ATACP Foundation Accreditation Process

The Assessment Process

Case Study

• The draft to be sent electronically to the mentor prior to the mentor session. The final case study to be submitted on or before the date of the practical assessment.
• To be 1800 words ±10%, typed and double-spaced in 12 font sent electronically.

Guide to Mark Allocation

Guidance for Completion of Case Study

Consider a patient you have treated with aquatic physiotherapy, demonstrating clinical reasoning and an evidence-based approach. It is advisable to select a patient with one main problem, which is appropriate for aquatic physiotherapy. If you are treating complex patient conditions focus on one area. A member of the assessment team will help advise on patient selection.

It is important to consider the weighting of marks as outlined above. All evidence and literature must be referenced.

• Patient Data
  Include patients age and gender, history of present complaint. Current medications and results of any investigations. Any relevant past medical history.
• Diagnosis
  State the diagnosis and reason for referral, including timelines.
• Assessment
  When undertaking the assessment include outcome measures and be sure to identify objective markers or measurements in the baseline data. Assessment must include land-based data and the assessment findings in water
• Risk / Benefit Analysis
  This is a critical element of your case study. From the screening of the patient show that you have considered any risks, from medical or environmental factors eg. precautions, weight-bearing, temperatures and entry / exit access, in relation to expected benefits.
• Problems / Goals
  Write a problem list and ensure the goals match the problems. Place time frames on the goal setting to assist in evaluating patient progress.
• Treatment profile
  Present the treatment programme demonstrating the therapeutic skills and progressions used, to indicate a clear understanding of the hydrodynamic principles. Relate to the treatment goals.
• Use the aquatic physiotherapy abbreviations (outlined in the ATACP Foundation handbook) when notating the exercises used. Ensure the starting position is included.
• Outcome
  Outline objective and subjective outcomes. Provide reflection on the effectiveness of your intervention.
• Critical Evaluation on using Aquatic Physiotherapy
  Show critical evaluation of the literature relevant to aquatic physiotherapy relevant to your patient.
• Presentation
  Includes spelling, grammar and general layout. Consider the use of bullet points, pictures and tables to reduce word count.

Marking Schedule – Case Study Mark Banding

70 – 100 (Distinction)

• Critical insight into awareness of implications for aquatic physiotherapy practice.
• Evidence of highly developed analysis and argument.
• Clear focused presentation of case
• Evidence of wide reading/use of varied & pertinent treatment techniques

60 - 69 (High Pass)

• Very good awareness of implications for aquatic physiotherapy practice.
• Logical development of analysis and argument
• Easy ordered flow of ideas
• Good understanding of topic/ Good use of evidence / use of sound treatment techniques

50 – 59 (Pass)

• Satisfactory understanding of implications for aquatic physiotherapy practice
• Lack of depth in the analytical process
• Adequate understanding of practical application of theoretical principles
• Over emphasis on programme material/Limited use of evidence or treatment techniques

0 – 49 (Fail)

• Superficial understanding of the implications for clinical practice
• Lack of development for analysis & argument
• Patchy and disorganised approach to topic
• No evidence of wide reading/ use of evidence/use of poor or inappropriate treatment techniques.

The Practical Assessment (20 minutes)

• Candidates will demonstrate on a model who normally is a fellow candidate
• Candidates are given two specific problems, a muscle group weakness to strengthen and a joint movement to mobilise. Candidates have 10 minutes preparation time prior to going into the pool.
• Candidates will be asked to demonstrate suitable techniques
  • To mobilise a joint movement through range the candidate would be expected to demonstrate the use of buoyancy assistance, buoyancy counterbalanced, turbulence assisted and drag assisted.  
  • To strengthen a muscle group isotonically and isometrically. The candidate would be expected to demonstrate the use of buoyancy assistance, buoyancy counterbalanced and buoyancy resistance concentric and eccentric, applied turbulence resisted and drag resisted, reversals and stabilisations, and the metacentric effect (where appropriate). The use of changing starting positions, lever length, float size or speed to create exercise progressions.
• Candidates will be expected to demonstrate safe and effective handling of the patient throughout, including attention to float use and patient support.
• The use of voice, quality of instructions, and demonstration of exercises where appropriate will be assessed during this time. 

Examples of Strengthening Techniques

Using Buoyancy

Buoyancy Assisted
The body part is moved towards the water surface. For strengthening none or minimal additional floatation required. Appropriate for grade 1 muscle strength. 

Buoyancy Counterbalanced
The body part is moved parallel to the water surface slow enough not to produce turbulent water otherwise this would be drag resisted.

Buoyancy Resisted Concentric
The body part is moved downwards against the up-thrust effect of buoyancy i.e. away from the water surface towards the pool floor. A floatation aid may be required with a dense limb or when progressing the exercise. An example to strengthen the left shoulder adductors would be a float held in the left hand. The patient stands with their shoulder immersed. The left arm is pulled down from the surface through the water to come to the patients’ side.

Buoyancy Resisted Eccentric
The patient controls / decelerates the rate of a movement towards the water surface slower than the buoyancy rate wants to take it. An example for eccentric quadriceps strengthening would be with the patient standing with a float around their ankle. The ankle is allowed to be moved towards the water surface, flexing the knee, with the patient controlling the speed of movement slowing it down so that it doesn’t become just passive knee flexion.

To progress a buoyancy resisted exercise:

• Increase the size of the floatation aid
• Slower movement
• Longer lever if possible
• Starting position

Utilising turbulence

Applied Turbulence Resisted
The therapist creates an area of fast-moving water to create turbulent water. This turbulent water has a negative pressure which the patient has to resist the movement towards. The muscle contraction can be isometric or isotonic. An example for the elbow flexors would be the therapist creates turbulence over the posterior forearm aspect, so the patient has to activate elbow flexors to prevent the arm being drawn into extension. If the patient holds the position of the forearm it is an isometric contraction however if the patient flexes the elbow with the turbulent water created behind it is an isotonic concentric muscle action.

Drag Resisted
Either the patient moves a body part through the water, or the therapist moves the patient to create an area of negative pressure behind the moving part. The muscle contraction can be isometric or isotonic. An example for the shoulder abductors would be the patient moves their arm out to the side faster than the rate of buoyancy progressing by increasing the speed of movement and/or un-streamlining such as with a hand bat. An isometric technique would be the patient is moved through the water while they hold a position against the drag of the water. For the shoulder abductors the patient would be supine, and the therapist would move the patient forward (or turn the patient) whilst the arm is held out to the side.

To progress a drag resisted exercise:

• Increase the speed of movement
• Increase the surface area (streamlined to unstreamlined e.g. use of a fin or bat)
• Longer lever if possible

Utilising the Metacentric Effect

The patient holds a position against the rotational forces created when the centre of buoyancy and gravity are not in vertical alignment. For example, a patient in supine lying works against the following movements to prevent the tendency for the body to rotate along its longitudinal axis (strengthening the trunk rotators):

• Turning the head
• Taking an arm or leg out to the side
• Lifting an arm out of the water

Patient in standing or in the “box position” (squatting in the water as if sitting on a chair). They work against the following movements to prevent the tendency for the body to rotate around its transverse axis (strengthening the trunk flexors or extensors).

• Taking the head forward or backward
• Taking the arms forward or backward

Rhythmic Stabilisations and Reversal techniques

Rhythmic Stabilisations are isometric, while Reversals are isotonic. Both techniques rely on the therapist being stable in the water – normally no deeper than T11 water level. The techniques rely on the patient moving through the water thus utilising drag resistance, apart from therapist resisted stabilisations where the resistance is purely created by the therapist.

Rhythmic Stabilisations
Agonist and antagonist muscle groups worked isometrically to create a joint stabilisation exercise.

Therapist resisted
The therapist applies suitable graded pressure against the appropriate body part surface which the patient can resist on the instruction to ‘hold’. The therapist changes handling between the agonist and antagonist surfaces to create the isometric muscle action. The exercise is made more difficult by increasing the speed of change between the surfaces and/or by increasing lever length. An example for the shoulder would be with the patient supine and the therapist applies alternating pressure against the adductor and abductor surfaces of the upper limb whilst the patient maintains the upper limb in the designated degree of abduction. An example for the trunk would be with the patient in supine the therapist resists either flexor/extensor surfaces from either the proximal lower limbs or from the upper trunk, or rotators from either the pelvis or upper trunk.

Drag resisted/stabilising against drag
The therapist moves the patient in the water in opposing directions asking the patient to ‘hold’ their position against the drag effect created for agonist and antagonist muscle groups. For example, for trunk side flexors the patient is supine whilst the therapist holds them from the upper trunk or through hand behind head position shoulder girdle. The therapist will move the patient from side to side asking them to keep their body straight. Another example for the shoulder would be with the patient supine with their arms abducted to the desired range then asked to ‘hold’ in the position whilst being moved forwards and back to activate isometrically the shoulder abductors and adductors.

Reversals
These are isotonic muscle actions therefore have an intent to move versus just hold. They still work both the agonist and antagonist muscles around a joint. An example would be for the shoulder the therapist stands in one position applying resistance to the abductor muscle group surface i.e. over the dorsum of the hand or posterior forearm for the patient to be able to push against, once full range has been achieved the therapist changes their hand hold to the adductor surface i.e. palmer aspect of hand and anterior forearm for the patient to pull in against. The patient’s body will move through the water whilst the therapist remains fixed in one position.

Improving Range of Movement (Joint and Muscle)

Buoyancy assisted
The body part is moved towards the water surface, assisted by a floatation aid. This can be done as a hold/relax technique at end of range or as a prolonged stretch as described in “Hydrotherapy - Stretching Techniques for Groups” presented by Jane Barefoot MCSP Dip Phys Ed, at “Konferens I Hydroterapi” 1992 and illustrated in handbook.

Buoyancy Counterbalanced
The body part is moved parallel to the water surface, this is done slowly in order to avoid turbulence behind the moving part. Whereas buoyancy assisted exercises will increase passive range buoyancy counterbalanced will work on improving active range of movement.

Turbulence assisted
Fast moving water is created by the therapist in front of the moving body part so the negative pressure assists the movement.

Drag assisted
The patient is moved by the therapist so that their limb is dragged into the desired movement to mobilise the joint or muscle. An example would be for shoulder abduction the patient lies supine and is instructed to take their arms out to the side to their available range then relax, the therapist pulls the patient from their feet towards them, so the arms are dragged out into abduction (this can be done unilaterally by spinning the patient on the spot). An example for a hip flexor muscle stretch would be with the patient supported by the therapist in side lying, the therapist holds one leg in hip flexion whilst spinning around so the other leg is dragged into extension.

The intensity of the drag assisted mobilisation is increased by increasing the speed of movement and/or un-streamlining the body part and/or increasing the lever length.

Marking Schedule - Practical Assessment

70 – 100 (Distinction)

• Demonstrates an innovative approach to a programme of techniques
• Shows flexibility, excellent observation skills, and effective modification of techniques where indicated.
• Demonstrates a high level of competence in all techniques.
• Fully cognisant of the links between theory and practice.

60 – 69 (High Pass)

• Demonstrates a very effective technique programme that is safe in all areas
• Shows good observational skills and modifies techniques where appropriate
• Demonstrates a confident and competent approach to techniques
• Demonstrates sound links between theory and practice

50 – 59 (Pass)

• Safe in all aspects of techniques and effective in most areas
• Observant at most times, and presents an effective but limited range of techniques
• Shows limited confidence in some aspects of techniques and handling
• Demonstrates a clear understanding of the link between theory and practice

0 – 49 (Fail)

• Is unsafe in the application of techniques on the patient
• Fails to observe and modify techniques Uses techniques inappropriate to condition/Demonstrates poor patient handling techniques.
• Demonstrates poor understanding of the links between theory and practice.

Unseen Theoretical Paper (30 minutes)

Five questions in total (short answers)

Question topics include:

• - the physical properties of water
• - the physiological effects of immersion
• - contraindications and precautions
• - aquatic physiotherapy pool management
• - patient management

Marking Schedule - Theoretical Paper

70 – 100 (Distinction)

• Demonstrates excellent knowledge and understanding of aquatic physiotherapy practice.
• Evidence of analysis and synthesis
• Clear focused presentation
• Evidence of wide reading

60 - 69 (High Pass)

• Demonstrates very good knowledge and understanding of aquatic physiotherapy practice
• Logical development of case
• Easy ordered flow of ideas
• Good understanding of topic

50 – 59 (Pass)

• Demonstrates satisfactory knowledge and understanding of aquatic physiotherapy practice.
• Basic presentation of ideas
• Over emphasis on programme material
• Basic understanding of topic

0 – 49 (Fail)

• Demonstrates poor knowledge and understanding of aquatic physiotherapy.
• Poor presentation of ideas
• No evidence of wide reading
• Patchy and disorganised approach to topic

Portfolio guidance

The portfolio will play an important role during the entire programme and is an important part of your own consolidation of skills, and reflection on your learning. Although it will not be marked, the mentor and assessor will review it.

Examples of the types of evidence that may be collected are:

• Case Summaries / Case Studies
• Patients Record:
  • Patient number – (your number) e.g. neuro patient 1
  • Age / Gender / Occupation / Lifestyle
  • Medical diagnosis
  • Physiotherapy diagnosis
  • Problem list with short- and long-term goals
  • Skills applied
  • Number of treatment sessions
  • Outcome
  • Reflection
• Lectures attended
  • Date & Topic
  • Length of lecture
  • Name of lecturer
  • Location
  • Main points you learned
• Literature reviews
• Presentations
  If you present any patients or IST keep a copy of the points you presented.

• Visits
  If you visit / observe at a hydrotherapy pool, note the main points which you learned. This may be good or bad points e.g. short staff, budgets limited, patients’ needs not met or good practice.

Cost

Accreditation cost £300

Resits