Early Intervention Speech Therapy : aqua therapy

Part 2: Aquatic Therapist Susan B. Nachimson, MA, CCC-SLP, CMT

Stephanie Bruno-Dowling — Tue, 20 Jan 2009 17:09:00 GMT

Last Friday's post, highlighted the first part of my interview with speech therapist, Susan B. Nachimson where we learned about her professional education, training and the experiences that brought her to the water.

Today's post is a continuation of our interview. In our discussion, Susan describes her experiences with aquatic therapy, the benefits she has seen and her recommendations for the conditions that need to be in place for a successful therapeutic session.

Stephanie: Susan, tell us how you have seen therapy in the water work for your clients.

Susan: I have seen aquatic treatment help children and adult speech in a variety of ways. Those with CP [cerebral palsy] have an opportunity to use more muscles while in warm water, as the water provides sustained compression to support diaphragmatic movement, ribcage and lung expansion with more midline control as the extremities can move easier with the voice projecting louder with more forceful voicing and clearer articulation. The water also serves to support the head for better positioning to provide trunk, neck, jaw, tongue support for more intelligible articulation. I have seen adult post-stroke patients attain an audible voice while practicing in warm water so that they have the experience of attaining a goal in water with information to then take onto land to imitate the success in water.

In addition, more SLPs are now working in rehabilitation centers with aquatic facilities. Physical therapists report to SLPs that their clients are using more vocalizations while they are doing their exercises in water and want to know what to do to facilitate the speech therapy portion of a patient's program. Many private practices are starting to contract with local pools to provide services in water.

Also one of my course participants reported that he brought an adult patient with Parkinson's from total g-tube feeds to soft foods and thickened liquids by utilizing WATSU [water shiatsu] strategies taught in the class with a very large patient to provide chin to chest exercises to increase laryngeal strength and function. When the patient was able to complete 30 consecutive repetitions, he was able to swallow more efficiently.

Stephanie: One of the criticisms I have heard, from a speech perspective, is that helping children be successful in the water, doesn't necessarily help them on land. Do you agree with that statement?

Susan: No, in fact one of the main benefits of aquatic therapy is having a successful experience in water that can then be referred to land for carryover. With very young children who are not able to reference one setting to another, the SLP has information gained in water to try to mimic on land. Having had a successful attempt provides motivation to facilitate that response into functional use.

One of the main problems is a lack of education. There are many aquatic therapy courses offered for therapists to learn how to handle patients in water to develop gross motor activities. There are very few speech pathology courses that teach directly to speech pathology issues. It is an area that can use a lot of exploration and development. For my professional needs, I have learned to use WATSU strategies and adaptations of those strategies to treat clients who are non-ambulatory and need full body support. Many small children need to be held unless there is shallow water for them to sit, crawl, stand and walk in.

Stephanie: Can you tell us what education courses/trainings currently exist for speech therapists interested in learning how to implement aquatic therapy as a method to stimulate communication?

Susan: As far as I know, there have been very few presentations regarding using an aquatic setting for speech therapy practice. There were a few articles in ADVANCE for Speech-Language Pathologists & Audiologists several years ago. I developed a course that began as a 16 hour course and is now 18 hours. I presented introductions at an ADVANCE Job Fair in San Francisco with Jerry McCue and at APT (Association of Pediatric Therapists) in Marin County with Dori Maxon, PT.

Before I taught my class, I had attended many aquatic therapy courses, one with NDT focus for pediatrics taught by pediatric PT, Jane Styer-Acevedo. The others were courses within the aquatic therapy emphasis including WATSU, Jahara and Aquatic Integration techniques. Jane addressed increasing overall functions, specifically upper and lower extremity work with children with speech addressed as something that increases with the movement. It was clear that a speech pathologist was needed to teach an aquatic course to address speech pathology issues. I invited Jerry McCue, WATSU Instructor to assist in developing the course. We held our first class in 2002 and proceeded to teach a total of eight classes through August 2007.

It might be a good idea to mention why I began to teach this course. It was after I wrote a note in a quarterly review for an under two year old client that he exhibited louder voicing and stronger swallowing following therapy in an aquatic setting. The parent was requesting more sessions than I could provide using MediCal (Medicaid) funding. The "can of worms" had been opened and I was told that aquatic therapy was Standard of Practice for PTs and OTs but not SLPs. It took me two years to figure out a way to appease the organization that pays for therapies by agreeing to teach a course to colleagues for continuing professional development. It was a challenge to develop the course. I treat it as a basic speech therapy class that addresses assessment and treatment from a traditional base that branches out into using NDT and other treatment approaches in the water using a diagnostic therapy approach. Emphasis is on using problem solving techniques from information gathered about a client from initial clinical assessment and translating it from clinic to pool.

Two participants in my course have presented informal and formal land lectures about the use of therapeutic water for speech therapy practice. I am unaware of any other specific classes.

Stephanie: I have learned recently that our colleagues in Israel often use and support doing speech therapy in the water. Have you had any experience with this?

Susan: The participant mentioned above, who did a formal presentation, was from Israel. She attended the course in August, 2007 and returned to Israel with information to share with SLPs there. She works at a non-denominational children's hospital in Jerusalem where they treat children with qualifying characteristics-a medical issue and a motor issue.

There is a certification course for Aquatic Therapists that all therapists who work in the pool with patients are required to take. It is an overview of various aquatic therapy techniques. Here, in the US there are a few of these courses available that can provide a framework for working within an aquatic setting. None address speech pathology, specifically.

Stephanie: So, with all this experience, what is your hope/vision for our field in this country with regards to aquatic therapy?

Susan: I have asked each of the participants of my course to open up to the possibilities of how they want to use an aquatic setting for speech pathology issues for our clients. It is expected that someone will develop another course that evolves from their needs as an SLP. I will continue teaching my course as long as anyone is interested in taking it.

It would be great to collect anecdotal information from any SLPs who provide therapy in water and compile a manual to motivate others to try.

Mostly, however, my hope and vision is that SLPs will feel comfortable looking at a client and thinking, "this child or adult would benefit from a warm water environment because...", and then arrange to use the aquatic setting in which to provide options without it being something that is an amazement, but, rather, an acceptable strategy. Just another tool in the SLP's "Box of Tools"!

Stephanie: Please outline for us the ideal conditions for treatment.

Susan: Here is a point-by-point outline of the ideal conditions:

Water is best 93-96F for best results so the body does not get cold or hot. For some conditions water temperatures need to be lower.
Depth for therapist should be to breast level if one is using strategies to float a client, as the therapist would need to bend knees to acquire appropriate positioning (for WATSU and other aquatic therapy techniques)
Shallow steps or a gradual ramp are good to start to work with children who can sit, pull to stand, crawl, etc. Sometimes children need to be held in the water.
Pool ledges are good to use for giving instruction, taking a break, working on following adult directions and learning to jump into water if appropriate.
Materials are as varied and creative as the therapist and the clients' needs. There are many blowing, squeezing, floating toys. Goals for clients determine what a therapist will need for equipment. Do not overlook laminating pictures for identifying words and concepts. They float and children can point to show what picture they want.

Stephanie: I have used laminated pictures in the water as well and it has been very helpful for many of my kids. So, tell us, what are you doing currently now as an SLP professional?

Susan: In my practice, right now, I work at a few rural public schools with students with a variety of needs including, but not limited to: severe oral apraxia, feeding issues, seizure disorder, language disability and articulation some with neurological issues, autism spectrum disorder, CP, etc. I also go to another distant rural town providing assessment and treatment to an under 3 population with one school aged child with feeding needs just recently added. I have cut back to once a month at the schools and the distant town providing training to instructional aides and a SLPA to provide follow through practice. I have also been providing some aquatic therapy sessions to adults who do not have speech pathology needs in a small indoor pool that I recently had installed at my home office. I am always available to schedule all aged clients with speech pathology needs in the pool or spa for therapy.

In addition, as I had mentioned, I am teaching, "Aquatic Therapy for Speech-Language Pathologists-An Introduction" as a 3 day, 18 unit class since January 2002. It is a course that addresses traditional speech and language therapy issues and the adaptation for identification, assessment and therapy within an aquatic setting utilizing NDT and aquatic therapy (WATSU, etc) approaches. SLPs, PTs, OTs, Aquatic Therapists, Special Education Teachers and parents of children with special needs have all been participants. Jerry McCue, CMT, WATSU Instructor, was my partner through August 2007, when leukemia suddenly took his life. He created a few WATSU/Orthobionomy moves that enhance increasing respiration that are valuable in facilitating better breathing and vocalizing for our patients.

Stephanie: Thank you so much for sharing all of this wonderful information about what you do and how aquatic therapy can be useful as an alternative to traditional service delivery models. How can our readers reach you and learn more about the work you have done and continue to do for our field?

Susan: Please explore my website: http://www.aquaslp.com/ for digital pictures and class information.

Feel free to send an email or call my office phone at 707-923-1625; sbnslp@asis.com

Interview: Aquatic Therapist Susan B. Nachimson, MA, CCC-SLP, CMT - Part 1

Stephanie Bruno-Dowling — Thu, 15 Jan 2009 22:37:00 GMT

I have had the absolute pleasure of speaking with and interviewing Susan B. Nachimson (pronounced /nakumson/). Susan has been practicing speech therapy for over 30 years in many different arenas and venues. Susan is trained in both NDT (Neuro-Developmental Treatment) and WATSU (Water Shiatsu). She is also a certified massage therapist and implements aquatic therapy with speech clients frequently in practice.

Susan's experiences both in the field of speech-language pathology and beyond, I'm sure, will delight and amaze you! Enjoy reading below as we embark upon Susan's professional journey from a young professional to a multi-dimensional therapist.

Stephanie: Susan, tell us about your background and when you first started practicing as an SLP.

Susan: I began practicing in this profession in August 1976 in public schools after having received an MA Degree in Speech Pathology at Humboldt State University, Arcata, California. I received a BA from Valley State College, now California State University, Northridge (CSUN), 1965. I spent those between years raising children and taking a graduate course here and there until I finally found myself in a great position to complete the teaching credential I began in the '60s and acquired an MA in the same year. My children were in elementary school by now and every time I volunteered as a parent I was enticed into screening students with speech and language issues who were not being served in the years before public law demanded identification, assessment and treatment for our students.

Stephanie: How did you become interested in furthering your certifications and getting NDT trained, as well as becoming a certified massage therapist?

Susan: After years of working within the ASHA model and following recommendations and strategies picked up from specialized continuing education courses, state and national speech pathology conventions and multitudes of purchased textbooks and manuals, I was asked to work with a two-year-old child with cerebral palsy. Her mother asked, ‘Are you an NDT Therapist?' ‘No', I said. ‘Do you know what that is?' she asked. ‘No,' I said again. ‘Are you interested in learning?' the mom then asked. ‘Sure,' I said.

That was the beginning of a shift in this profession for me that was very interesting, profound, and exciting.

After this, I was led to a colleague who taught NDT (Neurodevelopmental Treatment, aka Bobaths) strategies for speech pathologists and my hands-on education began. I had already enrolled in a massage therapy licensing course. I had a patient, post CVA, with oral apraxia of speech and severe limitations in breath support who appeared to benefit from a hands-on approach.

By this time I had taken some courses in Transpersonal Psychology that emphasized issues in the body that were affected by breath-holding incidents secondary to trauma. Stroke, CP, seizures were all conditions that resulted from trauma. It was simple to put the concepts together from a psychological approach to a functional speech pathology approach. I was aware that touch needed to be brought into my practice. As a certified massage therapist (CMT) I was licensed to practice hands-on chest compression to facilitate deeper and fuller breath control for my patients. So, now, I was enrolled in massage therapy and learning NDT simultaneously hoping I was heading in a positive direction!

Stephanie: Well, we know now that you definitely were! You have so many skills! So, now, tell us what led you to doing aquatic speech therapy?

Susan: In 1986, after my last child graduated from high school, I prepared to take an 8-week pediatric NDT course in order to enable me to work with young children with a variety of multiple disorders with feeding, speech and language needs. I was fortunate to have an opportunity to work at Easter Seals in San Francisco as a temporary replacement for a colleague on maternity leave. It was there that I saw many under 3-year-olds in both the clinic and home-care settings.

The child who led me into water was two-and-a-half years old. He crawled with a stiff body, had severe laryngeal blocking and was frequently very angry. It occurred to me that maybe we were not a good match after frequently being hit by him.

Finally, one day, I asked his mother, ‘How is this little guy in his bath? Does he enjoy the water?' It is so amazing when the perfectly correct moment occurs. His mom responded, "He LOVES his bath—he laughs and splashes all the time!"

I heard ‘laugh' and was inspired! I started to discuss working in water. The rest is history! This sweet boy locked into his body, traumatized by limited breath support and poor muscle development, became independent in water. His warm-up time on the ramp was seconds as he crawled into the water. Mom trusted me to do the right thing.

My personal experience was teaching all of my own children and nieces and nephews and friends' children to swim for fun. In addition, I learned in transpersonal psychology workshops about a prenatal journey in water that is a tool used to help people unlock deeply rooted traumas.

This little guy just went under and used all-fours to swim towards his mom, pulling his head straight out of the water and laughing a clear, open belly laugh with no traces of laryngeal blocking or limited inhalation! It was absolutely AWESOME to say the least.

I wasn't sure how to interpret the session per goals and objectives, but I knew we addressed increasing respiration for phonation! The most remarkable awareness was how independent and functional this child was in water in contrast to totally disabled on land. I knew there needed to be a transition from water to land. Unfortunately, there were no follow through sessions with this child, but many new sessions with other children were tried with new strategies being developed with each one and hence began my love for aquatic therapy!

Today, my favorite place to practice in my field is when providing diagnostic therapy in a warm water setting, preferably in a shallow swimming pool or spa that is at least 93F!

Thank you so much for reading the first half of my interview with the dynamic aquatic speech therapist, Susan B. Nachimson. Please join us Tuesday for the second half of our interview, when Susan will explain her recommendations for successful aquatic therapy as well as where you can find Susan now!

Taking the Plunge

Stephanie Bruno-Dowling — Fri, 14 Nov 2008 13:58:00 GMT

"Nature has provided us generously with everything we need to remain in good health."
--Sebastian Kneipp (1821-1897).

The historical beginning of aqua therapy dates back to the ancient practices of the Egyptians, Greeks, Chinese and Romans. Then, in the 19^th century, Sebastian Kneipp a Dominican monk revived the theory. He believed in the power of healthy living and is said to be the "father of hydrotherapy". You can read more about Sebastian Kneipp and his book My Water Cure at: http://en.wikipedia.org/wiki/Sebastian_Kneipp. Today hydro or aquatic therapy is used worldwide to treat a variety of diseases, ailments and injuries, including arthritis, spinal cord injuries, burns, spasticity, stroke and paralysis and much, much more.

Aquatic therapy is traditionally utilized by Occupational and Physical Therapists, not Speech Therapists. However, over the past several weeks, I "tested some new waters" by jumping in the pool with several of the children I work with in my full-time early intervention position. This is something that I have been interested in for several years. I am not an expert aquatic speech therapist, nor do I pretend to be. Other than being a licensed and certified speech-language pathologist who happens to love the water and is a pretty good swimmer, I do not have a ton of experience.

I admit I have always loved the water -- swimming, water-skiing, kayaking -- in the water is often where I feel most alive. Years ago, I taught swim lessons with little children and I earned my Junior Lifesaving Certificate at the Jersey Shore. About three weeks ago, I attended a three hour Hydro-Therapy training at CHOP (Children's Hospital of Philadelphia) for pediatric Occupational Therapists. It was a wonderful experience and I learned a great deal even though it was not tailor-made for my profession.

As you can see, today's post is a little more personal than usual. I am on the hunt for trainings to help me develop my aquatic speech therapy skills. In addition, I would love to find therapists (especially close to home in the Philadelphia, PA area) who share my love and interest in aquatic therapy. Over the last few weeks I found a few speech therapists across the country that are practicing aquatic therapy. I have also recently subscribed to the weekly Aquatic Resources Network internet newsletter which appears currently to be my best resource.

I would love to hear your thoughts and comments regarding aquatic speech therapy....thank you!