Aquatic therapy can be a wonderful treatment modality for a variety of sensory-related concerns. This is because the water allows me to provide various stimuli for each sensory system that may be: calming, alerting, preferred, regulating, and/or unfamiliar depending on a kiddo’s therapy goals and preferences.

Sensory Integration

When occupational therapists address sensory-related concerns, we typically follow basic principles of sensory integration. Sensory integration involves incorporating diverse types of input into functional, play-based activities to help kiddos first: process and organize stimuli; then: enact a context-specific, adaptive response. An adaptive response means that a kiddo reacted to stimuli in an appropriate way. For example, let’s say a kiddo with tactile sensitivity gets water on her face. A maladaptive response would be attempting to run out of the pool, while an adaptive response would be reaching for a towel to wipe the water away. Adaptive responses are ways that we manage or modify stimuli so that we can participate in our daily occupations within different sensory environments.

Sensory integration also incorporates kiddos’ unique sensory needs. Sensory needs are types of stimuli that are preferred by the nervous system. By meeting these needs, the nervous system will sustain a regulated state, which gives us the capacity to work on challenging, functional activities. This is true for all of us! For me, if I don’t squeeze in some heavy work first thing in the morning, I will be a bit crankier, restless, and less focused throughout the day.

Sensory Systems

Each of us have 8 sensory systems that have specific needs and preferences. In the water, these systems experience new and unique sensations, that I can tailor during OT interventions. Here is a brief description of each sensory system and how each is impacted by the water.

1. Vision

• light refracts off the water’s surface, so visual images can be slightly distorted

• Objects appear closer when underwater

• Visual input is less reliable overall, so we must draw upon other sensory systems to gather information about our environment

2. Hearing

• pool spaces tend to have acoustics that echo-this can make sounds feel a bit louder and less distinctive

  • If in a loud pool space, the auditory system may be overloaded (from the echoed sound), so we will reduce as much input as possible and use quiet and calming sounds

  • In a quiet pool space, the auditory system receives auditory input in a unique way, which can challenge auditory discrimination skills

• When submerged, sound waves travel faster, so sounds appear louder when submerged

  • it is also more difficult to detect the location or origin of a sound, which can force the body to focus the auditory system (more than typically required) and rely on other sensory stimuli.

3. Olfactory-smell

• pools often smell of chlorine, which can be either calming or dysregulating to some

• when submerging, the olfactory system does not gather any input and the body must use other senses

4. Gustatory-taste

• Many kiddos will explore the water orally (drinking, licking, spitting) to gather more information about the water

  • in OT, it is a priority teach kiddos safe techniques to orally seek and how to refrain from excessive drinking

• The water allows to work on many oral motor skills including: blowing bubbles, deep breathing, and lip closure patterns

• kiddos who are orally aversive to water on their face will demonstrate a preference to keep their head above the water. In these cases we will work to expose the face through child-led play and will teach adaptive responses.

5. Interoception- internal sensations

• include hunger, fatigue, the need to use the restroom, thirst, etc.

• swimming requires increased physical work and requires increased energy demands

  • therefore, interoceptive signals can be stronger (especially hunger and fatigue)

• the water’s hydrostatic force puts a slight pressure on all internal organs, so, it can increase the sensation of needing to urinate

• breathing and heart rate increase while swimming, so kiddos may feel these sensations with more intensity than they do on land

6. Proprioceptive: body awareness

• receptors located in muscles and joint cavities

• detect pressure, force, and body positioning; tells the brain where the body is in space

• Viscosity in the water slows the pace of each movement and adds resistance

  • Movements require more proprioceptive work; therefore, the body gets stronger proprioceptive input

• hydrostatic force provides the every proprioceptive receptor with deep pressure input, which is calming to the nervous system

  • pressure sensations intensify as we get deeper under water (this is why we equalize our ears during diving)

  • many sensory seekers will enjoy submersion and deep diving because of this pressure

    • Read more about deep pressure and the nervous system here.

7. Tactile: temperature/pain/object identification

• receptors are located on our skin’s surface

• receptors identify: when something is too hot or too cold or when something is painful

• can also identify objects through touch, especially when vision is occluded

  • For example, we use tactile receptors to reach into a box to locate our toys, or to navigate around a room when the lights are out.

• Kiddos with a high sensory threshold may prefer increased tactile input (to gather more information about their environment)

  • a common intervention approach is breaking the water’s surface tension (i.e. splashing and jumping into the pool)

    • this offers fast and intense tactile stimulus that quickly alerts the nervous system.

• Kiddos with a low sensory threshold may experience tactile defensiveness

  • a common intervention is to provide calming and preferred touch to prepare the body for more intense or uncomfortable sensations

    • examples: using warmer water temperatures, using localized, controlled touch (such as pouring water on one body part), and starting by exposing less sensitive areas to the water first (i.e. the palms before the back of the head), and modeling tactile exposure to water during play

8. Vestibular-head in space

• receptors located in inner ear; provide information on where the head is in space

• responsible for maintaining equilibrium and balance

• this input leads to an appropriate motor output to reorient the head/body

  • for example, correcting the trunk when losing balance is a motor output from vestibular input

• the water provides an increased vestibular challenge

  • this is due to the reduced sensation of gravity (read about buoyancy here)

  • also do to the less commonly used horizontal orientation of the head (especially during a prone swim or back float)

• vestibular under-responsiveness: will present as a tendency to keep the head vertical and the feet grounded; a kiddo will appear nervous in the water and will often to cling to the wall or therapist

• vestibular cravers will enjoy jumping in the pool, flipping underwater, floating on their back, and swimming horizontally

• the water offers the opportunity for both sensory tendencies to be safely addressed in a play-based manner

• read more about the vestibular system in the water here

Conclusion

The water is one of the most accessible environments to work on a wide range of sensory-related goals and needs. This is a very basic overview of how the water impacts each sensory system. If you are curious how your child’s unique sensory tendencies may present in the water, feel free to reach out to Emily with more questions!

References:

Agostoni, E. , Gurtner, G. , Torri, G. , & Rahn, H. (1966). Respiratory mechanics during submersion and negative‐pressure breathing. Journal of Applied Physiology, 21, 251–258. doi: 10.14814/phy2.15475

Aquatic Therapy University (2012). Aquatic Sensory and Motor Integration for the Pediatric Therapist. [Continuing Education lecture and manual]. https://www.atuseminars.com/product-page/aquatic-sensory-motor-integration-forpediatric-3-hr-w-manual 

Beck, C. (2023). Sensory needs. The OT Toolbox. https://www.theottoolbox.com/sensory-needs/

Brightwheel Blog (2023). How to improve children’s auditory discrimination. https://mybrightwheel.com/blog/auditory-discrimination

California Physical Therapy Association (n.d.) Aquatic physical therapy key messages. https://med.stanford.edu/content/dam/sm/pain/documents/AquaticTherapyKeyMessages.pdf

CLASI. (n.d.) About ayres sensory integration. https://www.cl-asi.org/about-ayres-sensory-integration#:~:text=Sensory%20integration%20theory%20provides%20evidence,smell%2C%20hearing%2C%20taste).

Ford, A. (2019). The ulimate guide to deep pressure therapy. Harkla. https://harkla.co/blogs/special-needs/deep-pressure-therapy?srsltid=AfmBOoqfm3E8FmqzLSZyMse1fopYpicCRN8TAP5toTFGmw9eIjzAOpX6

Cho, M. (n.d.) Dunn’s Model of Sensory Processing. OT Theory. https://ottheory.com/therapy-model/dunns-model-sensory-processing#:~:text=On%20the%20other%20hand%2C%20people,a%20continuum%20of%20behavioral%20construct.

Ruth, n.a. (n.d.) Swimming is great for supporting sensory integration. ASI Wise. https://sensoryproject.org/2018/07/08/swimming-is-great-for-supporting-sensory-integration/

Schwartz, M. (2022). What is tactile defensiveness and how to lessen the symptoms. The Virtual Pediatric OT. https://www.thevirtualpediatricot.com/tactile-defensiveness/

Tisser, A. & Freedman, C. (2021). Totally treatment-pediatric aquatic therapy course. [Continuing Education PowerPoint slides]. Swim Angelfish. https://swimangelfish.com/therapist-training/