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Aquatic therapy for Stroke Rehabilitation

Posted on Sep 04 2020
Posted by: Dr Brinda Merchant(PT)

Using Aquatic Therapy to enhance recovery for stroke survivors

What is Stroke?

Stroke refers to a condition caused by interruption of blood supply to the brain. It is also known as a “brain attack”Stroke may have severely debilitating consequences on a person’s sensory,motor,cognitive and emotional functions. Persons suffer from weakness of one side of the body,loss of postural control, decreased upper and lower extremity functioning, balance and walking .difficulties.

How is stroke treated?

Intensive medical management is required when there is an onset of stroke. Lifestyle management and nutritional management are factors which need to be necessarily addressed. Apart from above physiotherapy, occupational therapy, speech therapy, cognitive therapy and psychological support are crucial to functional recovery from stroke.

Physiotherapy for stroke

Physiotherapy management of stroke is targeted towards recovery of movements. Physiotherapy interventions address recovery of walking ability, balance and postural control. Various specialized stroke specific techniques are used such as Bobath/NDT and Proprioceptive Neuromuscular facilitation(PNF) are used.

Aquatic therapy/Aqua Therapy,previously known as hydrotherapy is a specialized form of intervention, where in physiotherapy interventions are performed in water,utilizing to best advantage physical properties of water.

An insider account of a stroke survivor

“Raman”,a young stroke survivor hero suffered a sudden stroke at the age of 37 years. Imagine such a setback happening in the prime of your life. Raman faced significant problems with his balance ,walking abilities and use of his __ hand. However he was extremely committed towards recovering, his motto being“The comeback is always stronger than the setback”. While he was following a home based physiotherapy protocol, his realization was that he has greater potential and can do intensive physiotherapy. . He visited Aqua Centric, and a treatment protocol comprising Aquatic Therapy and land based therapy was set.With Aquatic Therapy Raman perceived a distinct improvement in mobility,due to reduced stiffness.With every aquatic therapy session,he felt significantly more comfortable with movements.There is measurable difference in balance and walking,as reported by his treating physiotherapist.Functionally he feels stronger and has greater stamina which has improved his overall quality of life.

What is Aquatic Therapy?

American Physical Therapy Association defines aquatic therapy or aquatic physical therapy (APT) as “the evidence-based and skilled practice of physical therapy in an aquatic environment by a physical therapist.” Aquatic Therapy includes “treatment, rehabilitation, prevention, health, wellness, and fitness of the patient/client population in an aquatic environment with or without the use of assistive, adaptive, orthotic, protective, or supportive devices and equipment.”

Simplified,Aquatic Therapy is therapeutic use of water to promote movement.Innate properties of water such as buoyancy, viscosity and hydrostatic pressure are utilized for improvement in mobility, strength and balance. Therapy takes place in a temperature controlled therapeutic pool. The intent of therapy is to gain enhanced vertical functioning, in contrast to swimming which is more about horizontal movements in water.

How does it aid Stroke recovery?

While traditional physiotherapy is an absolute must,for movement and functions in stroke, well planned ,goal oriented aquatic therapy can provide a significant boost in improving functional mobility by

• Improvement in muscle tone
• Reducing dynamic stiffness
• Improved recruitment of core muscles
• Improvement in trunk control
• Improved muscle strength of upper and lower limbs
• Improved cardiovascular functioning
• Improved flexibility
• Increased endurance

Aquatic therapy provides a conducive environment to perform movements, often more so than land. For example, a person immersed chest deep in water experiences approximately only 25 percent of his body weight, making movements easier. Water provides a supportive environment, hence standing is easier in water. A very popular saying in neurological rehabilitation is “Use it, or lose it”.Water,especially for stroke related concerns makes it easier for a person to move,and hence relearn movements.

Is there any scientific evidence that it works effectively in stroke recovery?

 Royal Dutch Society for Physical Therapy (KNGF) Clinical Practice developed Guidelines for Physical Therapy in patients with stroke. Guideline recommends considering hydrotherapy(aquatic therapy) to increase muscle strength.(1)

 Clinical trial by Tripp et al evaluated effects of an aquatic therapy approach on functional mobility in subacute stroke patients. The study concluded that Aquatic Therapy is safe and well tolerated in stroke patients in post-acute rehabilitation and has positive effects upon some aspects of mobility.(2)

 Study by Montagna et al assessed the effects of aquatic physiotherapy on the balance and quality of life (SS-QoL) of people with pos stroke. Results were suggestive of aquatic physiotherapy using the method of Halliwick can be a useful tool during stroke rehabilitation to improve balance and symmetry.(3)

Scientific evidence from studies conducted around the world suggest,judicious use of Aquatic Therapy is beneficial for functional recovery of stroke survivors.

Four specialty techniques of Aquatic Therapy used for stroke rehabilitation

Since water is a therapeutic environment significantly different than land,techniques used in water are designed specifically keeping in mind the physics of water .Interventions in water are geared towards ultimately optimizing sensory-motor recovery in day to day function of stroke survivors.

Water Specific Therapy/Halliwicks Method-Halliwick’s Method is a form of adapted Aquatics.Principles of Water Specific Therapy are derived from Halliwick’s method for active aquatic therapy.Aquatic therapist progresses the client through a series of activities, in an attempt to facilitate control over movement. Independence is encouraged through an active disengagement process. All exercises incorporate varying degrees of rotational patterns. The client is required to respond to the demands of destabilizing forces provided by water, albeit in an environment which is safe and conducive to movement. Working against the destabilizing forces enable client to regain balance and postural control. Strategies of WST invariably incorporate trunk control and core muscle activation, consequently retraining postural stability.

Bad Ragaz Ring Method-This method is based on principles of Proprioceptive Neuromuscular facilitation,Bad Ragaz Ring Method(BRRM) comprises of three dimensional,diagonal movements based in water. Movements are active and therapist facilitated.Focus of movements and exercise interventions is on gains in strengthening and stability(4)

Clinical trial by Hyun-GyuCha9 et al .evaluated effects of the Bad Ragaz Ring method on functional recovery in chronic stroke patients.Study concluded Bad Ragaz Ring method may be beneficial for improving balance and leg muscle activation of chronic stroke patients.(5)

Clinical Ai-Chi-This is a series of postural control movements comprising of19 katas.Progressions are designed to present increasing difficulties as skills develop.(6)Ai Chi is actively performed with therapist typically being hands off .The client stands in chest-deep water and is verbally and visually instructed by the provider to perform a series of slow, rhythmic therapeutic movements combined with mindful breathing.

Pei-Hsin Ku et al investigated effects of Ai Chi for balance in individuals with chronic stroke. Study concluded Ai Chi to be feasible for balance training in stroke, and improve weight shifting in antero-posterior axis, functional balance, and lower extremity control as compared to conventional water-based exercise(8)

Task Type Training Approach (TTTA)-This approach was first described as a way to teach functional activities to patients who had sustained strokes. In the 1990s, David Morris, president of the American Physical Therapy Association- Aquatic PT Section, took these ideas into the pool. All health-care providers who perform task simulation as part of their scope of practice may integrate aquatic TTTA techniques as they are learned. Practitioners using the aquatic TTTA should have a thorough understanding of neurologic dysfunction, functional skill analysis and motor learning principles. Such a background is common with physical and occupational therapy professionals.Activities like pushing.pulling, carrying and bending lifting objects can all be incorporated into aquatic therapy programs.(9,7)

Aquatic Therapy at AquaCentric

At Aqua Centric Therapy we provide world class facilities for Aquatic Therapy for optimal recovery from stroke. Aquatic Therapy at our centers is conducted in indoor, temperature controlled therapy pools. Pool hygiene is given highest consideration, with pools being outfitted with UV, Ozone and glass bead filters. Water ph is maintained at 7-7.5 which is as good as drinking water. Chlorine levels are minimal, maintained at 0.5-1 PPM.

Specialized equipment used include

• Electronic pool hoist: Persons with stroke may have mobility issues that which make entry and exit difficult .Electronic pool hoists are used to facilitate entry and exit, making pool safe accessible for persons of all ages and abilities, eliminating need for ladders or steps.
• Underwater Treadmill: Invaluable for gait training, underwater treadmill allows individuals to practice walking patterns which mimic land patterns. The speed of the underwater treadmill changes in small increments allowing persons to safely progress at their own speed.
• Height adjustable drop in platforms: These are sturdy, on slip surfaces above level of pool floor. Sitting based exercises and other strategies of water specific therapy (WST) are facilitated using pool platforms
• Underwater stationary cycle: These are designed for improvement of cardiovascular endurance.

Therapy begins with a through land based assessment following which function based goals are set.

Therapy protocol is in accordance to functional goals.Therapy is provided by physiotherapists who specialize in neurological rehabilitation,and have received intensive training in Aquatic Therapy.

In COVID times, therapies would be conducted based on recommendations listed and followed by apex organizations of Aquatic Therapy like IATF ,IOAPT and ATNI. Strict SOPs would be followed, in keeping with national and state norms so that therapy is a safe and beneficial experience for our clients. To get more information, you are welcome to address your queries on contact number provided.

To know more about how Stroke can be managed at AquaCentric, click here.


1. KNGF Clinical Practice Guideline for Physical Therapy in patients with stroke F.1.19 Hydrotherapy, page 33. , can be downloaded from www.fysionet.nl. © 2014 Royal Dutch Society for Physical Therapy (KoninklijkNederlandsGenootschapvoorFysiotherapie, KNGF
2. Florian Tripp 1, KarstenKrakow;Effects of an aquatic therapy approach (Halliwick-Therapy) on functional mobility in subacute stroke patients: a randomized controlled trialClin Rehabil. 2014 May;28(5):432-9. doi: 10.1177/0269215513504942. Epub 2013 Oct 31
3. Jéssica Cristine Montagna 1, Bárbara C Santos 1, Camila R Battistuzzo 2, Ana Paula C Loureiro .Effects of aquatic physiotherapy on the improvement of balance and corporal symmetry in stroke survivors;1Int J Clin Exp Med. 2014 Apr 15;7(4):1182-7. eCollection 2014
4. Bad Ragaz Ring Method – IATF (International Aquatic Therapy Faculty), Valens, Switzerland
5. Hyun-Gyu Cha 1, Young-Jun Shin 2, Myoung-Kwon Kim 2Effects of the Bad Ragaz Ring Method on muscle activation of the lower limbs and balance ability in chronic stroke: A randomised controlled trial;Hong Kong Physiotherapy J. 2017 Apr 21;37:39-45. doi: 10.1016/j.hkpj.2017.02.001. eCollection 2017 Dec.
6. http://clinicalaichi.org/
7. https://www.nspf.org/ahbb/november-2017-specialty-techniques
8. Pei-Hsin Ku1, Szu-Fu Chen2, Yea-RuYang1, Ta-Chang Lai 3* & Ray-YauWang1*;The effects of Ai Chi for balance in individuals with chronic stroke: a randomized controlled trial Scientific Reports volume 10, Article number: 1201 (2020)
9. Andrea Salzman, PThttps://www.aquaticsintl.com/facilities/management-operators/task-masters