exercise for independence.  Here we will review the correlation between older adults, falls, healthcare and exercise.

According to the Centers for Disease Control and Prevention (CDC), 1 in 3 adults over age 65 years falls each year, in the United States.  Almost half of individuals over age 80 fall each year.  Falls are the leading cause of injury-related death in this age group.  Falls not only impact the independence and quality of life of individuals as they age, but they also are very costly to the healthcare system.  According to the CDC, the direct medical costs of falls among older adults in 2013, was $34 billion.  Because of an aging population, this figure is likely to continue increasing.  The direct costs are calculated by insurance reimbursements for treating fall-related injuries.  This does not include the long term costs for future disability, dependence on others, lost work time and lower quality of life.  It is estimated that the average hospitalization cost for a fall injury is over $35,000.  As therapists, we know that conservative treatment through physical therapy can reduce healthcare costs drastically.  It is much less expensive for insurance companies to pay for 12 visits of physical therapy, than to pay for a hip replacement and all the aftercare necessary.

physical therapy for falls

Those staggering statistics can be a bit discouraging for older adults.  By educating clients in the modifiable risk factors, they can take an active role in reducing their own fall risk.  Research shows that risk factors highly associated with fall risk include: history of falls, balance problems, leg muscle weakness, vision problems, taking more than 4 medications, and difficulty walking.  Many of these factors can be significantly reduced through exercise.  Exercises should focus on leg strengthening, balance training and flexibility.  There are many published medical research studies to support this claim.

In a study systematic review of literature performed by Gillespie et al.(1), 111 clinical trials were reviewed to analyze the efficacy of exercise in reducing fall risk.  The authors concluded that exercise interventions reduce both the risk and rate of falling in older adults.  In another review of literature, Powers et al.(2) examined what type of exercise has the greatest impact on reducing falls.  They found that a program of muscle strengthening and balance training that was individualized to a person’s need (one prescribed by a trained health professional, such as a physical therapist) was highly beneficial.  In addition, they found that Tai Chi group exercise was shown to reduce risk of falls, as was participation in a home hazard assessment and modification session.  Group exercise classes were beneficial, but not as beneficial as individualized exercise programs.  As therapists, we should consider incorporating Tai Chi as part of home exercise programs.  Also, we should educate our patients in home safety strategies to reduce environmental hazards.

In another systematic review of the published literature, 54 trials were analyzed by Sherrington et al.(3), and found that exercise was the single best intervention to prevent falls.  This study noted that the exercise program must challenge the balance and improve muscle strength through resistance training.  The exercise program should be progressive and individualized to the client’s needs and limitations.

The main learning points of these research reviews are that the exercise programs must be tailored to individual limitations.  If the client has limited strength in their hip flexors and trunk, then they will not be able to properly elicit a hip strategy to maintain balance.  Therefore, the exercise program should focus on strengthening those areas of weakness.  In addition, the client’s balance improves, you will need to progress the difficulty of the exercise for continued improvement.  These strategies all seem like common sense to an experienced clinician.  However, sometimes patient’s need to see the proof that therapy can improve their safety and independence as they age.

As therapists, we must be our own advocates.  The physical therapist is a vital component of the healthcare team.  We are the most capable healthcare experts to reduce the risk of falls in aging adults, through a thorough evaluation and treatment plan.  We should empower our clients with a comprehensive and easy to follow home exercise program, in order to further improve their confidence and independence after completion of physical therapy.  So, next time you have a client that is not a believer, show him the evidence that exercise truly does reduce fall risk.

Utilization of outcome measurement tools, functional mobility tasks and simple examination components such as single leg balance, and tandem stance are excellent means of demonstrating improvement in physical performance and reduced fall risk.  Through utilization of bestPT software, we can easily document objective measures and compare pre and post intervention outcomes.  These improvements can be easily faxed, printed and shared with our clients and their other healthcare providers.  You will be able to turn skeptics into therapy believers.

Disclaimer: For HIPAA compliance, all characters appearing in this post are fictitious. Any resemblance to actual persons or actual events is purely coincidental.

  1. Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, Rowe BH. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2009 Apr 15;(2): CD007146.
  2. Powers C, Farrokhi S, Moreno J. Can exercise reduce the incidence of falls in the elderly, and, if so, what form of exercise is most effective? Physical Therapy. 2002 Nov vol 82; no 11; 1124-1130.
  3. Sherrington C, Tiedemann A, Fairhall N, Close JC, Lord SR. Exercise to prevent falls in older adults: an updated meta-analysis and best practice recommendations. N S W Public Health Bull. 2011 Jun;22(3-4): 78-83.

Caring for the Complex Pelvic Patient Part II: Treatment techniques

In the second installment of this three part series: Caring for the complex patient, we will review the patient’s presentation and discuss the treatment techniques employed and how documentation using bestPT supported the treatment.

The patient was a 34 year old female referred to physical therapy (PT) by her obstetrician-gynecologist (OB-GYN) for evaluation of pelvic organ prolapse (POP). The patient presented to physical therapy para 2 grava 2 (P2G2) indicating 2 pregnancies and 2 live births. On the day of evaluation she was 5.5 weeks post vaginal birth after cesarean (VBAC) of her second child. Her primary concern was a feeling of heaviness and a sense that her organs were falling out, especially during standing and lifting tasks. Her physician had not yet performed a complete six week post-delivery examination, though this appointment was scheduled for three days after physical therapy evaluation.

The patient reported neither pain nor unintentional loss of urine (incontinence), though she felt weak throughout the abdominals and pelvic floor. Pertinent past medical history consisted of cesarean section 11/19/12 (almost two years prior to PT evaluation date) with subsequent hematoma at the surgical site which resolved with use of an abdominal binder. She is otherwise a very healthy woman with no comorbidities. The patient lived at home with her husband and two children, works as a physician assistant specializing in hospital based gastroenterology which requires prolonged standing during procedures and patient rounds. She is an avid runner and aerobics instructor. Her primary goal was to be able to safely lift each of her children without the sense of heaviness in the pelvis. Secondary goals were to return to running and teaching aerobics classes which are her primary sources of recreation and stress reduction.

Physical therapy examination revealed abdominal strength to be 3+/5 on the Kendall scale. The Pelvic Floor Impact Questionaire (PFIQ-7) was utilized as standardized outcome tool. This patient received a score total of 0 on the bladder and rectum subsets, and a score of 19 on the pelvis subset for a total score of 19 on the scale. Internal examination and musculoskeletal physical therapy differential diagnosis included pelvic floor dysfunction resulting in prolapse, and increased abdominal pressure due to visceral adhesions from previous c-section.

The first priority of intervention was patient education to avoid bearing down and valsalva maneuvers. Discussion on the day of evaluation included contracting the pelvic floor prior to lifting her toddler or infant, safe lifting spinal mechanics, and breathing technique to avoid abdominal bulging or bearing down. Avoidance of constipation was discussed, though this was not an issue for this patient, nor was weight management. The patient was issued a copy of the American Physical Therapy Association’s postpartum health awareness information brochure to provide further education regarding postpartum back and pelvic pain, pelvic floor muscle care, post partum fatigue, posture, and cesarean scar management.

Following the internal pelvic exam, the patient was given a pelvic floor strengthening program. Given that the role of connective tissue in providing support to the pelvic floor has gained significant emphasis in the literature, it is understood that if the patient does not benefit from a pelvic floor strengthening program than other means of intervention may be warranted. The rationale for intensive strengthening of the pelvic floor muscle to treat POP is that strength training will build up the structural support of the pelvis by elevating the levator plate to a higher resting point, and maintain this position through hypertrophy and improved stiffness of the pelvic floor muscles.

As no single or absolute protocol has been reported to be the absolute gold standard in the literature, pelvic floor muscle (PFM) training was dosed based upon compilation of evidence in the literature, and patient response. Initially the patient was given a program of 80-100 kegels per day, with 4 sets of 10 being 5 second hold, and 4 sets of 10 being 15 second hold to address speed and endurance of the muscles. These numbers were calculated based upon her muscle test scoring durng initial evaluation. Due to her busy schedule and PFM strength of 4/5, she was advised that these could be performed in various positions, including supine hooklying, sitting, and standing. She was educated to gently draw in the abdominals during PFM contraction as transverse abdominis co-contraction has been demonstrated to enhance activation of the pelvic floor.

Progression of PFM exercise and lumbo-pelvic stability exercises were increased each visit as the patient became stronger. Progressions included diaphragmic breathing pattern with pelvic floor muscle contractions, sidelying clams while performing a PFM and transverse abdominis contraction, and quadruped PFM with transverse abdominis contraction. This exercise was progressed by adding an opposite upper and lower extremity lift (commonly referred to by physical therapists as a bird dog). Pelvic brace with cough was added to address co-ordination and timing of PFM contraction prior to increased intra-abdominal force.

Planks in the forward and side position were introduced at the fourth visit with instructions to contract the pelvic floor muscles and transverse abdominis. At this point, the patient was able to sustain this contraction and sense lift of the pelvic floor for approximately 20 seconds. Sit to stand with kegel and small range squats were added as well. At this point in treatment the patient reported that she was already feeling much better, noting a 50% improvement in overall symptoms during activities of daily living.

Manual therapy consisted of myofascial release (MFR) and scar mobilization, and was performed on the first several appointments to address restriction and adhesion from her cesarean scar. The scar was mobilized in all planes by applying gentle pressure to the scar itself and moving it in the caudal-cephalad, medial-lateral, and rotational planes. Myofascial release of the surrounding tissue was performed similarly. Tissue restriction was assessed to be restricted in all planes both above and below the scar.

Treatment consisted of applying gentle pressure downward with the patient positioned comfortably in supine-hooklying with a bolster under the knees. The theory behind MFR is that the pressure will stimulate increased blood flow and subsequent heat production, enhance lymphatic draining, and provide proprioceptive input into the tissue addressed. Treatment technique of this nature can be direct, wherein the tissue is mobilized in the direction of restriction, or indirect wherein the tissue is mobilized away from the direction of restriction, similar to sliding a stuck dresser drawer backwards in attempts to gain a smooth slide outwards.

Both direct and indirect techniques were utilized on this patient due to the fact that she tolerated both quite well. Once pressure was established and direction of restriction determined, which was both superior and inferior to the Pfannenstiel’s incision, and on the left of the incision, gentle pressure was held until a giving way sensation was felt. The patient was educated in self scar massage technique and advised to perform daily. Additionally, strain-counter-strain (SCS) technique was utilized to release tight and shortened iliopsoas muscles bilaterally.

Muscle energy technique (MET) was utilized in order to re-establish symmetry to the sacroiliac joints of the pelvis. The pubic shotgun technique was utilized prior to torsion MET to draw the left anterior innominate posteriorly and thus level with the right. The patient responded extremely well to treatment. The final installation of this three part series will discuss her outcomes and provide insight to other possible treatment techniques for this patient population.

-Amanda Olson, DPT

Caring for the complex pelvic patient with Physical Therapy

Physical therapists specializing in pelvic health are confronted with a myriad of pelvic floor diagnoses and impairments which may result in pelvic organ prolapse (POP). Pelvic floor weakness secondary to muscle fiber damage or connective tissue abnormality may account for this phenomenon. Extenuating circumstances, such as a vaginal birth after cesarean section (VBAC), add further dimension to the patient’s presentation clinically. A 2014 study suggests that 65% of women experience successful VBAC deliveries, and there seems to be a growing trend of women requesting them.

I recently had the privilege to treat such a woman in the clinic. The patient was a 34 year old female referred to physical therapy (PT) by her obstetrician-gynecologist (OB-GYN) for evaluation of pelvic organ prolapse. The patient presented to physical therapy para 2 grava 2 (P2G2) indicating 2 pregnancies and 2 live births. On the day of evaluation she was 5.5 weeks post vaginal birth after cesarean (VBAC) of her second child. This three part series will analyze how documentation supported the evaluation, treatment, and outcomes of the patient.

At the time of initial evaluation her physician had not assigned a grade to her pelvic floor prolapse. Furthermore, the patient had not been evaluated for prolapse during cough; bear down, or in standing position, per patient report. Her primary concern was a feeling of heaviness and a sense that her organs were falling out, especially during standing and lifting tasks. Her physician had not yet performed a complete six week post-delivery examination, though this appointment was scheduled for three days after physical therapy evaluation.

The patient reported neither pain nor unintentional loss of urine (incontinence), though she felt weak throughout the abdominals and pelvic floor. Pertinent past medical history consisted of cesarean section 11/19/12 (almost two years prior to PT evaluation date) with subsequent hematoma at the surgical site which resolved with use of an abdominal binder. She is otherwise a very healthy woman with no comorbidities. The patient lives at home with her husband and two children, works as a physician assistant specializing in hospital based gastroenterology which requires prolonged standing during procedures and patient rounds.

She is an avid runner and aerobics instructor. She reports that there is good stress in her life with the birth of her second child. She was concerned that she would be unable to safely lift her toddler, run, or teach classes in her current state. Her primary goal was to be able to safely lift each of her children without the sense of heaviness in the pelvis. Secondary goals were to return to running and teaching aerobics classes which are her primary sources of recreation and stress reduction.

Physical Therapy Electronic Documentation

Click to Enlarge the image.


Past medical history is easily entered and accessible in the electronic chart.

There is burgeoning evidence to support physical therapy intervention for pelvic organ prolapse. A Cochrane Database System Review analyzed three randomized control trials (RCT’s) and found that pelvic floor muscle training may result in prevention of symptom worsening, and better self-reported patient outcomes. Furthermore, there is Level I evidence via 3-D ultrasonography that supervised pelvic floor training can increase PFM volume, close the levator hiatus, shorten muscle length, and elevate the resting position of the bladder and rectum in patients with POP. The researchers noted improvement in muscle thickness in both stage I POP and in symptomatic women with stage II or greater as determined by the Pelvic Organ Prolapse Quantification Scale (POP-Q).

As a measure of functional outcome, the patient was asked to complete the Pelvic Floor Impact Questionnaire-short form 7 (PFIQ-7). This outcome measure is a patient report of impact of symptoms of bladder, bowel, and prolapse impairments, and allows the therapist to gauge the level of impact and frustration that the patient experiences due to their symptoms so that treatment may be tailored to fit their individual needs. The PFIQ-7 was found in long form to be valid and reliable for women with disorders of pelvic floor including urinary and fecal incontinence, as well as pelvic organ prolapse. It is internally consistent (0.96-0.97), and reproducible (0.77-0.92), and the prolapse section was found to be significantly correlated with the stage of prolapse of the individual. The short form is faster for the patient to complete, and was found to maintain excellent correlation with the long form (r=0.95 to 0.96), with test-retest reliability P<.001). The outcome may be analyzed in subsets for bladder, bowel, and pelvic symptoms, respectively. This patient received a score total of 0 on the bladder and rectum subsets, and a score of 19 on the pelvis subset for a total score of 19 on the scale.

Musculoskeletal screening included assessment of posture in standing and sitting as this can be beneficial as an assessment of structural alignment according to the American Physical Therapy Association’s Guide to Clinical Practice 2nd Edition. The patient demonstrated mild forward head, mild anterior shoulder positioning with mildly increased thoracic kyphosis and lumbar lordosis. Pelvic symmetry was assessed by palpating the bony landmarks of the anterior superior iliac spine (ASIS) bilaterally, and the pelvis was mildly anterior rotated on the left. This pelvic position was verified in the supine position to account for possible interaction of limb length discrepancy. Limb length was measured and found to be insignificant with the right lower extremity measuring 1 millimeter longer than the right. Abdominal strength was graded 3+/5 as she was able to lower her legs no greater than a 60 degree angle while maintaining posterior pelvic tilt, according to Kendall’s muscle testing scheme.

PT examination sought to determine the nature of the heaviness in the pelvis through observation and palpation of the pelvic floor in supine hook lying position. This is done in order to assess the response of the pelvic floor and determine which walls of the pelvic floor appear to be affected.
Musculoskeletal physical therapy differential diagnosis included pelvic floor dysfunction resulting in prolapse, and increased abdominal pressure due to visceral adhesions from previous c-section.

Physical Therapy Electronic records

Click to Enlarge the image.

Documentation to demonstrate verbal and written consent for external and internal pelvic floor examination are pertinent.

bestPT is able to create unique objective components to demonstrate that consent has been verified. Furthermore it is possible to scan in and attach release forms that have been signed by the patient.

In the next installment, we will discuss treatment techniques in this unique women’s health sub-population.

-Amanda Olson, DPT

Physical Therapy Software | Improve Patient Retention with Care Plans

Physical Therapy software_ patient-treatment-plansAre you worried about paying next month’s bills because your patients don’t show up for their appointments? If your patients are noncompliant with your prescribed care plans, you cannot predict the cash flow at your physical therapy practice. What’s even worse is that your patients won’t get better.

Without consistent patient flow your practice cannot grow or be profitable. But unfinished care plans can also cause compliance issues and hurt your cash flow even further when you have to return payments. You can figure out just how much money your practice might be losing due to unfinished or unused care plans. Simply replace the assumptions below with your own practice numbers and complete the calculations.

For example:


  • 1 visit = $89
  • 1 care plan = 10 visits
  • Average number of no-shows per care plan: 5

Calculations: Potential income and losses from unfinished care plans per patient:

  • Potential income from 1 care plan: 10 visits x $89 = $890
  • Potential loss from no-shows per care plan: 5 visits x $89 = $445

Conclusion: You risk losing half of your income when patients don’t finish their treatment plans!

Identifying patients who don’t understand  the need for multiple visits to achieve their health goals is easier said than done, however. You really need to know what the entire plan looks like in order to track multiple visits. For instance, you need to track any patient that goes through a traditional  treatment step-down ladder, such as four visits per week for the first four weeks, then three visits per week for the next three weeks, and so on. Such unique nuances on many patient schedules are difficult to track manually, and this difficulty grows dramatically with each added care plan. Not to mention, tracking the respective discounts given for each care plan is nearly impossible without a tool.

Thousands of care plans are created for new patients every month to schedule multiple appointments and then track all payments and visits with your bestPT EHR software. When patients don’t show up for their appointments you can receive automated alerts on your physical therapy software workbench. You can also receive alerts via tickets when patients don’t have a future appointment scheduled or when they cancel their existing appointments. That way you can assign your staff the task of scheduling the next appointment. Another useful tool for helping your patients stay on track with their care plans are appointment reminders sent via phone, text, or email. bestPT physical therapy software has integrated several apps which serve this purpose.

Physical Therapy Software_ CarePlan

To set up care plans when your patients come into your practice, simply go to bestPT’s Scheduler and click on the “More” tab to open the wizard. You can also create a full care plan from the patient account. Make sure you turn on the settings in your bestPT physical therapy software for Patient Relationship Management and Reminders.

Physical Therapy Billing | Patient Education Improves Rehabilitation Results

Physical Therapy Billing_Patient EducationStatistics show that PT patients retain less than seven percent of what is explained to them through traditional methods of physical therapists. Surveys also show that the lack of understanding by the patient of their condition is the number one reason for patient visit cancellations, a poor clinical experience and inadequate treatment plan compliance.

Solution – Patient Education
When patients know why they tend to comply! 3D Animation is a tried and tested method of communication that allows easy understanding by the patient and longer term retention of the information presented them.

3DRX have created the most extensive and professional library of Medical 3D Animations along with a massive library of Rehabilitation Exercises and a fleet of other Innovative Patient Education Products. The survey results from 22 practices across three countries, over a 8-month period using the 3DRX Products have been staggering:

  • 19% increase in New Patients
  • 27% reduction in Patient cancellations
  • 36% improvement in Patient Satisfaction with their clinical experience
  • 94% overall Practitioner satisfaction rate by the clinics using the program


Solution Features
Some of the main features that Practitioners liked most about the product:

  • World’s largest library of Physical Medical  Animations Library
  • New Rehabilitation Component with extensive Protocols
  • The Ability to communicate both Animations and Rehabilitation Programs
  • Being associated with the high end technology and innovative program
  • Having a tool that differentiates your clinic from others
  • Marketing your clinic in a professional and non- over solicitorial manner
  • Marketing your practice without feeling
  • like you are selling something to the patient


What we have done – The first PT-specialized Practice Management System solution integrated with Patient Education

BestPT has integrated with 3DRX to provide you with the Leading 3D Physical Medicine Animation and Rehabilitation Products. Our current practices can have in one click the full functionality of 3DRX, being able to vividly educate their patient and build a training rehabilitation program that will be accessible to the patients through our Patient Portal.