Aquatic therapy has been an effective means to help patients comply with treatment plans and heal without the burden of pain. The relief and benefits they receive from the properties of water continue to impact their lives long-term.

Aquatic therapy has been an effective means to help patients comply with treatment plans and heal without the burden of pain. The relief and benefits they receive from the properties of water continue to impact their lives long-term.

By Alyssa Adkins, PT, and Joseph Hilleary, PTA

In ancient times Swiss Monks recommended it, Hippocrates treated with it, and Greeks and Romans bathed in it. What is this special substance that healers have enduringly sought? Water!

For Wesley Glen Retirement Community, Columbus, Ohio, the journey with water began in 2017. Aquatic therapy has become an integral part of how therapists serve their patients at the facility, and lives have been transformed. Compliance and well-being increase, while pain and anxiety decrease. How this 6-foot x 10-foot piece of real estate helps so many is worth closer investigation.

Overcoming Pain for More Robust Compliance

Compliance is a major concern among therapists. Patients may be prescribed 5 hours of therapy each week, yet when appointment time arrives they may find a myriad of reasons to miss. Factors for noncompliance include low levels of activity prior to injury/surgery, a poor support network, anxiety and depression—and pain.

Immersed in water, patients experience decreased joint loading and decreased swelling. Both functions drastically reduce pain. Water offloads the joints and allows closed-chain activities that, because of intense discomfort, are impossible on land.

Product Resources

The following companies provide products for aquatic therapy:

Aquatic Access Inc

Endless Pools

Hudson Aquatic Systems LLC


Nespa Tiled Spas

NZ Manufacturing

Sprint Aquatics

Sure Hands Lift and Care Systems

SPRI Products


Ease of Access for Better Compliance

Some pools incorporate user-friendly lifts that easily transport patients into the pool. The pool floor at this facility is fully adjustable in height, allowing patients to stand or sit on the treadmill while it is static and level with the pool deck. The pool floor, which doubles as an underwater treadmill, gradually lowers patients into the pool. This allows for virtually any patient, even those with balance issues, obese patients, or folks with complex medical issues, to utilize the pool. A game-changer!

The addition of a pool lift ensures access for all levels of patients. There are many pool lifts on the market, including models that provide a stretcher, two-piece seat, or flip-up arms, such as those from Aquatic Access Inc, Louisville, Ky.

Among the company’s models for in-ground pools is the IGAT-180, certified to meet the 2010 Standards for Accessible Design and powered by water pressure. It is engineered to lift up to 400 pounds at 55 to 65 PSI open-flow water pressure. The lift also offers a custom heavy-duty modification to meet the needs of larger users. Aquatic Access above-ground lifts include the Pool Lift Model AG72 for walls 60 inches high, featuring assisted operation, a manual 360-degree seat turn, and the ability to lift up to 300 pounds at 55 to 65 PSI.

Pine Island, NY-based SureHands Lift & Care Systems also offers a Wheelchair-to-Water Lift, built to take the patient directly from the wheelchair into the water. The mobile lift uses rechargeable batteries, is designed to easily engage and disengage from the floor socket, and features an emergency stop button that halts all motion of the lifting arm. The SureHands Body Support and ceiling motor is also usable for hydrotherapy and targets a larger lifting range. It can be used for intensive use and in pools where floor sockets cannot be installed.

Why Water Works

Staff at this facility have found it extremely beneficial for patients, colleagues, and administrators to understand the science of aquatic therapy—the wonder of water—and why it works so brilliantly for patients. Following are the most important properties of water as it pertains to physical therapy outcomes:

Buoyancy. We all experience this natural force as we float carelessly in our favorite summer swimming spot. Buoyancy is the upward thrust exerted by a fluid that opposes the weight of an immersed object, the amount of thrust being equivalent to the weight of the displaced fluid. Translation? A patient submerged chest-deep in water bears only 20% to 25% of his or her body weight. As stated, patients experience less joint stress and, therefore, less pain when submerged in water. Buoyancy also assists with any movements occurring in the direction of the water’s surface, allowing more dynamic gross motor movement.

Hydrostatic pressure is the pressure exerted by a fluid onto an immersed object. It varies according to its depth in the fluid. Hydrostatic pressure intensifies the rate of blood flow from extremities back to the heart. This increased venous return works to decrease swelling, improve joint position, and increase proprioception.

Viscosity, also referred to as resistance. Strength increases when patients work against the constant resistance of the water, both in abduction and adduction, flexion, and extension. Together with buoyancy, viscosity strengthens muscle groups in a way land-based therapy cannot.

Water temperature. Because submersion into warm water relaxes muscles, widens blood vessels, and increases blood flow, we’ve often seen early range-of-motion gains in our patients. Those suffering from chronic pain especially appreciate the soothing effect of warm water. A heated pool helps lubricate joints and loosens muscles. Patients find it easy to move freely and tolerate longer bursts of exercise with minimal residual soreness.

The Stories Behind the Science

Recently, a middle-aged female came to the facility with chronic back issues. She has been through multiple courses of therapy, reporting that she never felt satisfied with her recovery. Here, she was placed in the water, emphasizing stretches and movement using the properties of water. With the weight and pressure off her joints, therapists were able to strengthen her in a new way. She immediately felt the benefits of water, continued with aquatic therapy, and later joined the facility’s health center to utilize the large, static pool. It was amazing to see what 30 minutes twice a week in the underwater treadmill did for her.

The discomfort and pain associated with land-based exercise had been her barrier. When the pain was removed, she flourished.

This patient told her friends and family about her amazing progression with aquatic therapy. This, and other word-of-mouth experiences, has helped build our reputation as a facility that uses cutting-edge technology to help folks heal.

Resources for Water-Based Therapy

Success with aquatic therapy necessarily means having equipment on-site that is effective, reliable, and versatile enough to meet the needs of a mixed population of patients and conditions. Options for aquatic therapy range from single-user chambers that fit into smaller spaces such as outpatient clinics, to in-ground pools that have multiple depths or perhaps even movable floors. One provider of aquatic therapy pools for the physical therapy market is Angola, Ind-based Hudson Aquatic Systems LLC, which offers a variety of pools for individual users or multiple occupants.

The company’s AquaCiser III, for example, is a modular underwater treadmill system appropriate for sports medicine, PT clinics, hospitals, or nursing homes. It is designed as a modular fiberglass unit with controllable water temperature and water depth, as well as treadmill speed and direction which can be controlled from a console within the unit. The HydroWorx 200 from HydroWorx, Middletown, Pa, also accommodates a single user and is equipped with a variable-speed underwater treadmill and resistance jet with therapeutic massage hose. An onboard touchscreen controller allows functions to be controlled from inside the unit. This compact product is made to be useful for gait training and sport-specific activities, and water levels can be adjusted from 1 inch to 50 inches.

For larger spaces and multiple users AquaPools from Hudson Aquatic Systems are designed in a variety of sizes, configurations, and options, such as spa jets and resistant swim currents, to provide a complete workout. In-ground, above-ground, partially above-ground, and fiberglass pool designs are available. Also built for facilities that need larger pools, the HydroWorx 2000 Series variable-depth pool features a moveable floor, an 8-foot x 12-foot underwater treadmill, resistance jet technology, and computer and camera systems to satisfy the varied demands of traditional physical rehabilitation, as well as those of athletes. This pool can fit up to four people.

Higher Education Provides Powerful Data

Over the past decade, teams of scientists at several United States-based universities have conducted clinical studies to understand the importance of water-based therapy, specifically addressing the benefits of underwater treadmills. Doctors Dennis Dolny and W. Matthew Silvers at the University of Idaho found that an underwater treadmill can create a metabolic and cardiovascular environment as stressful as traditional land-based treadmills but with reduced joint stress. Positive results such as heart rate, ventilation, oxygen consumption, blood lactate, fat reduce swelling, leg stride rate, and length were also confirmed in their initial and follow-up studies. Subsequent studies from this team confirmed the effectiveness of aquatic therapy versus land-based treadmills.

Additionally, a team of scientists led by Stephen F. Crouse, PhD, FACSM, and Interim Director at the Sydney and JL Huffines Institute for Sports Medicine and Human Performance at Texas A&M University conducted two experiments comparing land-based treadmill exercise to exercise on an underwater treadmill. Their experiments included 32 overweight adults older than age 40 years. The duration of the study was 3 months. The results revealed the following:

• Four out of five of the subjects preferred exercising in the water rather than on the land treadmill;
• Using the underwater treadmill versus the land-based treadmill burned more calories per minute when walking or jogging at 4 MPH or above (with jets at 50%);
• Subjects lost a higher body fat percentage using the underwater treadmill (with jets at 50%); and
• More lean muscle mass was gained through usage of the underwater treadmill.
These results were found to be significant in the rehabilitation process. And, at this facility, therapists have seen firsthand how these results manifest themselves through better compliance, outcomes, perception of well-being, and quality of life in patients.

Can Aquatics Work for everyone?

Training will be a key determinate.

Despite its current success, the road to aquatic success had a somewhat shaky start. For example, once the pool was purchased there was an initial failure to enlist the proper training. When pool usage was not progressing as hoped, the problem was quickly rectified. The manufacturer provided a skilled aquatic trainer in-house for a full day of in-service training. The entire therapy staff spent a day in hands-on learning, practicing creative treatment ideas and approaches. This was a turning point.

It will be imperative for key individuals within any organization to understand the benefits of aquatic therapy and how to effectively work with patients in the pool.

Aquatic therapy has been one of the most effective means used at this facility to help patients comply with treatment plans and heal without the burden of pain. Patients have graduated from physical therapy to aquatics exercise programs that become part of their everyday lives. The relief and benefits they receive from the properties of water continue to impact their lives long-term.

The Russian author and biochemist Isaac Asimov once said, “The science of today is the technology of tomorrow.” To the delight of patients, technology has provided a modern-day application of one of the world’s oldest healers. PTP

Alyssa Adkins, PT, is a physical therapist at Wesley Glen Retirement Community, Columbus, Ohio.

Joseph Hilleary, PTA, is a 2012 graduate of Rhodes State College, Lima, Ohio. He is the Rehab Manager at Wesley Glen in Columbus, Ohio, and has more than 6 years of experience as a treating physical therapist assistant. For more information, contact