Chronic effects of traumatic brain injury are getting the attention and research necessary to better identify, prevent and rehabilitate these injuries. Aquatic therapy, while still in need of its own research, can treat these difficult cases in a healing environment

Brain injuries can be traumatic as well as nontraumatic. Various types include those from trauma, blast-induced TBI, orthopedic/ sport and concussions/mild TBI. The Centers for Disease Control and Prevention estimates 1.6 million to 3.8 million sports- and recreation-related concussions each year in the United States

TBIs result from a blow or jolt to the head (closed-head) or a penetrating head injury (open-head) where the skull is crushed, fractured or penetrated and normal function of the brain is disrupted. Nontraumatic injuries can result from stroke, lack of oxygen, infection, brain tumors, shaken baby syndrome and some types of whiplash

All brain injuries can lead to physical, cognitive and psychosocial/behavioral impairments, including balance and coordination deficits; hearing, vision and speech problems; fatigue; memory loss; difficulty concentrating; anxiety; depression; impulsivity; and impaired judgment

Closed-head injuries are more common and usually result from falls, motor vehicle crashes, assaults and sports/recreation accidents. The National Football League is spearheading research into these injuries. Downhill skiers now are being encouraged to wear ski helmets — partly because of the deaths of prominent people while skiing

A person with a brain injury may present difficulties for aquatic rehabilitation or aquatic exercise because of other limiting physical injuries. The mild TBI or TBI may not be apparent to others upon meeting, but the person’s personality may have completely changed. Suspecting or recognizing that the patient/client has suffered a brain injury requires specialized protocols and appropriate safety measures

Rehabilitation begins with motor, vestibular, somatosensory and cognitive evaluation. Activities include balance and gait training, core strength exercises, gaze with head movement, and stretching/range of motion. Selection of exercises is complicated by the possibility that the patient/client may have neurological involvement, balance/coordination deficits, dizziness, and cognitive issues. Patient/clients often have other injuries complicating or delaying aquatic activity. The first safety issue is to assess if they have a fear of the water. Such a fear may present a situation too complex for aquatic activity to be acceptable

Additional safety concerns start from the time the patient/client enters the dressing room. Upon exiting the dressing/locker room, are entries and exits clearly and simply marked? It is very easy in many locker rooms to forget where the entrance to the pool area is accessed. Does the entry to the pool area open to the deep water or the shallow, and is it clearly marked with proper barriers in place? Are there rules on when/where to enter the pool, and are they understood? Does the patient/client need guidance after the session to return to the locker room? Is the person prone to dizziness or seizures?

Successful aquatic activities require simple instructions and a check with patient/clients for understanding. One simple direction is what many can follow. Giving a list of movements may confuse and irritate, and could result in anxiety or impulsivity. Be prepared for the impulsivity response. The water's buoyancy assists with balance and reduces people's fear of falling. Many yoga positions are performed with simple instructions, and the patient/client can be held or supported if necessary

Another concern with supporting persons in a position or assisting them into a position requires identifying if they have negative reactions to touching. Always cue what you'll be doing. Ai Chi is another option for developing balance and core strength, and a beginning to combine movements. For some, introducing each Ai Chi movement separate is a proper start. Once they're familiar with several movements, begin to string together — omitting some of the more coordinated, complex moves until they are ready

Being in the water allows the provider to communicate directly with the patient/client (eye to eye, hearing, assisting) to create the feeling of a supportive environment. It also lets the provider quickly identify any changes in the person. Balance and coordination deficits, reduced fitness and anxiety require the provider to be ready to give support, such as the walking assist taught in risk awareness and safety training courses

Some TBI are susceptible to seizures. This takes immediate response and knowledge of how to support them in the pool until the seizure subsides

Traumatic brain injuries and the need for research — prevention, identification and rehabilitation — are receiving national attention. The aquatic arena has much to offer. Research for aquatic rehabilitation of TBIs is needed, including the effect of water temperature and appropriate protocols to address the many deficits presented.