Efficacy of aquatic therapy in people with spinal cord injury: a systematic review and meta-analysis.

STUDY DESIGN: Systematic review and meta-analysis. Spinal cord injury (SCI) is a pathological condition that provokes the loss of one or more body functions due to an injury to the spinal cord as a result of trauma or disease. Hydrotherapy plays a key role in the rehabilitation of neurological patients due to the properties of water environments. OBJECTIVES: The goal of this study was to evaluate the efficacy of hydrotherapy in patients who suffer from SCIs. METHODS: We searched 5 different databases: CINAHL, PubMed, Scopus, Web of Science, and PEDro for studies to include. Only randomized controlled trials (RCTs) published in English were considered. To evaluate the risk of bias, Jadad and PEDro scales were used. RESULTS: Eleven Randomized Controlled Trials were included, and 3 articles remained to be analyzed. According to the evaluation through Cochrane Risk of Bias tool, one study had a high level of quality. The remaining 2 studies achieved a score indicative of a low level of quality. A total of 71 individuals with SCI were included in the studies; age and level of injury varied in each study. The outcome measures used in the studies were: Functional Independence Measure (FIM), Ashworth scale, CardioTouch 3000 s in sitting position and Quark CPET. CONCLUSION: The aquatic environment provides a rehabilitation tool able to facilitate movement, physical and cardiovascular exercise, resistance training, and body relaxation.

Effect of Water Exercise Therapy on Lower Limb Function Rehabilitation in Hemiplegic Patients with the First Stroke.

Objective: To investigate water exercise therapy's effect on lower limb function rehabilitation in patients with the first stroke. Method: 160 patients with the first stroke and lower limb dysfunction who received rehabilitation treatment in the Geriatric Hospital of Hainan, China, from May 2020 to June 2021 were randomly divided into two groups, the control group, and the hydrotherapy group. Each group comprises 80 cases in each group. The control group received conventional drug therapy and traditional rehabilitation training, while the hydrotherapy group received underwater exercise training in combination with the routine group treatment plan. The National Health Center Stroke Scale (NIHSS), the modified Rankin scale (MRS), the limb motor function score table (Fugl-Meyer assessment, FMA), Functional Walking Scale (functional ambulation category scale, FAC), Berg Balance Scale (BBS) and the modified Barthel index (MBI) were respectively used to evaluate the neurological function, lower limb motor function, walking function, balance function and daily living ability before and after treatment. Result: There was no significant difference in NIHSS, MRS, FMA, FAC, BBS, and MBI scores between the two groups before treatment (P > .05). However, after 8 weeks of treatment, there was a significant difference in FMA, FAC, BBS, and MBI scores between the two groups (P = .00035). The FMA scores in control group was 16.60 ± 4.49, while 21.45 ± 2.96 after treatment. The FAC scores in control group was 1.45 ± 0.68, while 1.95 ± 0.783 after treatment. Conclusion: Early water exercise training in hemiplegic patients with the first stroke can significantly enhance the balance ability, walking ability as well as limb coordination of patients.

Rationale and current evidence of aquatic exercise therapy in venous disease: A narrative review.

Chronic venous disorders (CVD) of the lower limbs can be treated with different strategies. Typically, conservative management is based on compression therapy, anticoagulants and venoactive drugs. Endovenous treatments remain the gold standard to treat saphenous insufficiency, with sclerotherapy and surgery maintaining a role in selected cases. In addition, several 'unconventional' approaches have been proposed to prevent CVD progression and complications, minimize symptoms and improve the quality of life and postoperative outcomes. Among these, balneotherapy and aquatic exercises are proving as valid and effective supporting treatments, as mentioned in a growing number of scientific publications. Moreover, aquatic protocols have been studied for both venous and lymphatic insufficiency. For these reasons, they were mentioned in the last CVD guidelines provided by the European Society for Vascular Surgery. The aim of this narrative review is to overview and summarize current literature evidences on the role and effectiveness of aquatic rehabilitative protocols in CVD, reviewing old and current literature. Furthermore, the physical basis of the effects of water immersion on lower limb venous and tissues modifications are also described.

Acute high-intensity interval exercise versus moderate-intensity continuous exercise in heated water-based on hemodynamic, cardiac autonomic, and vascular responses in older individuals with hypertension.

OBJECTIVES: This crossover study design aimed to assess hemodynamic, cardiac autonomic, and vascular responses to high-intensity interval (HIIE) vs moderate-intensity continuous exercise (MICE) in older individuals with hypertension. METHODS: Twenty (67 ± 7 y) older individuals with hypertension were randomly assigned to perform HIIE, MICE, or control (CON) sessions in the heated swimming pool (30-32°C). Blood pressure (BP), arterial stiffness, endothelial reactivity, and heart rate variability (HRV) were measured pre, post, and 45 min (recovery) after each intervention followed by 24-h ambulatory BP and HRV. RESULTS: One single aerobic exercise session was not effective to provoke post-exercise hypotension and vascular improvements. HIIE was superior to MICE and CON to increasing parasympathetic modulation at post and recovery. Exercise sessions showed to disturb the autonomic system at nighttime compared to CON. CONCLUSIONS: These results may have important implications in water-based therapy and the elderly with hypertension.

A qualitative pilot study exploring clients' and health-care professionals' experiences with aquatic therapy post-stroke in Ontario, Canada.

BACKGROUND: Aquatic therapy is beneficial for people post-stroke, as it improves their physical function, well-being, and quality of life. There is a lack of description of users' experiences and perspectives toward aquatic therapy that could elucidate contextual factors for aquatic therapy implementation. OBJECTIVES: To explore participants' experiences with aquatic therapy post-stroke as part of a participatory design project to develop an education tool-kit to address the users' needs for aquatic therapy post-stroke. METHODS: A qualitative descriptive study was employed using a purposive sampling. Letters were sent to stroke and aquatic therapy organizations. Individual interviews were conducted either by phone or Zoom with nine participants in the chronic phase of stroke and 14 health-care professionals. All transcripts were coded and analyzed independently by two researchers. Inductive thematic analysis was used to identify the main themes. RESULTS: Health-care professionals practiced aquatic therapy in rehabilitation hospitals (N = 7), community centers (N = 8) and private clinics (N = 3). From the interviews, two organizing themes were identified: (1) Importance of aquatic therapy (e.g. experiences, benefits, and program approaches); and (2) Aquatic therapy education (e.g. knowledge gaps, sources of learning and communication). CONCLUSIONS: Health-care professionals and clients reported numerous benefits of aquatic therapy post-stroke including, but not limited to, improvements in mobility, balance, wellbeing, and socialization. Lack of formal and informal education and communication as participants' transition from rehab to community were viewed as barriers to aquatic therapy use post-stroke. Developing education material and communication strategies may improve the uptake of aquatic therapy post-stroke.

Pain neuroscience education improves quality of life when added to aquatic exercise therapy for women with fibromyalgia: randomized controlled clinical trial.

PURPOSE: The aim of the present study was to investigate the effects of adding Pain Neuroscience Education (PNE) to an aquatic therapy protocol on pain, fibromyalgia (FMS) impact, quality of life and sleep. MATERIALS AND METHODS: Seventy-five women were randomly allocated into two groups: aquatic exercises (AEG, n = 36) and aquatic exercises + PNE (PNG, n = 39). The primary outcome was pain, and the secondary outcomes were FMS impact, quality of life, sleep and pain sensitivity (pressure pain thresholds - PPTs). Participants performed 45-min sessions of aquatic exercises, twice a week, for 12 weeks. PNG also received 4 PNE sessions during this period. Participants were assessed four times: initial (before treatment), after 6 weeks (intermediate) and 12 weeks (final) of treatment and after 12 weeks after the end of treatment (follow-up). RESULTS: Both groups improved pain after treatment, with no difference between them (p > 0.05, partial ƞ2 0.10). FMS impact and PPTs improved after treatment with no difference between groups, and sleep did not change. Quality of life improved several domains for both groups, with slightly better results for the PNG, with low effect sizes between groups. CONCLUSIONS: The present results show that the addition of PNE to an aquatic exercise intervention did not provide larger effects than aquatic exercises alone for people with FMS concerning pain intensity, but provided benefit for health-related quality of life for this population. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03073642, version 2, April 1st, 2019). PERSPECTIVE: The addition of 4 Pain Neuroscience Education sessions to an aquatic exercises protocol did not add benefits for women with fibromyalgia syndrome on pain, fibromyalgia impact, and sleep, but improved quality of life and pain sensitivity.IMPLICATIONS FOR REHABILITATIONAquatic exercises are commonly prescribed, but patient education is crucial for the treatment.The addition of Pain Neuroscience Education to an aquatic exercises protocol did not add benefits for women with fibromyalgia syndrome.The positive changes on quality of life and pain sensitivity that this combination led to had small effect sizes and did not achieve minimal important clinical difference.

Effects of Exposure to Formal Aquatic Activities on Babies Younger Than 36 Months: A Systematic Review.

This systematic review investigated the possible effects of exposing infants to formal activities in aquatic environments. A literature search of eight databases was concluded on 12 December 2022. Studies were eligible if they: (i) focused on 0-36 months of age infants, (ii) addressed the exposure of infants to formal aquatic activities, and (iii) compared the 'same condition of aquatic exposure with the control' or 'before and after exposure'. The PRISMA protocol was used. Articles considered for inclusion (n = 18) were clustered in the health, development, and physiological outcome domains. The results show that research is focused on indoor activities, mainly in baby swimming programs and baby aquatic therapy interventions. Swimming and aquatic therapy practices are generally safe for babies' health, and there are benefits to preterm and newborns exposed to aquatic therapy once the physiological parameters are maintained in normal and safe patterns. A positive effect is also suggested in general gross and fine motor skills, visual motion perception, cognitive flexibility, and response selection accuracy for infants who participated in aquatic programs. Further investigation with high-quality experimental designs is required to establish the effect of exposure of infants to formal aquatic activities (Systematic Review Registration: CRD42021248054).

Feasibility Testing of Wearable Device for Musculoskeletal Monitoring during Aquatic Therapy and Rehabilitation.

The objectives of this study were to test the feasibility of the developed waterproof wearable device with a Surface Electromyography (sEMG) sensor and Inertial Measurement Unit (IMU) sensor by (1) comparing the onset duration of sEMG recordings from maximal voluntary contractions (MVC), (2) comparing the acceleration of arm movement from IMU, and (3) observing the reproducibility of onset duration and acceleration from the developed device for bicep brachii (BB) muscle between on dry-land, and in aquatic environments. Five healthy males participated in two experimental protocols with the activity of BB muscle of the left and right arms. Using the sEMG of BB muscle, the intra-class correlation coefficient (ICC) and typical error (CV%) were calculated to determine the reproducibility and precision of onset duration and acceleration, respectively. In case of onset duration, no significant differences were observed between land and aquatic condition (p = 0.9-0.98), and high reliability (ICC = 0.93-0.98) and precision (CV% = 2.7-6.4%) were observed. In addition, acceleration data shows no significant differences between land and aquatic condition (p = 0.89-0.93), and high reliability (ICC = 0.9-0.97) and precision (CV% = 7.9-9.2%). These comparable sEMG and acceleration values in both dry-land and aquatic environment supports the suitability of the proposed wearable device for musculoskeletal monitoring during aquatic therapy and rehabilitation as the integrity of the sEMG and acceleration recordings maintained during aquatic activities.Clinical Relevance-This study and relevant experiment demonstrate the feasibility of the developed wearable device to support clinicians and therapists for musculoskeletal monitoring during aquatic therapy and rehabilitation.

The Effectiveness of Aquatic Therapy Based on the Halliwick Concept in Children with Cerebral Palsy: A Systematic Review.

The aim of the review was to evaluate the evidence regarding the effectiveness of aquatic rehabilitation based on the Halliwick concept (HC) in psychomotor development, gross motor function and aquatic skills of children with cerebral palsy. We followed PRISMA recommendations, performing a systematic search in PubMed, Science Direct, LILACS, SciELO, and PEDro database. We identified 474 studies; five met the eligibility criteria and were included in the review. Four studies demonstrated a significant improvement in gross motor function and aquatic skills. Social interaction skills were also improved. However, the methodological quality of these studies was limited, and then, research that adopt controlled experimental designs are necessary.

Effectiveness of aquatic therapy on sleep in persons with fibromyalgia. A meta-analysis.

CONTEXT: Fibromyalgia syndrome (FMS) is a chronic musculoskeletal condition characterized by persistent, widespread pain, myofascial tenderness, negative affect, fatigue, memory problems and sleep disturbances. OBJECTIVE: To summarize the evidence of the effects of aquatic therapy on sleep quality in patients with FMS. METHODS: This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2020 (PRISMA) guidelines and registered in the International Prospective Register of Systematic Reviews (PROSPERO), whit the registration number CRD42021249982. Cochrane library, Medline (PubMed), Science Direct Web of Science (WOS), Scopus, and PEDro were searched from inception until September 2021. The search included only randomized clinical trials. RESULTS: Of the 7711 studies identified in the initial search, a total of 7 trials (361 participants) satisfied the eligibility criteria. Finally, a meta-analysis was conducted with 6 studies (311 participants). The overall pooled effect favored aquatic therapy interventions in improving sleep quality in patients with FMS (pooled MD, -2.05; 95% CI, -4.35 to 0.25). CONCLUSIONS: The results of this systematic review and meta-analysis provide evidence that aquatic therapy improved sleep quality in patients with FMS. This study highlights the importance of aquatic therapy for sleep. Nonetheless, although an aquatic therapy intervention may represent a good option to improve sleep, given the low number of studies the evidence should be taken with caution.

Effects of aquatic therapy on balance in older adults: a systematic review and meta-analysis.

PURPOSE: Balance is a key component of movement for daily activities, especially in older adults. Previous studies examining aquatic therapy as an effective way for improving balance have yielded inconsistent findings. The current systematic review and meta-analysis investigated the effectiveness of aquatic therapy on balance among older adults. METHODS: Sources include Cochrane Central Register of Controlled Trials, Medline, ISI Web of Science, EBSCO, Embase, Cumulative Index to Nursing and Allied Health Literature, and Scopus. Randomized controlled or cross-over trials published by Feb 2020 were included following pre-determined search and selection criteria. Data extraction was performed by two researchers independently using a pre-determined data extraction form. Methodological quality was assessed by two reviewers using the PEDro scale which was used to rate trials according to criteria such as concealed allocation, blinding, and intention-to-treat analysis. Furthermore, meta-analysis was conducted where possible. This review was registered at PROSPERO CRD42018118382. RESULTS: Fifteen trials with 385 healthy participants aged 50 or over were included. Results showed that aquatic therapy had a significant effect on dynamic balance (SMD, - 1.13; 95% CI, [- 1.45 to (- 0.82)]; I2 = 77%). The analysis indicated that aquatic therapy improved balance ability compared to controls. CONCLUSIONS: Aquatic therapy has a positive impact on dynamic balance in older adults. However, further high-quality and appropriately powered studies are required to confirm this assertion.

Aquatic Therapy for Persons with Neuromuscular Diseases - A Scoping Review.

BACKGROUND: Aquatic exercise is among the most common physical activity modalities performed by people with disabilities. OBJECTIVE: The present paper reviews currently-available research on aquatic therapy (AT) for persons with neuromuscular diseases (NMD). METHODS: A scoping review of the existing literature was conducted on PubMed, Embase, Medline, Scopus, Web of Science, SPORTdiscus, CINAHL and Lilacs from the earliest date available until October 2020. It follows the methodological framework for conducting a scoping review proposed by the Joanna Briggs Institute. RESULTS: A total of 28 articles were analyzed and the study parameters grouped by the topography of NMD; most of the studies (n = 16) addressed myopathies. A considerable increase in the number of studies was found over time, and heterogeneity was identified across and within AT interventions for persons with NMD; hence, to allow more effective interpretation of study results, there is a need to standardize the fundamental parameters and procedures for AT. CONCLUSIONS: This scoping review provides a comprehensive outline of available literature; the findings could serve as a starting point for clinical studies on the effects of AT on persons with NMD, and encourage a more coherent approach to their design.

Aquatic Therapy after Incomplete Spinal Cord Injury: Gait Initiation Analysis Using Inertial Sensors.

Populations with potential damage to somatosensory, vestibular, and visual systems or poor motor control are often studied during gait initiation. Aquatic activity has shown to benefit the functional capacity of incomplete spinal cord injury (iSCI) patients. The present study aimed to evaluate gait initiation in iSCI patients using an easy-to-use protocol employing four wearable inertial sensors. Temporal and acceleration-based anticipatory postural adjustment measures were computed and compared between dry-land and water immersion conditions in 10 iSCI patients. In the aquatic condition, an increased first step duration (median value of 1.44 s vs. 0.70 s in dry-land conditions) and decreased root mean squared accelerations for the upper trunk (0.39 m/s2 vs. 0.72 m/s2 in dry-land conditions) and lower trunk (0.41 m/s2 vs. 0.85 m/s2 in dry-land conditions) were found in the medio-lateral and antero-posterior direction, respectively. The estimation of these parameters, routinely during a therapy session, can provide important information regarding different control strategies adopted in different environments.

A Community Outbreak of Legionnaires' Disease with Two Strains of L. pneumophila Serogroup 1 Linked to an Aquatic Therapy Centre.

An outbreak of Legionnaires' disease affected 18 people in Montpellier, a town of the south of France, between December 2016 and July 2017. All cases were diagnosed by a positive urinary antigen test. No deaths were reported. Epidemiological, environmental and genomic investigations (nested Sequence-Based Typing (nSBT) and whole genome sequencing) were undertaken. For the cases for which we had information, four had a new isolate (ST2471), one had a different new isolate (ST2470), one had a genomic pattern compatible with the ST2471 identified by nSBT (flaA = 3), and one had a genomic pattern not compatible with two previous identified STs (pilE = 6). The analysis conducted on the pool of an aquatic therapy center revealed seven isolates of Legionella pneumophila. Whole genome analysis confirmed the link between the environmental and clinical isolates for both ST2470 and ST2471. As the outbreak occurred slowly, with several weeks between new cases, it was not possible to immediately identify a common source. The sixth case was the first to report having aquatic therapy care. Of the 18 cases, eight had attended the aquatic therapy center and the other 10 were inhabitants who lived, worked or walked close to the center. The main cause for this outbreak was the lack of facility maintenance. This investigation highlights the risk to public health of aquatic therapy centers for users and nearby populations, and emphasizes the need for risk reduction measures with specific guidelines to improve health and safety in aquatic facilities.

Evidence-Based Aquatic Therapy Guidelines for Parkinson's Disease: An International Consensus Study.

BACKGROUND: Aquatic therapy is one therapy option for people living with Parkinson's disease (PD). However, the optimal prescription, dosage, and delivery remain unclear. OBJECTIVE: i) To generate consensus statements, ii) to establish evidence-based clinical practice aquatic therapy guidelines for PD. METHODS: Seventy-three international experts were invited to participate in a 3-step modified Delphi study. Gaps in the aquatic therapy evidence, patient preferences, and stakeholder engagement were considered when developing the initial list of 43-statements identified by the research development group. Practice experts rated each statement on an 11-point Likert scale. Consensus for inclusion was set at a priori of ≥70% of respondents scoring an item ≥7. Two rounds of Delphi questionnaires were completed online, and the expert comments were analyzed using content analysis. An online consensus meeting with an expert subgroup (n = 10) then advised on the guideline's acceptability and debated items until consensus for inclusion was reached. RESULTS: Fifty experts participated in the Delphi round one (83% response rate) and 45 in round two (90% response rate), representing 15 countries. In round one, 35 statements met the criteria for consensus. Content analysis informed the revised statements in round two, where 12 of the remaining 16 statements met consensus. The final agreed aquatic therapy guidelines include key information about dosage, content, safety, contraindications, and the optimal aquatic therapy delivery throughout the disease course. CONCLUSION: Stakeholders, including international practice experts, informed a rigorous evidence-based approach to integrate the best available evidence, patient preferences, and practice expertise to inform these guidelines.

Application areas and effects of aquatic therapy WATSU - A survey among practitioners.

INTRODUCTION: WATSU (WaterShiatsu) is a treatment administered in warm water. The present study investigated if and how frequently scientifically studied application areas and effects of WATSU occur in practice, whether similar effectiveness of WATSU is observed in trials and practice, and whether practitioners can contribute additional application areas and effects of WATSU. METHODS: Application areas and effects of WATSU reported in a recent systematic review were extracted verbatim to be assessed in a worldwide multilingual cross section online survey, generating quantitative and qualitative data. A pre-test and retest were conducted to ensure quality and evaluate the questionnaire's psychometric properties. RESULTS: Answers of 191 respondents were processed. All proposed 26 application areas and 20 effects were confirmed, each with relatively high ratings of observed effectiveness of WATSU. WATSU was frequently applied in healthy individuals (including during pregnancy), and individuals in various pain- (e.g., low back pain, neck pain, myofascial pain, fibromyalgia) and stress-related (e.g., stress, depression, sleep disorders, fatigue, anxiety disorders) conditions. Frequently confirmed effects were physical relaxation, relief of physical tension, pain relief, increased mobility and flexibility, improved quality of life, spiritual experiences, and increased psychological health. Respondents contributed 73 additional application areas and effects (both, mental and physical) of WATSU. CONCLUSIONS: Application areas and effects of WATSU are consistently employed practically and scientifically. Respondents' ratings of effectiveness of WATSU match tentative research efforts. WATSU is cautiously recommended for the use in pain- and stress-related conditions. Short- and long-term effectiveness of WATSU need to be evaluated in high level intervention studies.

Community aquatic therapy for Parkinson's disease: an international qualitative study.

PURPOSE: To explore the opinions of people living with Parkinson's disease about access to and participation in community aquatic therapy. METHODS: Focus groups and individual interviews were conducted with people living with Parkinson's disease in Ireland (n = 24) and Australia (n = 10). All discussions were audio-recorded, transcribed verbatim, and thematically analysed. RESULTS: Four main themes were identified. Primarily, participants were optimistic about their reasons for choosing aquatic therapy and found it beneficial to their health and well-being. Optimal components of aquatic therapy identified were access to individually tailored aquatic programs, completed as a minimum once a week, at a moderate to high-intensity level, and guided by a credentialed instructor. Fear was a significant barrier for a small proportion of participants and was linked to water competence, past experiences, and fall risk associated with the aquatic environment. Participants identified a strong need for education and increased awareness about aquatic therapy benefits to promote greater engagement. CONCLUSION: Aquatic therapy is a popular exercise choice for people with Parkinson's disease, especially in the early to middle disease stages. Considering the views of people living with Parkinson's disease can aid the design and implementation of interventions and future aquatic research internationally.Implications for RehabilitationAquatic therapy is emerging as an effective physiotherapy approach for managing motor and non-motor symptoms in Parkinson's disease.Little is known regarding community-based aquatic therapy programs from the perspectives of people living with Parkinson's disease internationally.People with Parkinson's disease may benefit from timely information about the unique benefits, prerequisites, and local aquatic therapy facilities to promote greater uptake of aquatic programs.Tailored aquatic therapy interventions delivered within a group setting by a credentialed healthcare professional may increase long-term adherence.

The state of aquatic therapy use for clients with spinal cord injury or disorder: Knowledge and current practice.

CONTEXT/OBJECTIVES: Aquatic therapy (AT) has been reported to be beneficial for individuals with spinal cord injury or disorder (SCI/D); however, AT has also been reported to be underutilized in SCI/D rehabilitation. We aimed to understand the knowledge and current practice of AT for clients with SCI/D by physiotherapists, physiotherapy assistants and kinesiologists across Canada. DESIGN/METHOD: A survey with closed- and open-ended questions was distributed (July-October 2019) to professionals through letters sent by professional associations. Non-parametric analyses were used to compare AT knowledge and practice between AT and non-AT users; content analysis was used to identify the themes from open-ended questions. RESULTS: Seventy-eight respondents from 10 provinces were included in the analysis: 33 physiotherapists, 5 physiotherapy assistants and 40 kinesiologists. Respondents using AT (73%) reported greater knowledge of AT benefits and confidence to apply AT than respondents not using AT (p<0.01). Four themes were identified: 1-Variety of physical and psychosocial benefits of AT for people with SCI/D; 2-Attainment of movement and independence not possible on land; 3-Issues around pool accessibility; and 4-Constraints on AT implementation. CONCLUSIONS: Respondents implemented AT to improve health outcomes for patients with SCI/D, despite facing challenges with pool accessibility and numerous constraints. Respondents who provided AT reported having better knowledge of AT and a supported AT practice in the work environment than respondents not providing AT. This study will inform AT stakeholders and institutions when considering strategies to increase the access to AT after SCI/D.