Aquatic therapy, hydrotherapy, pool therapy, hydropathy – call it what you will, using water as a medium for rehabilitation has long proven its efficacy as a treatment modality for a wide range of conditions. Therapy experts from a range of orthopedic and neurological backgrounds agree that patients recovering from injury or surgery can begin therapy sooner using water’s buoyancy to aid in rehabilitation.

Aquatic therapy has been well known for treating musculoskeletal disorders such as arthritis or spinal cord injuries, and in patients suffering from debilitating burns, spasticity, stroke, and paralysis. However, the field has come a long way from its foundations in physical therapy; while manufacturers continue to expand upon the designs of specialty pools, rehabilitation specialists and therapists in other fields have begun to take advantage of the benefits of bringing patients to the water.

The Wet Workout

The United States is officially experiencing an obesity epidemic. With more than 97 million people currently overweight or obese, this trend has become a major contributor to the prevalence of chronic disease and physical disability, including osteoarthritis, cardiovascular disease, hypertension, and stroke. Therapists working with obese patients are inclined to use aquatic therapy as the water can easily accommodate their weight where standard exercise machines might not.

“I think the patients and conditions that benefit the most from aquatic therapy are those that correspond with our weight-bearing joints,” says Beth Bamesburger, PT, co-owner of Live Well Physical Therapy in Grand Island, Neb. Well known for their aquatic therapy accommodations, Live Well uses a pool design from Fall River, Mass.-based SwimEx. Commonly called resistance swimming pools, SwimEx pools use laminar water current to create a consistent wall-of-water resistance, which the therapist can control from inside the pool.

“In particular, we see a lot of low back pain, which is a weight-bearing joint, especially if someone has a weight problem,” says Bamesburger. “Basically, the spine takes a lot of compression, along with the hips, knees, and ankles. Therefore, the lower extremities are typically the first place to see ailments in these patients, whether post-surgical or simply following an injury. But when you put these weight-bearing joints in an aquatic setting, that component of stress is really eliminated.”


Another demographic experiencing the benefits of aquatic therapy are individuals who are mobility-impaired, such as those suffering from multiple sclerosis or paralysis due to injury. In a weightless environment, there is no fear of falling or the relentless muscle struggles against gravity. Aquatic therapy can improve circulation and relax or loosen stiff muscles – not to mention the psychological benefits of building confidence and feeling free from their physical restraints.

“It’s not uncommon for us to have patients that see or show us movement in the water that we don’t necessarily see on land,” says Jan Black, MS, PT, cofounder and clinic director of South Jordan, Utah-based Neuroworx. “Physical therapists grade on a 0 to 5 scale: 0 meaning nothing. A 1 out of 5 just means you can feel a palpable kind of contraction, but doesn’t move. However, a lot of times, those weaker muscles can be seen in the water.”

Black’s facility utilizes an aquatic therapy pool from Middletown, Pa.-based HydroWorx, which features a hose attachment that can be used for deep tissue massage and scar tissue breakdown. Also, the water temperature is kept warmer than typical pools to avoid cold-induced muscle stiffness and because individuals with spinal cord injuries may have difficulty with temperature regulation.

“We have one gentleman from another state who comes in,” says Black. “He’s a C4-5 complete quadriplegic, which really means he just has some shoulders and head movement. Everything he does, he does with his head, because that’s how little arm muscle and movement he has. What he actually does is go face down in the water with snorkel and mask so that his arms float in front of him in the water. And that’s the only place he’s actually able to see his arms move.”

Ever-changing Waters

As with several other therapy fields, the aging baby boomer population and the product manufacturers looking to fit the demands of this demographic have transformed the therapeutic approach – the aquatic therapy field is not only changing but becoming more disability-focused each year.

“My dad was a therapist, and he set up an aquatic program back up in the late-’60s; that program was just done in a pool where people participated in group aerobic exercise, where you have 10 or 12 people doing the same exercise, with an instructor in the middle,” says Roger Meade, PT, director of rehab services at Carolina Spine and Neurosurgery Center in Asheville, N.C.

“Now, we’re seeing developed protocols for all the different-type diagnoses, different patterning, therapists working one-on-one with patients trying to get certain movement patterns back, focusing on range-of-motion,” says Meade. “The field is looking more at specifics to improve, instead of general conditioning; there are a multitude of different techniques out there, especially among aquatic experts, that are specialized for the pool. The biggest thing I see differently is that therapists are looking at the advantage that buoyancy gives them to do exercises more aggressively than they can do outside of water.”

In addition, due to medical advancements, incomplete injuries to the spinal cord are more common than they were in previous years. With an incomplete injury, some motor and sensory function remains. Patients may have feeling, but little or no movement, while others may have movement but little or no feeling. Regardless, some residual sensory or motor function opens the possibility of a return to some mobility, especially when aquatic therapists begin an ambulation regimen without dealing with the strain of gravity.

“Water was available for therapeutic intervention even when I was a student and just learning, about 25 to 30 years ago, but there were limited facilities,” says Bamesburger. “Therapists mostly worked with pediatrics in water, especially in the 1950s, when polio patients were put in water. But this wasn’t the norm, and it wasn’t really in the traditional realm of physical therapy.”

She continues, “I would say over the last 10 to 15 years, it’s really escalated, with better aquatic facilities, with better technology, in terms of the pools, and research always backs that up a little bit. So it’s really changed from being kind of a limited scope and focusing on just the pain patients. Today, we use our pool, especially with the laminar flow, and it’s just another modality of an isokinetic piece of equipment.”

Making Some Breathing Room

For patients with chronic lung diseases like chronic obstructive pulmonary disease, emphysema, and chronic bronchitis, exercise is a crucial part of their pulmonary rehabilitation. Exercise is necessary to improve the function of the heart and lungs, and also to strengthen the muscles used for breathing. It is common for people with lung disease to limit physical activities because they are fearful of becoming short of breath; unfortunately, this is counterproductive to therapy and actually atrophies the patient’s ability to breathe.

“Although it’s not an area that’s been researched a great deal, we do see respiratory patients,” says Bamesburger. “When we submerge someone into an aquatic setting, another of the aquatic properties that we utilize – aside from the heat, buoyancy, and resistance of the water on the body – is hydrostatic pressure.”

Hydrostatic pressure is the pressure exerted by water on an object immersed in the water. The deeper an object is submerged, the more pressure there is on that object. With respiratory patients, the pressure of the water on the chest wall resists muscles that expand the chest for breathing. In this way, these muscles are strengthened and can more efficiently expand the chest to allow a greater volume of air to be inhaled when performing daily tasks.

“It’s kind of like putting a blood-pressure cuff on or even a supportive hose,” says Bamesburger. “The respiratory patient benefits by improving their inspiration, so when they breathe in, they have got some resistance. They have to kind of breathe in a little bit, and it gives a little bit of resistance for them to breathe in against. Also when they exhale, this pressure assists with their expiration. So therapists can really do some breathing-type exercises simply by using the hydrostatic pressure of the water.”

When working with respiratory compromised patients in an aquatic setting, therapists must take several factors into account, namely the temperature of the water, how quickly patients tire during a regimen, and avoidance of heavy cleaning chemicals – chlorine, for example – that might aggravate breathing issues. While there are several official precautions and indications listed for people in the water when it comes to a patient with respiratory complications, many of those parameters are based on someone being vertical in the water.

“A lot of the data that is out there for aquatic therapies is geared toward the person who is vertical in the water,” says Black. “However, a lot of the patients that would fall under that compromised level or contraindication rarely go vertical in our water anyway, because they can’t. They’re horizontal, which takes some of that compromise and contraindication away for us. But we still allow them to better use the water and movement that it allows them without compromising their respiratory systems.”

She adds, “It’s something you have to be careful with and work very closely with when dealing with the restrictions of the water on their respiratory system. It’s definitely a specialty, but I think it’s a doable thing if you understand what your doing and the patient population that you’re seeing.”

Across the Field

While aquatic therapy still has its roots planted firmly in the physical therapy field, the growing number of accessories available for specialty pools has broadened the scope of its applications. While therapy pools have become a common sight in retirement communities and assisted living facilities working with ailments common to the Baby Boomers, innovative therapists working with much younger patient populations intent on pushing the envelope in aquatic therapy application.

“It’s much less utilized, but I know there are some occupational therapists out there that have used therapy pools to work with functional ability, whether that be standing, pre-transfer, or balance applications,” says Black. “I think the Hydroworks pool with the elevating floor really allows some of the occupational therapists – if you have a therapist who is quite creative – to do some of the things that they do on land, because you can change the depth of the floor. We’re able to do kneeling activities or even long-sitting balance activities in the water that could carry over to dressing and that kind of mobility.”


Aquatic therapy has become the new frontier for several rehabilitation specialists and therapists, who are using the almost alien sensory environment and water-based games to create new activities for their patients. For example, an occupational therapist may use the unique sensation of water to work on sensory integration or motivate patients by diving for rings to improve fine motor skills. A speech therapist, on the other hand, may use water to help with oral motor skills through activities like blowing bubbles to improve strength or motor planning.

“From what I’ve seen, occupational therapy uses therapy pools quite a bit,” says Meade. “I’ve seen a lot of occupational therapists working with pediatric patients in the pool – especially the younger kids who have neurodevelopmental problems and require a multitude of disciplines involved in using water during therapy. I’ve even seen speech therapists working with children in the water, since it assisted in relaxing the patients’ upper bodies and helped those who were susceptible to spasms.”

Other rehabilitation professionals, such as orthopedic specialists and recreational therapists, are also making endeavors to open bridges into aquatic therapy. “I know that recreational therapists have asked to use our pool to teach some adaptive kayak entrance and exiting when it comes to the disabled,” says Black. “Therapists are beginning kayaking programs, as well as basic swimming and some scuba programs for people with spinal cord injuries.”

Bumps in the Road Ahead

While aquatic therapy has opened a new frontier to rehabilitation professionals, getting reimbursed for aquatic therapy can be a challenge in this ever-fluctuating industry. Between referrals, evaluations, proper documentation, and correct coding procedures, aquatic therapy reimbursement remains a minefield of setbacks for many professionals.

“There are still payors that don’t pay for an aquatic code,” says Black. “Medicare is pretty picky about what diagnoses go in the pool. It’s ironic that you have someone in Medicare that won’t allow me to put an incomplete quadriplegic in the pool who is walking – that diagnosis does not fall into putting someone into a pool. But the same people who make that decision will allow me to put in a C1 through C4 quadriplegic – which means the patient’s head moves. There’s a code for me to be able to do gate training with them, which is impossible.”

Black adds, “Obviously, the people making the decision on what we get paid for have no clue as to what they’re doing. I think one of our biggest obstacles is having payors understand what happens in the pool, why that’s beneficial, and why they should pay for that.”

No longer just an emerging trend, aquatic therapy continues to redefine its niche in the realms of mainstream medicine. Today’s therapists and rehabilitation specialists continue to push the boundaries beyond the conventions of physical therapy and are moving to make aquatic therapy a crucial part of the recovery regimen for a patients across the spectrum.

— Bob Stott is the editor of Therapy Times. Questions and comments can be directed to bstott@therapytimes.com.