PHOTO CAPTION: Physical therapists can use a variety of flotation devices including pool noodles during aquatic therapy sessions to facilitate achieving appropriate positioning, to provide assistance with maintaining positioning, and to maximize patient safety. (PHOTO: Kessler Institute)

Don’t discount the benefits of aquatic therapy for patients diagnosed with CVA, SCI, TBI, and progressive neurologic diseases.

By Brittany Hicks, PT, DPT, and Maegen Johnson, PT, DPT

In the inpatient acute rehabilitation setting, therapists are often tasked with treating patients newly diagnosed with various neurologic disorders or conditions, such as cerebrovascular accident (CVA), spinal cord injury (SCI), traumatic brain injury (TBI), and progressive neurologic diseases. Based on the patient’s presentation, therapists establish an appropriate plan of care to meet the patient’s needs, as well as address recognized impairments. There are a variety of treatments available to use at the therapist’s discretion, and with technological breakthroughs, it appears as though treatment options continue to expand. However, a highly underutilized tool for patients with neurologic diagnoses is the use of aquatic therapy.

Benefits of the Aquatic Setting

Aquatic therapy, although underused for a variety of reasons including medical comorbidities, access to resources, or patient preference, is a remarkable tool in rehabilitation, as it makes use of the therapeutic properties of water. At Kessler Institute for Rehabilitation – Marlton Campus in New Jersey, there is a therapy pool that measures between 92 and 94 degrees Fahrenheit. The increased temperature promotes relaxation and improved circulation and allows for prolonged immersion to perform therapeutic exercise.1

In addition to the thermodynamic properties of the therapy pool, aquatic therapy provides benefits through buoyancy, hydrostatic pressure, and viscosity. Buoyancy allows for progressive offloading of the immersed limbs, which may benefit patients in pain or allow for active assisted exercises for patients with decreased neuromuscular strength.1 Hydrostatic pressure assists with decreasing edema, which, in turn, improves overall range of motion.1 Viscosity of water allows for constant resistance against a moving limb, noting increased resistance with increased force production. This specific property is beneficial for improving neuromuscular strength and control, while maintaining the patients’ comfort.1

Pool Set-up and Underwater Equipment

The therapy pool at Kessler is accessible from one of two entry points. Patients who are at a higher level of function, such as those who are ambulatory and performing elevations, may descend the stairs into the pool, while those who are more impaired are aided into the pool via the pool lift from Spectrum Aquatics based in Missoula, Montana. This specific lift is a water-powered system that allows the chair to rotate over the pool edge and lower into or raise out of the pool using water pressure. The lift chair has a swing-away armrest that allows for increased accessibility to the chair for those patients who need to be transferred via squat-pivot or transfer board transfers.

Although exact pool set-up can vary between facilities, the therapy pool at Kessler consists of a shallow portion of 3 feet in depth and a deep-water portion ranging between 4 and 4.5 feet of depth. In both the shallow and deep-water sections, adjustable parallel bars are placed in the center to support pre-gait training, gait training, and a variety of standing activities. There are stairs of various heights strategically placed to allow for early elevation training. Benches or seating surfaces are also available, with and without jets, for therapeutic rest or submergence of the shoulder to perform upper extremity tasks.

Flotation Devices

In addition to the specific pool set-up and built-in equipment, a variety of equipment is often used during an aquatic therapy session for a multitude of reasons, including to facilitate achieving appropriate positioning, to provide assistance with maintaining positioning, and to maximize patient safety. We use flotation devices such as the buoyancy belts by AquaJogger, based in Springfield, Oregon. This specific device is designed to aid with buoyancy to keep a patient suspended in deep water. However, it can also be utilized for those patients with decreased trunk strength or motor control to maintain flotation in a supported supine position while performing therapeutic exercise or provide assistance with maintaining upright posture while in supported stance to facilitate gait training.

Other flotation devices are used, including simple items such as standard pool noodles or a Nekdoodle, which specifically provides head and neck support. These objects prove to be beneficial in assisting patients to achieve and maintain supported supine, side lying, or prone positions, to allow for the treating therapist to facilitate relaxation for specific aquatic treatment techniques, such as Bad Ragaz, or allow for optimal performance of strengthening tasks.

Bad Ragaz

Bad Ragaz is a specific aquatic treatment intervention focusing on “relaxation exercises and progressive stabilization”2 and utilizing the therapeutic properties of water. In addition, flotation devices are strategically placed to support the axial skeleton and extremities to assist with both mobility and stability of the upper extremities, trunk, and lower extremities. It is based on the principles of proprioceptive neuromuscular facilitation techniques (PNF).2 These activities are performed mostly in the supine position and include both strengthening and mobilization activities against the resistance of the water.

In most basic terms, in Bad Ragaz, the treating therapist determines a specific “fixed point” on a patient’s body and stabilizes this point. The patient attempts to move this “fixed point.” However, since it is stabilized, the body instead moves toward the fixed point. For example, if the foot were deemed the “fixed point,” the patient would intend to flex the hip and knee to move the foot toward the trunk. However, since the foot is stabilized, the hip and knee would still move into flexion, while the trunk would move inferiorly toward the foot. This technique has grown to include unilateral and bilateral movement patterns, including diagonal movement patterns to mimic functional movements.5 Research shows that Bad Ragaz is one of the most effective techniques in the aquatic setting in supporting recovery from neurologic diagnoses.4,6

Resistance Devices

Therapists can also use resistance devices during aquatic therapy sessions to improve patient proprioception, combat water buoyancy, and improve the effectiveness of strengthening tasks. Cuff weights can be applied to the lower extremity to optimize patient stability and provide feedback to allow for improved management of a hemiparetic leg. When applied to the upper extremity, a cuff weight can provide a prolonged stretch to facilitate decreased spasticity, in addition to a more functional arm position during gait. The All Pro Power adjustable cuff weight from Oceano, Calif-based Sprint Aquatics allows for adjustment of the amount of weight provided to the limb by adding or removing a weighted cylinder that attaches to the cuff sleeve.

Wobble boards are useful for targeting a patient’s core control while in the pool. Helping a patient to sit on the wobble board can be difficult initially. But once the person is seated on the board appropriately, physical assistance can be scaled back to allow for a challenge of the patient’s core and pelvic control to resist the movements of the board against water buoyancy. Physical assistance may be required at times to facilitate appropriate positioning on the board as well as to control excessive movements.

Breaking with Tradition

As noted, there are a variety of products that physical therapists can utilize in the aquatic setting to enhance patient safety and performance to allow for optimal outcomes from each session. Each product is designed to exploit the benefits of water including buoyancy, hydrostatic pressure, and viscosity.

Although aquatic therapy is not a traditional method for treating patients with neurologic diagnoses, there is a wide range of benefits that the aquatic setting provides over typical land-based intervention, specifically in the acute inpatient rehabilitation setting. A comprehensive treatment plan, with combined land- and aquatic-based approaches, would be beneficial to facilitate enhanced neuromuscular return and improved performance in functional mobility. PTP

Brittany Hicks, PT, DPT, is a senior physical therapist with more than 6 years of experience and has spent the majority of her career in inpatient acute rehabilitation. Although she treats a variety of patient populations, she does have a special interest in the neurologic population and aquatic therapy. She is the chairperson of the Stroke Committee at the Kessler Institute for Rehabilitation Marlton Campus and is a certified stroke rehabilitation specialist.

Maegen Johnson, PT, DPT, has been a physical therapist for more than 6 years and is a well-rounded therapist who has experience in both inpatient and outpatient settings. Johnson is a co-chair of the Kessler Institute Marlton Campus’ Cancer Program. However, she also loves the neurologic population. She sees the vast benefits of aquatic therapy for patients with a variety of diagnoses. For more information, contact [email protected].


1. Becker B. Aquatic therapy: Scientific foundations and clinical rehabilitation applications. PM&R. 2002;1(9),859-872. DOI: 10.1016/j.pmrj.2009.05.017

2. Stan AE. Applications of Bad Ragaz method in aquatic programs of rehabilitation. Marathon. 2017;9(1),86-93.

3. Gamper UN, Lambeck J. The Bad Ragaz Ring Method. In: Becker BE, Cole AJ, eds. Comprehensive Aquatic Therapy. 3rd edition. Butterworth-Heinemann: 2010: 1-28.

4. Veldema J, Jansen P. Aquatic therapy in stroke rehabilitation: Systematic review and meta-analysis. Acta Neurologica Scandinavica. 2020;143(3),221-241.

5. Salzman AP. An aquatic bag of tricks: Specialty techniques for water-based intervention. Team Rehab. 1998;26-28.

6. Cha HG, Shin YJ, Kim MK. Effects 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 Physiother J. 2017;37:39-45. DOI: 10.1016/j.hkpj.2017.02.001

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