COVID-19- impact on the practice of Aquatic Therapy 

What COVID-19 precautions must I have in place to treat patients in the pool?

1.  Screen prior to arrival/entry, asking the COVID questions - can be done 24 hours ahead. 

2.  Do a quick temperature check upon their arrival and ask the questions again; document.

3.  Wear masks at all times when out of the pool. 

4.  Your clients sign a waiver that they are taking these risks and will not hold you accountable if they get COVID.

5.  Clients are to arrive with their bathing suit on, to enable the client before to be using sanitized changeroom and reduce the their time at therapy.

6.  Consider any changeroom use as risky. Some facilities are asking clients not to use the changerooms even once they've completed their therapy.

7.  Therapist can wear a shield/ shield+mask/ mask - a medical mask is best and cannot get wet (then ineffective)

8.  Maintain 6 foot distance as able, ie. when demonstrating exercise, evaluating movement. 

9.  Shields can be cleaned and re-used. Note: your voice reverberates, and it's hard to hear people with shields on. 

10. You can get close depending on client's needs and therapeutic choices. Chlorine kills the virus so the chloramines that hover on the surface of the pool do a good job of mitigating risk... but they are with only within 6 inches of the water's surface. 

11.  If the client is really working hard, expiration droplets have higher velocity and can travel farther. However, in a moist environment, those droplets are heavier so less likely to travel farther - this is the problem in land gyms, spinning classes, etc. Manage the risk when supervising cardiovascular work; maintain distance.

12. COVID is not transmitted in chlorinated water (CDC website), but all railings, hand holds, etc, should be wiped down before and after. There are many cleaning products on the market. Beware of the different drying times for different products. 

13. Avoid using equipment that is difficult to wipe down. Don't use the same equipment as the client before - allow for sanitization.  There has been some conversation about the absorption of COVID in noodles - however, COVID does not survive in chlorinated water or some surfaces. Here is a link to WebMD detailing how long COVID survives on different surfaces - porous noodles are not included; average is 2 to 3 days for other surfaces.

14. The client must have a dry mask. If providing techniques with risk of a wet mask, client can wear a face shield or can go without, and therapist is double-masked and wearing a shield to protect both parties.

15. Dosage is related to duration - limit your time F2F to less than an hour. 

16. Follow up with the client virtually to ensure healthy outcomes. 

What or if aquatic therapy is happening in the community and what are the safeguards with respect to therapist and clients.

Each community has had a different COVID response.  I know that some are opening for a restricted time allotment (ie 45 minutes) then closing to clean for a short time (ie 15 minutes). The outdoor pools would be safer to use, although their water temperature is usually colder. 

 

I have seen patients in their own private pool and social distancing was pretty easy. Masks were worn when not in the pool. We were doing deep-end work so masks would not have worked while in the pool as we were submersed to clavicle most of the time and/or in the deep end, and I am sure they would have been wet shortly upon entry. Wet masks are not effective. I am confident in the CDC's assessment that COVID does not travel in a highly chlorinated environment; I acknowledge that splashing should be avoided; you do not want to elicit a cough from your client - and if you think this might occur, then wear a shield. I would wear masks before and after the in-pool part of the session. All surfaces should be wiped down between patients; so not advising to use equipment or must sanitize it. We used PreEmpt at U of T and the drying time is 3 minutes.

Regarding the air flow - in a good pool there should always be airflow over the pool water, or there is a build-up of chloramines and they are the ones you breathe in a gag - very nasty. The air humidity would actually reduce droplet velocity from your patient and thus any cough or wet expiration is less effective in spreading the virus. If I was outside and it was very windy, I may be concerned about droplet transmission and consider wearing a shield. We need to assess the chances of eliciting a coughi/expectoration...Know your patient.

 

The Ontario Government screen has an age question - "Are you over 70?" and if the answer is yes then it is advised not to see them F2F. I am torn with this as so many of our patients are active >70 y.o.s and to stay active, they embrace the low impact pool exercises. This is a case-by-case choice. I was just screened at my mum's LTC home... it was a lengthy checklist of symptoms - stomach pains, unusual fatigue, hoarse voice, fever, etc. So your client screening can be ramped up, too, involving both a phone call and completion of a documented list of questions the day of the session. 

 

The community pools should have protocols in place: like screening, one entrance way in and other exit way out, where to stand in line-6ft, etc. - basically managing traffic flow. They are also limiting capacity (25-50%) and there is a time limit on use - shorter. Some are taking bookings. I would advise you call your community pool to find out their protocols and the quietest times. If you need to use a lift for entry - make sure they are allowing its use, and take your own wipes to use on it. Use the change room as little as possible; take sanitizer and wear a mask when not in the water. Take extra masks to replace wet ones.

This is about transmission and exposure control, = risk management. This translates to which is both the frequency, intensity and duration of possible exposure... so the load/total is important to every person's health.

I am wondering if you can give me some advice or direct me regarding aqua fit classes and how and when they can start during COVID?

1. Presume you are all wearing masks when out of the pool and you are screening prior to arrival/entry, asking questions, and taking temperature as a routine.

2. Have your clients sign a waiver that they are taking these risks and will not hold you accountable if they get COVID.

3. Clients could be asked to arrive with their bathing suit on, as this reduces the number of times you have to sanitize the changeroom. Some facilities are the opposite, asking clients not to use the changerooms once completed their therapy.

4. When in the water, clients are 6 feet away from each other as they are not wearing a mask. I am beginning to see just the use of a shield (no mask) in the community. If used in the pool it could reduce the 6 feet distancing measure. Note that shields should be assigned to 1 person, are about $10 and must be cleaned before and after use. They allow you to breath but your voice reverberates, so its hard to hear people with shields on. 

5. If the client is really working hard, expiration droplets have higher velocity and can travel farther. However, in a moist environment, those droplets are heavier so less likely to travel farther - this is the problem in land gyms, spinning classes, etc. Risk assess your CV work. 

6. COVID is not transmitted in chlorinated water (CDC website), but all railings, hand holds, etc, should be wiped down before and after. Public pools are doing this on an hourly basis.

7. Avoid using equipment during your aquafit as they become another item to clean. You can choose designate equipment to each person and keep it aside for them, still sanitizing it but being sure it is only being handled by them. There has been some conversation about the absorption of COVID on the noodles - however, COVID does not survive in chlorinated water and if the class is every week, then that is long enough idle. Here is a link to WebMD detailing how long COVID survives on different surfaces - porous noodles are not included; average is 2 to 3 days for other surfaces.

8. When the client exits the pool, they put a mask on. 

9. Determine how many persons can socially distance in your changeroom; then sanitize the changeroom after.

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Canadian Aquatic Rehab Instructors


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2014