Aquatic therapy is a developing modality in the treatment of brachial plexus injuries in both the adult and pediatric populations.

Ideally, it is recommended that aquatic exercises are performed in a therapeutic pool environment where the water temperature ranges from 89 to 94 degrees. Doing therapy in a warm water environment assists with muscle relaxation, tone reduction and pain control. In addition, one can also utilize the properties of the water to address strength, motor control, proprioception (knowing where an extremity is in space), conditioning, endurance, edema, coordination and range of motion concerns (whether in a warm water pool or in a regular fitness pool where the temperatures are colder). Gross and fine motor play skills and functional activities can be simulated in either water temperatures.

Before aquatic therapy is initiated, medical clearance is highly recommended. The increased temperatures associated with a therapeutic pool may be contraindicated for specific medical conditions (e.g., cardiac issues).

Because of the specific property of the water in that it can temporarily create more joint space, one needs to be aware that there is a greater risk of dislocation in the water. If there already is a dislocation or subluxation in any of the upper extremity joints, one should consult with a brachial plexus specialist and/or therapist for specific motions that need to be avoided or done with great care. There may also be specific pieces of equipment that need to be avoided as well.

There are many properties of water that can assist with the treatment of a brachial plexus injury. One is the buoyancy property of water. This property is the upward force of the water that is opposite to the force of gravity. It is responsible for the ability to float in water. Buoyancy also assists with the dramatic freedom of movement in water and creates a low impact environment to exercise. The buoyancy property of water reduces body weight therefore it decreases the musculo-skeletal stress/impact of the body. For example, water will assist weak or paralyzed muscles to move more easily in a protected environment.

Another property of water is the resistance from the hydrostatic pressure. This is the force of the water on anything that pushes into it. Water resistance is approximately twelve times more than air resistance. Resistance assists with increasing muscle strength and power. Resistance is increased when the extremity or object is moved with increasing amounts of speed or when equipment is used to increase the amount of surface area. The advantages of utilizing the resistance property of water are that the amount of work can be immediately modified by a quick change in the speed of movement or equipment.

The pool environment is a fun and playful one. It is a wonderful and positive way to encourage play activities, general health and physical fitness for children of all ages. Aquatic therapy and/or swimming can be a lifetime sport for the participant. Below is a list of recommended treatment activities and equipment to utilize in the pool as well as some helpful play ideas. Have fun!

Buoyant or Supportive equipment uses the buoyancy property of water to strengthen the shoulder and scapular and address range of motion throughout the entire arm. In addition, this equipment enables one to feel supported in the water.

• Swim Floats and/or Wet Vest – This is a device to assist with encouraging independent floatation in the water. It promotes one to utilize bilateral upper extremities to propel themselves through the water in various positions. These vests come in a variety of sizes and can generally fit any adult and any average sized one year old child and up. These vests are also helpful when addressing dressing concerns.

• Buoyancy Belts – These can be positioned in a variety of locations on the body and/or extremities to assist an individual.

• Hand Foam Barbells – These come in various sizes and can be used with one or two arms.

• Padded Swim Bar Float – This is a long bar with two barbells.

• Medium to High Density Foam Mats – These come in a variety of shapes and sizes.

• Buoyancy Cuffs – for legs and/or arms

• Noodles / Funny Floats / Inflatable Boats / Neck Collar / Air Arm Splints / Water Wings

• Pull Floats/Buoys – For the legs to work on pulling activity with the arms

• Foam Swim Disks – These can be placed on the arms and/or legs.

• Pool Pony

• Comfy Log

Resistive Equipment is very helpful to address range of motion, stabilization and strength issues. One uses this equipment to increase the amount of force or surface area when the extremity is pushing through the water.

• Hydrotone Bells

• Pool Paddles – Power, Hand

• Webbed Aqua Gloves or Mitts

• Resistant Cuffs or Wings

• Thera-Band/Theratubing

• Fins

• Ankle/Wrist Weights

• Hand Paddles

• Water Weight Bells

RANGE OF MOTION: Generally, it is recommended to initiate aquatic activity with gentle passive and/or active range of motion activities. This allows the person to become accustomed to the water as well as help to "warm-up" the arm prior to more challenging activities. Range of motion should include all motions of the shoulder, scapular, elbow, wrist and fingers. Furthermore, attempt to submerge the arm under the water when possible. The warm water will assist with muscle relaxation and maximizing the available range of motion.

SWIMMING ACTIVITIES: Any and all of the standard swimming strokes can be modified to encourage safe upper extremity movement. It is less challenging for the involved arm if one swims with the arms remaining under the water. A modified front crawl is an excellent beginning stroke to start with. One can be taught to "scoop" up the water with both arms and crawl forward in the water. Some children and/or adults may need to be supported. This can be done by various adaptive swimming equipment and/or floats or with some physical assistance from a caregiver or parent.

Another stroke that is helpful is performing a modified backstroke. Have the person lie on their back and bring both their arms and legs apart and together (similar to a snow angel). The standard backstroke is also a helpful stroke to perform. One can swim laps or to and from various landmarks or toys. Younger children can swim to and from caregivers and/or parents. Goggles mask and snorkels can be helpful to encourage underwater swimming. At all times, ensure that the person feels comfortable and is safe. It is also recommended that recovery and other water swim skills are practiced.

WEIGHT BEARING ACTIVITIES: Weight bearing activities are an excellent way to strengthen and facilitate proprioceptive input. Weight bearing will also assist with shoulder and scapular stabilization. One can use the foam mats to perform various developmental transitions and positions. For instance, the prone and/or the prone prop on elbows or extended arms are excellent weight bearing positions. Also, the quadruped or side prop positions can also be performed. Initially, have the child/adult attempt to maintain the various positions independently. Then encourage them to use both extremities to play, one at a time and together. One can reach for any object/toy or splash the water. This helps to facilitate independent and spontaneous arm movement. In addition, the mat can be used to climb in and out of the pool via the deck.

Other weight bearing activities include arm "walking" on the side of the pool, pool side rail and/or stair/ramp rail. Also, one can utilize a kickboard and/or dumbbells to kick and blow bubbles. Also, you can try pushing and pulling a kickboard or toy against the water in various directions. A person may also attempt to use the barbells or the padded swim bar float to make pizza and cookies by rolling out the dough. In addition, one can try to commando crawl or crawl up and down a ramp or stairs.

Another helpful activity is having a child hold onto a pool pony or noodle to pretend to ride a horse or ride a swing through the water.

STRENGTHENING AND STABILIZATION EXERCISES: One should be encouraged to strengthen a variety of muscles throughout the extremity to maximize functional movement and activity. Utilize any of the equipment recommended to address the specific areas needed. Remember, one can use the equipment either to assist or resist movement. The advantage of water is that one can easily modify an exercise for their specific needs.

FUNCTIONAL ACTIVITIES AND PLAY IDEAS: There are numerous activities that one can perform in the water. Attempt all play activity with both the involved and uninvolved arm. Also, encourage bilateral extremity play. Have the involved arm manipulate toys/objects as well as act as a stabilizer. Furthermore, there are numerous songs to sing during pool activity. Try to emphasize clapping and finger/hand movements during the songs. Below is a list of some creative play activities to perform:

• Songs – "Wheels on the Bus", "When You are Happy and You Know it", "Patty Cake", "Itsy-bitsy Spider", "Ring around the Rosey", "Row, Row, Row Your Boat", "Motor Boat, Motor Boat", etc.

• Balls – These come in a variety of sizes, shapes and textures (Goof, Sensory, Beach, Rubber, Playground and Volleyball). Balls of all sizes are fun and very helpful. One can throw, roll, feel, catch, squeeze, hit, swing at, lay or sit on and aim for these balls. A basketball and a modified "water" bean bag toss game can also be helpful.

• Various Pool Workout Stations – A child can use these to climb on, like a jungle gym.

• Foam Blocks - Foam blocks can be a lot of fun in the pool. One can build a castle on a kickboard and then knock it down. This encourages hand manipulation and release of objects with the grasp of choice.

• Dolls – One can pretend carry, feed, dress and care for a doll using one or two hands.

• Stacking Cups, Plastic Eggs, Watering Cans, Pails and/or Barrels – These can be used to practice opening and closing, as well as scooping up and pouring out the water. Also, one can use other toys that can be opened and closed by twisting the lid.

• Tea Party and/or Kitchen Set – This can be used to promote functional movement and practice manipulation of food.

• Dive Toys – This include various rings and games to facilitate under water arm movement.

• Ring Toys – These come in a variety of shapes and sizes. They can be placed on and off objects and/or arms.

• Floating Pool Games – (Play Bricks, Ring Toss, Fishing Game, Boats) Have the child/person move and manipulate these toys throughout the pool in a variety of ways.

• Water Puppets – There are puppets available for both the finger and hand.

• Squeeze Toys – There are a variety of toys available. This is wonderful way to promote functional grasping of objects.

• Toys with Net – Have the child use the net to "catch" fishes and/or toys in the water.

• Pretend Jewelry – Bracelet, rings and necklaces can be used to encourage various types of grasp and hand manipulation.

• Water Books – These can be used to encourage functional arm activity.

Cathie Feeney, P.T., is a staff therapist in an outpatient hospital setting at Hospital For Special Care in New Britain, Connecticut. She treats a variety of diagnoses and has both adult and pediatric clients. Her treatments are both in the outpatient clinic and in the two available pools. Cathie has been a therapist since 1993.