Dip into the Pool


Guidelines to providing excellent aquatic care

By Kelly McFarland, PT, DPT

Risk. Thrill. Heartache. Sleepless nights. Profit.

Perhaps like many of you, I come from a family of entrepreneurs. My father started his own business. As did my mother, and my brother, and my sister, and myself. We are passionate about what we do. This makes for some interesting kitchen table discussions about customer service, leadership, return on investment (ROI), return on equity (ROE), and net operating income (NOI).

Business may run in my veins, but so does another substance.


I opened my physical therapy practice with the goal of helping people heal the best way—my way—with personalized plans and individual care. I knew going into private practice would be my best shot at accomplishing this. Because of personal experience and the positive outcomes that I have witnessed, I believe in aquatic therapy as an adjunct to a patient’s care. Water soothes, relaxes, promotes movement, compresses, and—when used correctly—heals. From the beginning, I wanted to make water my “niche.” I researched many options and eventually chose to invest in a therapy pool with an underwater treadmill, resistance jets, and underwater video monitoring system. With a pool and a place to put it, I was ready to roll.

Twelve years, three clinics, and 18 employees later, aquatic therapy remains a focal point of our practice. Its mere existence in our practice draws clients to us and its effectiveness brings them—and their friends—back. Water has helped brand us as a premier clinic; expanding into new markets, and serving people with diverse conditions. Along the way we have learned a few things about how to create and maintain a high-quality aquatics program.

One Patient at a Time

Treating multiple patients in the therapy pool at the same time is possible, but at Premier, we like to specialize in individualized care as a best practice. We found patients tend to feel apprehensive when they are being treated in the pool in a small group setting. Some are not comfortable exposing their bodies “publically” in a swimsuit. They want privacy. Others may be rehabbing from a joint replacement surgery and are unsure of their body’s functionality, while others are ready for speed training. They want personalized attention. When a therapist is juggling multiple patients it cuts down the quality of care, at least in the patient’s mind. With a single-patient policy and 45-minute sessions, the maximum capacity each day for our pools is 12 patients. We average 8-12 patients per day.

Invest in the Best Product on the Market

I heard a respected attorney once answer this question from a young, soon-to-be law student. “I’m choosing between two schools. One will pay my way but the other is in the top 10. Where should I go?” His answer: “Always choose the better school. It will pay off in spades.”

I opened my first clinic in 2003 with the crowning feature being a therapy pool with underwater treadmill, resistance jets, and video monitoring system. Since the day we opened, we have strived to provide premium service, special attention, and a more personalized approach, much like a “private school” version of physical therapy. People notice that we are different. Having water helps us “niche” our practice and stand out, but having the best water and using its tools creatively conveys to our patients our dedication to innovation and quality care. Many patients seek us out simply for our aquatic tools.

Create Personalized Programs

Our patients receive individual care created specifically for their situation. Some programming inevitably overlaps, but we progress patients based on their needs for each visit.


Judy suffered from scoliosis since she was a child, undergoing various amounts of pain medication and physical therapy through the years. As she progressed through middle age, the pain and neuropathy increased dramatically. She lost function. At age 55, Judy chose lumbar spinal fusion surgery, from T9 to sacrum, totaling nearly half of her back.

Judy was presented to our clinic two and a half months postsurgery. She was unable to sit during the initial evaluation due to her pain level and limited mobility. After an initial evaluation, we moved her immediately into the pool.

We instituted a Core/Lumbar Stabilization program where we were able to focus on muscle reeducation and establishing the proper firing patterns from the core stabilizers. We also incorporated functional movements such as squats, step ups, and walking.

Judy began the walking program without the use of the resistance jets, holding the handrails 100 percent of the time. She progressed quickly. Soon she was able to walk pain-free in the pool. We increased the treadmill speed, duration of the walk, and added resistance jets.

Judy now walks pain-free on land and has increased her stride length and range of motion. She also drives, sits for longer periods of time and walks—pain free—up stairs. She feels her “spirit has been lifted” as she has regained her functional mobility that she thought might be forever lost.

Educate Others about the Value of Water

Because of some therapists’ perceptions that patients are simply “floating around in the water,” aquatic therapy sometimes gets dismissed as a nonaggressive modality. With the underwater treadmill, resistance jets, and monitoring equipment, this is not true. Many research studies show its effectiveness for advanced recovery time, return to running, exercise advancements, weight loss, and rehabilitation.

Doctors W. Matthews Silvers and Dennis Dolny conducted several conclusive hydrotherapy research experiments at the University of Idaho. In the first study, it was found that training on an underwater treadmill can create a metabolic and cardiovascular environment as stressful as traditional land-based treadmills but with reduced joint stress. In follow-up studies, positive results were also verified with factors such as maximal oxygen consumption, heart rate, ventilation, blood lactate, leg stride rate and length, and perception of effort. Each study confirmed the effectiveness and equivalent responses with aquatic fitness vs. land-based treadmills.1

Offering a low-pain and less-feared method of exercise, physical therapy can greatly enhance patients’ quality of life. In the water, there is no fear of falling. Research from the University of Utah shows that older adults who consistently exercise on an underwater treadmill improve flexibility and even sleep patterns. 2 As we educate patients, caregivers, and practitioners about the benefits of aquatic exercise, we become the “facility of choice” in the region and a valuable asset to their overall health.

Business ownership may be many things, but it is always interesting. My goal in opening a physical therapy practice was to provide the highest standard of therapy with compassion to each patient, focusing on return to function, education, and wellness. Creating and maintaining an innovative aquatics program helped me accomplish this and in so doing, brand our practice as “creative,” “premier,” and “innovative.”

Run a quick check to see what is running through your veins. I bet you’ll find some platelets, plasma, and—if you’re lucky—a little water.

Kelly McFarland, PT, DPT, is a member of the American Physical therapy Association and serves as a guest lecturer for the Texas Physical Therapy Association, HydroWorx. She founded Premier Rehab Physical Therapy in 2003. She can be reached at premierrehab@sbcglobal.net.

Copyright © 2018, Private Practice Section of the American Physical Therapy Association. All Rights Reserved.

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