Photo above: A marathoner uses an underwater treadmill after an intense strength workout on land. The HydroWorx 500 provides immersion in cool water, hydrostatic compression, and movement with buoyancy to expedite his recovery. (Photo by Rachel Carson)

By Mike Studer, PT, MHS, NCS, CEEAA, CWT, CSST

How and why would a practice with an already successful aquatic rehab program chose to significantly grow its infrastructure? This article will answer that question and explain the properties of water that make aquatic therapy so valuable in clinical treatment. Readers will not only learn about the essential equipment and features needed to power up aquatics growth, but also discover how serving the community and avoiding therapy and fitness “fads” helped these specialized programs succeed. By exploring the key decisions behind this growth, clinicians who work in practices that have existing aquatic therapy services may ask themselves: Should we consider doing the same?

Create What the Community Needs

In 2015 Northwest Rehabilitation Associates (NWRA), a small but already successful and growing outpatient rehabilitation clinic in Salem, Ore, was hitting its stride. The practice’s success was built on three factors. First was having an excellent reputation shared by two thriving locations in the community. Second was outright ownership of the land on which the facilities were built, which helped to control costs. Third was the decision to build the structures that housed these programs so the clinics could operate in facilities that fit the therapists’ specific needs. For many practice owners, such circumstances would make it tempting to simply maintain the status quo. The leadership and staff at NWRA saw it differently, however. They recognized that they had a chance to do something more and to create something that the community needed. So they did.

Salem, Ore, is not unlike many midsized cities in the US. It has plenty of rehabilitation options, a decent economy, yet limited opportunities for sports science and for the athlete with higher aspirations in college or professional competition. The leadership of NWRA recognized those limitations and decided to build a facility that would collapse those limitations and equip it in a world-class manner. By July 2019, NWRA opened The RE_Building, offering REhabilitation (physical therapy), REdevelopment (personal training), REgeneration (PRP injections), REinvision (sports vision), REalign (chiropractic), REeach (Fascial Stretch therapy), and RElax (sports massage). This multidisciplinary program needed the option of aquatics in a sports-specific application for four distinct reasons:

1) Early mobilization for the injured athlete (ankle sprain, pulled hamstring, back pain);
2) Early mobilization for the surgically recovering athlete (ACL, meniscectomy, patellar tendon repair);
3) A second application of exercise on a given day, accelerating recovery from an earlier-in-the-day program that may involve more of a breakdown followed by an aerobic schedule. Weights, eccentrics, full contact early, and circulation, hydrostatics, and lower temperature to follow; and
4) Tapering in the days leading up to a big event, such as a marathon, weekend tournament, or high-stakes match.

Underwater Treadmills Send a Message

Placing two new underwater treadmills in a new site only 3.5 miles from an existing one was a decision made with clear intention: A bold message of re-investment in the total package for the athlete. While cryotherapy and compression in recovery were considered for the new clinic, ultimately the decision was made to purchase two underwater treadmills from HydroWorx, Middletown, Pa, because of the four points listed above. The treadmills allow users to perform a variety of activities with a substantial reduction in the force of body weight, including sprinting, walking, retro-walking, shuffling, and back-pedaling. They can serve as a high-intensity, early mobilization environment as well as a respite for recovery.

Two underwater treadmills in the new building also facilitates:

1) A word-of-mouth talking point that makes sense to people. Many programs invest in equipment that follows the latest trend, only to fade in 2 years or less. In addition, consumers are comfortable with water; payors have a policy to adopt and reimburse.
2) A fun, engaging, athletic opportunity that can be dialed up or down that enables all athletes, would-be athletes, and returning athletes to participate. With the combination of ease through buoyancy and challenge through treadmill speed, jet resistance, and fluidodynamics, there is a wide range of patients that can be served and engaged in conditioning.

While NWRA selected its underwater treadmills from HydroWorx, there are additional sources for underwater treadmills suitable for use with aquatic therapy programs. One source is Hudson Aquatics LLC, Angola, Ind, which offers a series of underwater treadmill systems for rehabilitation and conditioning. Another manufacturer, SwimEx, headquartered in Fall River, Mass, offers a belted integrated treadmill technology with several of its pool models.

[sidebar float=”right” width=”250″]Product Resources

Pools, spas, and accessories for water-based rehabilitation are available from these manufacturers:

Aquatic Access Inc

Endless Pools

Hudson Aquatic Systems LLC


Nespa Tiled Spas

NZ Manufacturing

Sprint Aquatics

SureHands Lift and Care Systems

SPRI Products


A Differentiator

For practices that want to invest in something that continually distinguishes them from their competitors, they could be taking a risk that any new equipment purchase is either quickly overtaken by a fad, doesn’t catch on in the community, or is adopted only by a few and affordable to even fewer because of the slow pace of insurance coding changes. Aquatics is the exception. The benefits and comfort of therapy in water has a long and documented history that makes sense to the cash-paying patient and third-party payor alike.

An Accelerator

Practices that want to invest in something that provides an opportunity for early mobilization after injury or surgery and meets the above-stated conditions (reimbursable, makes sense, not a fad) will find aquatic therapy infrastructure suitable. Water-based therapy can provide the best combination of intensity and safety in mobilization.

An Opportunity

Some individuals, due to pain, obesity, hypermobility syndromes, and other considerations, simply cannot exercise on land to a dosage that would be rehabilitative. With an aquatic program a rehabilitation provider can be the only opportunity for some people.

ROI: The RE_Building deserved the opportunity to be a complete REstorative experience. As noted above, and now extended, the HydroWorx underwater treadmills could be recognized as an early mobilizer for recovery (injury, surgery, exertion, or event). Additionally, the program needed to be a place that offered exercise opportunities for all ages and capabilities to move to their desire and preference—a lane that the underwater treadmill could widen. And, finally, the program needed to offer everything possible that was endorsed and used at the highest level of our sports culture.

Additionally, when considering ROI, NWRA sees the underwater treadmill as a great stand-alone or as a part of a full wellness package. Some clients only come to the program to use the underwater treadmill so they can begin to get into shape again or continue their lifelong love of running—without pain. Finally, as noted, the underwater treadmill improves any comprehensive wellness package, being coupled with local partners in massage, cryotherapy, nutrition, or personal training. These packages include services that The RE_Building provides in-house and others that it does not, which extends the practice’s reciprocal community partnerships.

Stop Swimming Upstream

Water makes clinical sense. Research supports the physiologic properties and the interventions. However, just as important, water makes sense to consumers. In and of itself, it can make the difference in a practice receiving that word-of-mouth recommendation or referral because of the diverse rehabilitative avenues on which a practice can travel. Finally, perhaps most importantly, water-based rehabilitation is the preference for some patients and the only way for others. The benefits and attractions of water have persisted before and after science has supported this environment. Water never fades. PTP

Mike Studer, PT, MHS, NCS, CEEAA, CWT, CSST, is president and co-owner of Northwest Rehabilitation Associates. Studer is recent past chair of the Geriatric Section’s Balance and Falls Special Interest Group. He has been board-certified as a clinical specialist in neurologic physical therapy since 1995. In 2011, Studer received the Neurology Section Clinician of the Year from the APTA and received the same award from the Geriatric Section in 2014. For more information, contact [email protected].

Table 1.

Hydrostatic pressure is the external compressive force exerted on an object or body underwater. This force is proportional to the depth of submersion. In the human body, it may assist venous return and the lymphatic system for submerged body parts.

Buoyancy is the flotation provided by a liquid, due to the difference in specific gravity. Buoyancy provides body weight support, reducing compressive forces in weight-bearing. The amount corresponds directly to the depth/submersion/height and is modified by relative lean body mass. Most applications bring about 60% reduction if submerged to the sternum.