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As the treatment of anterior poliomyelitis at Warm Springs is in part dependent on the exercising of muscles in warm water, much thought has been given to the construction of pools and equipment for this special purpose. These notes on the results of experience here are presented in the hope that they may be of value to other interested institutions.

The present facilities consist of three large pools, one enclosed and two outdoor, all connected by waterways, so that patients may swim from one to another. Of the two outdoor pools, one, 35 feet by 69 feet, is equipped with tables for the various exercises. The other, the same size, is used for swimming and water sports. The enclosed pool which is heated and glass-roofed, was built particularly for winter use (35 feet by 85 feet), and is used both for exercises and swimming. In summer this pool is used for the treatment of those patients who burn easily from exposure to the sun. In all cases, the table exercising equipment is secured to the floor so that it may be easily removed to free an area for swimming or play.

Heating water for the pools has not been a problem at Warm Springs, since the water there comes from a natural spring, at a temperature of approximately 89o. It can, of course, be done artificially.

The outdoor pools for patients at Warm Springs have been adapted in part from old pools which existed before the organization of the Warm Springs Foundation; consequently their sizes are somewhat the result of chance. The 35-foot dimension, however, seems to be an economical width. It is sufficient for three rows of exercise tables. The 70-foot length allows for four tables. (See diagram A). Such pools could be increased or decreased in units of 12 feet in width from center to center of tables. The determination of this unit depends not only on providing sufficient working space for the operator but also on avoiding too much disturbance of the water. Choppy water hinders the operators as they are unable to see clearly under the surface. The indoor pool at Warm Springs was built 35 feet by 85 feet to provide a space for play in addition to an exercising area similar to the out-door pool.

The pools vary in depth from 4 feet to 5 feet. The indoor pool is 4 feet 6 inches at one end and 6 feet at the other, the bottom being sloped only for drainage. As diving is difficult or impossible for most patients a greater depth is not needed. The depth of approximately 4 feet 6 inches was arrived at as sufficient for swimming and not too deep for the average patient to stand on the bottom, as it is desirable for the patients to be able to walk in the water. Pools built specially for children should be relatively more shallow, though the young patients have used one end of the play pool at Warm Springs without hardship. Most patients contrive to get considerable exercise by holding to the pipe rail which encircles the pool at about the water level. This rail is also important as an aid to getting in or out of the pool. The water levels of the pools are maintained approximately six inches below the surrounding platforms, a distance less than the usual standard for pools. This was done as many patients find it easier to enter or leave the water by slipping themselves over the edge, consequently the less distance between the platform and the water the better. A scum trough is most desirable.

For entering and leaving the pool steps or ramps with rails must be provided. An arrangement which is adaptable to both adults and children and successfully used is shown in diagram B. Children use the lower rails and adults the upper. The steps were made wide to provide a place for patients and particularly children to rest from their exercise and yet remain in the water.

Numerous aids for giving patients under-water exercises are being developed by the medical staff at Warm Springs. The principal ones at the present time are as follows:

Wooden chairs, diagram C, secured to the floor with the seat at such a height that the patient's shoulders and neck are under water, are used for arm, shoulder and neck exercises. For children a small chair is secured on the seat of the larger.

Tables, diagram D. This table is extensively used for various groups of exercises. Its usefulness would be increased by making its height adjustable, as in all cases it is important to keep that portion of the patient under water which is being exercised. Cuts 1, 2, 3, 4 and 5 show how the table is particularly adapted to the different exercises. 1 shows the position of the patient on the table for abdominal hip flexion, lateral and anterior abdominals; 2 for abdominals, also abduction and adduction of the hip and rotation of the hip; 3 Patient on side for hip flexion, hip extension, knee flexion and knee extension, lateral trunk and the more difficult abduction and adduction exercises; 4 is lower back exercise, hip extension, abdominal exercises and abduction exercises; 5 is foot work, toes, ankles, knees, knee flexion and extension, hip flexion and hip rotation and back exercises.

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The chairs and tables are made of cypress wood, which resists the decaying action of water. It is not the perfect solution, however, since it becomes somewhat slippery. Another material, which is neither expensive nor so heavy that the equipment would be difficult to remove, is needed.

A pipe rail (a 2-inch diameter pipe, centered two inches below the water surface and nine inches from the side is satisfactory), already mentioned as an aid to the patients' getting in or out of the pool, has proved also of value for coordination exercises, with the arms resting on the bar for simulating bicycle exercises, for spreading the feet apart, and for lateral trunk. It is convenient to have this rail around the entire perimeter of the pool.

For practice walking in water with hand support, parallel bars have been devised with adjustable hand rails and a level plank floor.

The steps into the pool with hand rails on either side are important for graduated exercises in negotiating stairs; the lower steps naturally being easier to manage than the ones nearer the surface of the water. Rails for steps should be approximately 2 feet apart and 3 feet high, measured from the top of the step at the face of the riser. A good step has a 6-inch riser and 12-inch tread, with no nosing.

Flying rings hung over the pool have been shown to be of assistance for trunk, hip, and arm exercises, as well as for play.

Stools of different heights are necessary for the physiotherapists to stand on for managing the various exercises.

For giving exercises when a physiotherapist is unable to work in a pool and for cases of arthritis, spastic, hemiphigia and post acute poliomyelitis, where heat is beneficial to eliminate soreness, a very large bath tub is used. (See diagram E). Note that this tub has a wide rounded wood rim, so that the operator may comfortably lean against the edge.

For exercising patients who are unable to enter the water, tables approximately 3 feet by 6 feet in dimension, with padded tops, have been found useful.

It is rather beyond the aim of these notes to take up the matter of pool construction, of which there are a number of well known methods. It isn't only necessary to emphasize the urgent importance, in planning pools for polio patients, to take every precaution to prevent slipping of patients and of attendants carrying patients. The pools and surrounding platforms at Warm Springs are of concrete, and have given a very satisfactory service. The platform surface is rough float surface. Tile floors necessarily are more easily kept clean, and there are many kinds of non-slip tile for the platforms which safeguard the patient.

Other important features used with the pools at Warm Springs are the sun rooms and outdoor curtained spaces for sun baths. The former are heated, glass enclosed and roofed rooms 20 feet by 30 feet where patients may remove bathing suits, and take sun baths. The latter are similar for use in warm weather and consist of curtained-off spaces open to the sky. Dressing rooms are provided with a hand rail on either side wall. Of especial interest are the porches, with floors at grade, surrounding the pool building for over 300 feet, which enable buses and private cars to be parked close to the porch and patients to enter the building with a minimum distance to walk or be wheeled.