Aquatic Physical Therapy
18
Thomas Cesarz and David Speach
k e y p o i n t s
ll Swimming skill is not required for patients to safely engage in water-based
therapies.
ll Aquatic exercises are generally as safe as land-based exercises but health
contraindications exist that may prohibit water-based therapy.
ll Aquatic physical therapy is indicated when an individual cannot tolerate
land-based therapies.
ll Pain relief and improved function are the most common reasons for
prescribing aquatic-based physical therapy.
ll Scientific literature supporting purported benefits of aquatic therapy is
limited. Extrapolated research in patients with knee arthritis and ankylosing
spondylitis do demonstrate modest benefits in pain reduction and well-being
following aqua therapy.
For millennia people have used water for healing and for rituals, tradi-
tions continuing through the present. Today, water is applied in a variety of
therapies, with proponents of each often making broad and unsubstantiated
claims of health benefits. Commonly used terms for water-based therapies
include hydrotherapy, aquatic therapy, balneotherapy, and spa therapy.
Hydrotherapy and aquatic therapy are often used interchangeably to
refer to physical therapy performed in water. Spa therapy refers to physical
modalities applied in a relaxing atmosphere that may be purely commer-
cial, devoid of oversight from a licensed practitioner at point of delivery.
Spa therapies can include land-based modalities such as massage and
electrotherapy, as well as water-based forms such as balneotherapy and
whirlpool. Spa treatments, even when water-based, are typically passive.1
Studies of spa interventions prove difficult. Balneotherapy refers to the
immersion of patient or limb in a natural thermal mineral water, defined
as at least 20° C, and containing a concentration of specific salts in excess
of 1 g/L.1
This chapter focuses on aquatic therapy exercises that are analogous to
land-based physical therapy. It will cover the theoretical underpinning of
aquatic exercise with appropriate indications and contraindications.
CLINICAL CASE EXAMPLES
A 78-year-old woman with advanced bilateral knee osteoarthritis and leg
and back pain occurring only when walking and standing has been unable
to tolerate land-based aerobic exercise due to pain.
A 68-year-old obese male smoker with chronic axial low back pain and
poor endurance presents to a chronic pain center with markedly reduced
daily function and pain with any movement or prolonged positioning.
BASIC SCIENCE
For such a widely used and presumably safe activity, immersion in water
has far-reaching physiological effects that help explain the patient’s relief
of symptoms but also raise the flag of specific contraindications. Water
d­ iffers from air in density, buoyancy, and viscosity, rendering it of different
therapeutic value.
Water is nearly 800 times as dense as air.2 The bottom of a mass of
material exerts a pressure based on the density of the material. For example,
at sea level, effectively at the “bottom” of the earth’s atmosphere, patients are
exposed to the pressure of air. When a patient enters a body of water, be it
a hot tub, swimming pool, or ocean, the water exerts pressure that increases
with increasing depth. Water affects the cardiovascular and renal systems.
Water’s hydrostatic pressure compresses veins, increasing venous return and
pushing blood centrally, leading to a rise in central blood volume, cardiac
blood volume, and cardiac output.3 Compression of veins can reduce edema.
Healthy individuals seated for 2 hours in water from the renowned spa at
Bath, England, showed a doubling of diuresis and 50% increase in cardiac
index. The increase in diuresis is not due to an increase in creatinine clear-
ance, though alteration of renally active hormones may play a role.4 It is
unclear if hydrostatic pressure is the primary mechanism underlying all of
these systemic effects.
Water is a viscous substance that resists movement. The resistance
offered by the water increases as speed of movement increases, so when the
patient first starts exercising in water, a slower velocity is naturally used. As
strength and endurance improve, faster movement is possible with greater
challenge. Because of the mechanics of fluid, resistance is maximized if the
patient performs exercises in a continuous movement in which the limb
is kept below the water surface. Resistance can be strategically lessened
to accommodate the patient’s strength level with partial submersion and
pausing during the movement. For the stronger patient, water mitts and
hand paddles can be added to increase drag of the limb.5 Training in water
has several advantages compared to land. Movements against water are
inherently more difficult than identical movements against air because of
water’s viscosity, making virtually any movement against water a resistance
training exercise. Performing resistance training movements in water puts
less stress on joints because they are unloaded of gravitational forces com-
pared to land.
Pain decreases in water through several mechanisms. The natural
buoyancy of water unloads joints and supports the body so less muscle
activation and coordination is required to maintain balance. Standing
upright with water up to the neck, the upward buoyant force counteracts
gravity so that about 10% of the normal gravitational force is exerted on
the body. Discs, facets, and peripheral joint structures are unloaded allow-
ing for functional movements such as walking with less stress.6 Reduction
of muscle activity to maintain balance allows for easier control of proper
pelvic tilt and lumbar curvature. Body support from buoyancy in posi-
tions of spinal flexion and extension means the patient can actively range
through normally painful spinal load movements with less compression
on the spine. Normal range of motion may be achieved in a pain-free
manner in the aquatic environment before trying similar exercises on
land.5 A negative effect of buoyancy is a decrease in body stability with
water levels above the T8 spinal level. Shallower water may be indicated
if the patient has difficulty keeping his or her feet planted on the pool
floor.5 An additional factor in aquatic therapy pain relief is that water
acts as a diffuse sensory stimulus that can alter or suppress the typical
pain experience.5
103
104 P A R T I I I  Conservative Treatment Modalities
Case Studies
TREATMENT, CLINICAL CHALLENGES,
AND FUTURE TREATMENTS
A 78-year-old woman with bilateral knee osteoarthritis and leg and back
pain occurring only when walking and standing has been unable to tol-
erate land-based aerobic exercise. For this individual, her knee arthritis
interferes with her ability to bear weight and train her spine on land.
Evidence exists showing that aquatic exercises decrease pain from periph-
eral joint arthritis. The unloading effect that occurs in water allows for
strength training and aerobic conditioning while in a supportive envi-
ronment that protects from falls. Her history is suggestive of neuro-
genic claudication from lumbar spinal stenosis, a condition where the
patient often obtains relief while in positions of flexion. In water a flexion
­posture is achieved with less compressive force on the vertebral bodies,
limiting the risk of an exercise-induced osteoporotic compression frac-
ture or aggravation of mechanical low back pain. Eventually, this patient
can try transitioning to a land-based program with the goal of improving
her walking tolerance.
CLINICAL PRACTICE GUIDELINES
Physician Evaluation and Prescription
While obtaining the history and physical the practitioner will pay special
attention to factors that will make aquatic therapy uniquely beneficial, as
well as to contraindications. Evaluation includes a focused neurologic
and musculoskeletal examination with a focus on spinal range of motion,
strength, sensation, and gait. A common example of an aquatic therapy
regimen is that outlined by Dr. Andrew Cole.7 Static and dynamic exercises
of progressive difficulty are used for development of spinal stabilization.
Examples include sitting against the pool wall with neutral spine posture,
walking forward and backward, abdominal crunches, a host of exercises
designed for the facilitation of neutral spine posture, flexibility, conditioning
and core strength.
Indications
Indications for water therapy are similar to those for land-based therapies
with the most important criterion being unsuitability for a fully land-based
program. The patient may need extra support due to weakness or proprio-
ceptive loss and concurrent land-based spinal rehabilitation is possible if the
patient can tolerate some land-based exercises.7 Ultimately the patient needs
to function on land in an air atmosphere without the support and comfort
of water. Aquatic therapy can be used to decrease pain, and improve gait,
strength, endurance, or coordination. In water, skills can be simulated in
a less challenging setting than land with the ultimate goal being improved
function and pain level while on land. The water milieu can serve as a bridge
to improved land function.5
Contraindications
There are general contraindications for use of any form of water immersion
including home bathing. These include open wounds, fever, severe heart
disease, bowel or bladder incontinence, open ports such as tracheostomy,
feeding tube, or colostomy, and extreme cognitive or functional impairment
rendering a water environment unsafe.5
Evidence Base
High quality evidence supporting the efficacy of water therapy for pain relief
and functional restoration in patients with spinal disorders has been limited,
with the practice supported primarily by anecdotal reports and extrapola-
tion from studies of peripheral joint arthritis. The purported special ability of
aquatic therapy to reduce pain has been challenged in a recent meta-analysis.
Hall et al.8 conducted an exhaustive search of 18 databases for studies of water
A 47-year-old obese male smoker with chronic axial low back pain and
poor endurance presents to a chronic pain center with markedly reduced
daily function and pain with any movement or prolonged stationary posi-
tion. Chronic low back pain is very challenging to treat. Once an individual
becomes deconditioned, land-based exercises can be too challenging, partic-
ularly in patients with limited pulmonary capabilities as in obstructive pul-
monary disease. Water is an ideal environment to begin recovery of strength,
endurance, and flexibility. The prescribing physician must pay attention to
any contraindications for aquatic therapy that are present in this patient,
such as comorbid severe heart disease or open wounds. The primary goal
for this patient will be to decrease the pain associated with movement. The
buoyant aquatic environment reduces axial load on his spine. Limb exer-
cises performed quickly under water will be more difficult than on land.
An aquatic-based conditioning program must be titrated to his endurance,
which will increase over the course of therapy.
therapy in the treatment of pain for neurologic or musculoskeletal conditions.
The authors distilled the 793 identified studies down to 19 that were of ade-
quate quality with sufficient data to analyze. Three of the included studies
were of chronic low back pain, while the remaining were of rheumatoid arthri-
tis, osteoarthritis, fibromyalgia, and multiple sclerosis. The authors found that
in aggregate there was no additional pain-relieving effect of aquatic therapy
compared to land-based therapies. When compared with no treatment at all,
aquatic therapies provide a small amount of pain relief.8 These results do not
eliminate the possibility of water-specific pain-relieving properties. The pain-
relieving effect may be the same for land- and water-based therapies yet their
mechanisms may differ. For the individual unable to tolerate land-based thera-
pies aquatic therapies are a means to seek a pain-relieving effect.
A useful resource for clinicians interested in exploring the evidence base
for water therapies is http://aquaticnet.com/index.htm, an online repository
of references for scholarly and non-scholarly writings on water therapies.
CONCLUSIONS AND DISCUSSION
Aquatic therapy is an alternative form of physical therapy that is indicated
when land-based exercises are prohibitively challenging. Exercise in water
can be performed with lower requirements of strength, balance, and coordi-
nation. Buoyancy reduces forces across joints, making movement less pain-
ful. Despite these theoretical advantages there has been limited literature
evidence especially in the form of randomized controlled trials to show that
exercising in water translates to decreased pain and improved function on
land. For special populations, however, such as those with peripheral joint
comorbidities, severe edema, and deconditioning, water-based therapy is
useful when land-based exercise is intolerable.
References
1. T. Bender, Z. Karagulle, G.P. Balint, C. Gutenbrunner, P.V. Balint, S. Sukenik, Hydrotherapy,
balneotherapy, and spa treatment in pain management, Rheumatol. Int. 25 (3) (2005) 220–224.
2. P.A. Tipler, Physics for scientists and engineers, third ed, Worth Publishers, New York, 1991.
3. B.E. Becker, Cole, J. Andrew, Aquatic rehabilitation, in: J.A. DeLisa (Ed.), 4 ed., Physical medicine
and rehabilitation, Vol. 1. Lippincott Williams & Wilkins, Philadelphia, 2005, pp. 479–492.
4. J.P. O’Hare, A. Heywood, C. Summerhayes, G. Lunn, J.M. Evans, G. Walters, et al., Observa-
tions on the effect of immersion in Bath spa water, BMJ (Clin. Res. Ed.) 291 (6511) (1985)
1747–1751.
5. R.L. McNeal, Aquatic therapy for patients with rheumatic disease, Rheum. Dis. Clin. North
Am. 16 (4) (1990) 915–929.
6. C. Konlian, Aquatic therapy: making a wave in the treatment of low back injuries, Orthop.
Nurs. 18 (1) (1999) 11–18; quiz 19–20.
7. J. Andrew, R.E.E. Cole, Marilou Moschetti, Edward Sinnett, Aquatic rehabilitation of the
spine, Rehab. Management (April/May) (1996) 55–62.
8. J. Hall, A. Swinkels, J. Briddon, C.S. McCabe, Does aquatic exercise relieve pain in adults with
neurologic or musculoskeletal disease? A systematic review and meta-analysis of randomized
controlled trials, Arch. Phys. Med. Rehabil. 89 (5) (2008) 873–883.