Safe aquatic physiotherapy practice in relation to the COVID-19 pandemic

The Aquatic Therapy Association of Chartered Physiotherapists (ATACP) have released recommendations for safe aquatic physiotherapy practice in relation to the COVID-19 pandemic.

The recommendations are in accordance with Government, NHS, Public Health England (PHE), Pool Water Treatment Advisory Group (PWTAG) and the Chartered Society of Physiotherapy (CSP).

This information is provided as being accurate as of 7 July 2020 and is subject to change.

These recommendations are made to minimise risk related to COVID-19 when providing aquatic physiotherapy in a hydrotherapy pool. The treatment of COVID-19 patients is not included within these recommendations.

COVID-19 has affected aquatic physiotherapy services due to minimising social contact to reduce the risk of spreading the virus. There has been some ambiguity as to whether aquatic physiotherapy should be provided or not.

Many hydrotherapy pools have been closed (PWTAG Technical Note 43).

With the Government now  progressively reducing lockdown restrictions, managers of hydrotherapy pools should re-opening for the treatment of patients. For pool operation guidance in the re-opening of a closed pool refer to PWTAG Technical Note 45.

ATACP recommendations

The ATACP make the following recommendations:

  1. All patients must be screened prior to treatment. Treatment should not be provided to anyone with absolute contraindications (ATACP Guidance on good practice in aquatic physiotherapy) or to those who present with COVID-19 main symptoms as stated by the NHS of:
    – high temperature: this means you feel hot to touch on your chest or back (you do not need to measure your temperature)
    – new, continuous cough: this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual)
    – loss or change to your sense of smell or taste – this means you’ve noticed you cannot smell or taste anything, or things smell or taste different to normalIn addition, those who are having to self-isolate due to coming into contact with someone with COVID-19 symptoms should not attend treatment.
  2. If treatment can be directed by the aquatic physiotherapist on poolside, maintaining social distancing of 2m, this would be recommended to minimise risk of viral spread.
  3. For those patients who require assistance within the water from the aquatic physiotherapist a risk benefit analysis should be performed to decide whether hands on treatment is appropriate in accordance with CSP face-to-face consultation guidance.
    – For CSP guidance on face-to-face consultations, download this documentation on the CSP website.
    – For HCPC guidance on adapting your practice in the community, go to the HCPC website.
  4. Patient numbers should ideally be 1:1. If the hydrotherapy pool is large enough for more patients ensure 2m social distancing can be maintained within the pool as well as throughout the reception/waiting room, changing area, showers and poolside.
  5. All staff and patients entering the pool must comply with infection prevention and control guidance provided by PHE, NHS, and PWTAG. It is recommended all staff and patients wash their hands with soap as per the guidance, but also to full body wash with soap and shampoo prior to putting on their swim wear just before entering the pool. If anyone does not wish to get their hair wet they should wear a swim hat.
    If a patient, on risk assessment, is unable to get their head wet due to a clinical reason, eg aspiration or hypersensitivity, then washing their head would be inappropriate.
  6. In accordance with PHE and NHS COVID-19: infection prevention and control guidance, clinical PPE recommendations include the wearing of face masks, for both the therapist and patient (infeasible), where the therapist is providing hands-on treatment within 2m.If either the patient or therapist are required to submerge in the water then wearing a face mask is not possible. The mask should be removed for the submersion and stored on the poolside in a disposable bag. The face mask must be replaced for exiting the pool.– If the face mask becomes wet it will be ineffective and need to be changed. A full-face shield or visor could be used to prevent the mask from becoming wet through water splashing onto it.

    – It may become necessary to wear a face mask in the pool environment ie. on poolside and in the changing rooms, as well as the pool itself.

  7. The current ATACP standard of at least two members of emergency evacuation trained staff within the pool area must be complied with. Appropriate PPE must be available including face mask in the pool area. For CPR, follow your local policy.
  8. After each patient treatment the areas which the patient came into contact with must be cleaned and disinfected for example; handrails, benches, shower beds, hoist equipment and walking aids. PWTAG Technical Note 44 provides clear guidelines on disinfection requirements.
    To summarise:
    – First clean surfaces before disinfection by washing with a detergent (hot soapy water), thoroughly rinse and then air dry.
    To disinfect the:
    – Pool surrounds, changing rooms and toilets – use a chlorine solution of 1000mg/l ensuring cleaning residues go to drain and not into the pool system. At least or more than twice a day.
    – Frequently touched surfaces eg door/toilet handles, lockers, changing cubicles – cleaned and disinfected at least twice daily, also when known to be contaminated with secretions, excretions or body fluids.
    – Pool equipment – ideally cleaned after each use submerging in a solution of 100mg/l chlorine for one hour, then rinsed off with mains tap water before reuse. PWTAG suggest a rotation of equipment using a dirty and clean storage system so that used flotation devices are submerged for an hour before transfer to the clean holding area.
    – If therapy equipment is not suitable for chlorine disinfection, particularly at the higher levels, then a suitable alternative would be 70 per cent iso-propanol or ethyl alcohol wipes which are both at least as active as chlorine against SARS-CoV2 (PWTAG). Floats and noodles made from open-celled ethylene propylene diene monomer (EPDM) cannot be disinfected with wipes and need to be submerged as above.
  9. PWTAG recommend mechanical ventilation should operate on 100% fresh air with no recirculation. The Chartered Institution of Building Services Engineers (CIBSE) website provides further information related to general buildings for building services engineers to adopt to reduce transmission risks in the built environment.
    PWTAG advise a free chlorine concentration of 1.5mg/l to get at least 99.99 per cent inactivation in 30 seconds in pool water with the pH 7.0-7.2 regardless if secondary disinfection used such as UV or Ozone. The table below indicates the residual free chlorine required at higher pH levels.

    Pools which use alternative disinfection to chlorine, such as Baquacil, are not recommended for clinical use.