Precautions For Aquatic Bodywork


By Peggy Schoedinger, PT


It is impossible to predict all of the possible problems our clients may have.  Listed below are some of the more common precautions to aquatic therapy and Watsu.  If in doubt about the safety of aquatic therapy for a medical problem or impairment, don’t proceed until you seek further medical advice.


1.      Fever


2.      Cardiac failure, unstable angina, severely compromised cardiovascular system.  Excessively high of low blood pressure.


3.      Significantly limited vital capacity (below 1000 ml) as a result of a spinal cord injury, pulmonary disease, etc.  Inability to tolerate a 10% decrease in vital capacity.


4.      Absence of cough reflex as a result of a stroke, brain injury, ALS (Amyotrophic Lateral Sclerosis), etc.


5.      Unpredictable bowel incontinence


6.      Significant open wounds and small open wounds on a person very susceptible to infection (diabetes, etc.).  It may be possible to cover a small, clean wound with a bio-occlusive dressing such as Tegederm that is gas permeable but not water permeable.  A cast-guard airtight sleeve can also be used to prevent water from reaching a covered wound or cast.  


7.      Epilepsy, especially if uncontrolled.  Light reflecting off water may increase probability of seizures.


8.      Contagious water or air-borne infections/diseases


9.      Sensitivity to chemicals used in pool (chlorine, bromine etc.)


10.    Recent cerebral hemorrhage (wait until patient is medically stable)


11.    Uncontrolled diabetes (keep glucose tablets or juice available at pool for emergencies)


12.    Perforated eardrums.  Keep all water out of ears.


13.    Kidney disease where patient cannot adjust to fluid loss


14.    Patient with severely impaired ability to regulate body temperature


15.    If patient is on long-term steroids or has had recent deep x-ray therapy, water tends to make already delicate skin even more fragile.  Dry skin gently and thoroughly.


16.    Tracheostomy.  Extremely high risk for getting pool water into lungs.  A capped tracheostomy is still extremely high risk.


17.    Deep vein thrombosis.  Do not proceed until problem is resolved.


18.    Impaired sensation, especially in legs (stroke, brain injury, spinal cord injury, diabetes, etc.).  Extra care must be taken to protect client from sustaining an abrasion injury on bottom or side of pool (a thin pair of socks can provide extra protection).  Underwater lights generate considerable heat.  Clients must not lean against them.


19.  Amputations.  Creases in the residual limb must be gently and carefully dried after each session.  Even after initial drying, skin will still be fragile.  Allow limb to continue air-drying for 10-20 minutes before donning prosthesis.


20.    Multiple sclerosis.  Many clients with MS are very sensitive to heat.  Check first to see if your client tolerates warm weather, hot showers, etc.  If heat is a problem, do session in a pool with a cooler water temperature.


21.    Intravenous lines, heplocks, hickman lines etc.  Check with physician.


22.    Gastrostomies, colostomies, iliostomies, etc. can come into pool if the skin around the stoma is well healed.  Drain bag first.  Be sure to check seal around the stoma before entering pool.


23.    Catheters can usually come into the pool.  Drain bag first.  Attach bag to client’s leg.  Don’t raise the leg to a position that would cause urine to flow from the bag into the bladder.  Check with physician first if client has a suprapubic catheter.      


24.  Osteoporosis.  Use extra caution during a Watsu session to protect fragile bones, especially in the hips and spine.


25.  Acute ligamentous instability following trauma. Check with physician first.


26.  Specific joint range of motion precautions following trauma or surgery.

       Learn what movements must be avoided.  It may be necessary to provide a

       splint for a joint or postpone the Watsu until precautions have been



27.    Autonomic dysreflexia.  This can be a problem for some clients who have had a spinal cord injury, especially a T8 or higher injury.   Autonomic dysreflexia usually occurs in response to a noxious stimulus such as increased or decreased body temperature, blocked catheter, etc.  Autonomic dysreflexia  is a medical emergency.  


28.  Psychological special needs.  Although Watsu often alleviates emotional pain, additional psychological support provided by a qualified therapist may be needed.  Watsu practitioners do not provide psychotherapy or counseling.  However, practitioners are invaluable as caring listeners who give unconditional, non-judgmental acceptance.  


Watsu with Special Needs ... Guidelines for Utilizing Watsu