Therapy in water may be an environment that supports training movement during rehabilitation after cerebrovascular disease or in some people who have Parkinson's disease. This method is an environment for exercising and training activities, not a treatment for the damage to the brain or for the degenerative process of the nervous system that is the root cause.
Cerebrovascular disease and Parkinson's disease affect movement differently, so evidence from one disease should not be applied to the other automatically. The programme, the supervision, the outcome measures, and the change to training on land should correspond with the diagnosis, the stage of recovery, medical readiness, and the goals of each person.
When exercising in water, what changes?
Buoyancy helps reduce the weight going down onto the legs as the water level becomes deeper, so it may make standing, stepping, and moving the joints more comfortable for those who are weak, in pain, or not confident on land. But it does not make the body weightless or remove the needs of balance and the safety of the airway.
Water resists movement in every direction and in general makes movement slower. The physiotherapist may use this property in order to adjust the level of force or to give the patient more time to organise the movement. Water pressure changes the distribution of fluid in the body and the load of breathing, which is useful information in planning, but it also makes it necessary to screen the cardiac and respiratory systems.
Warm water may make one feel comfortable and want to take part more. Comfort alone is not evidence that spasticity, the recovery of the nervous system, or the progression of the disease has changed.
It should not be concluded what therapy in water can do
Water does not train walking anew automatically, prevent falls, return movement to normal, or guarantee that skills will transfer to daily life. Patients may train compensatory movement in water just as on land. The choice of activity, the cues given, the assistance, the repetition, and the increase in level are still important.
The pool also changes the information from the senses, the speed, and the load-bearing force, so functioning better in water does not confirm that the same task is safe on land. Therapy in water should have a clear purpose, not be added merely because it feels easier or because the equipment is there.
The evidence for those who have had a cerebrovascular event
After cerebrovascular disease, patients may have weakness, changed sensation, spasticity, impaired coordination of movement, neglect of the visual field or the space on one side, as well as problems of communication or cognition, all of which have an effect on movement and safety. The NICE guideline on rehabilitation after cerebrovascular disease (opens in a new tab) supports physiotherapy specific to the individual within multidisciplinary rehabilitation for problems of movement, but does not make therapy in water a necessity for everyone.
A systematic review on therapy in water for balance and walking after cerebrovascular disease (opens in a new tab) found that there may be a benefit, but gave a low level of supporting evidence. The research differs in the participants, the programmes, the comparison groups, and the measures. Exercise in water may therefore suit some goals in those who have passed selection, but should not be described as superior to well-designed rehabilitation on land, or as making the nervous system recover more quickly.
The evidence for Parkinson's disease
Parkinson's disease may affect the initiation of movement, the size and the rhythm of movement, turning, posture, balance reactions, and the state of freezing of gait. The response to medicine, fatigue, cognition, and changing blood pressure may make the capacity differ at different periods of the day.
The APTA clinical practice guideline for Parkinson's disease (opens in a new tab) clearly supports aerobic exercise, resistance training, balance, walking, training in specific activities, and the use of cues to help. These principles are not tied to training in a pool.
A systematic review on exercise in water for Parkinson's disease (opens in a new tab) found low-confidence evidence that it may help balance in participants most of whom had impairment at a slight to moderate level, but found no clear change in mobility or participation. Therapy in water may therefore be a supplement for some people, but it does not slow the progression of the disease and should not replace a review of medicines or rehabilitation specific to the disease.
Who may be considered?
Therapy in water may be of benefit when reduced load-bearing or a supportive environment is favourable to a specific goal, such as endurance in standing, balance, stepping, aerobic training, or confidence. The patient must be able to get into the pool, get out of the pool, and take part in the training with a suitable level of assistance.
Selection should consider medical stability, the ability to follow safety instructions, communication, cognition, fatigue, pain, the condition of the skin, continence, a history of seizures, the risk of falling, and the help needed while transferring. For Parkinson's disease, the timing of medicine, patterns of freezing of gait, or dizziness may need to be considered. After cerebrovascular disease, attention should be paid to neglect, loss of sensation, problems of swallowing or the airway, and newly arisen neurological symptoms.
Medical screening and water safety
Therapy in water may not be suitable, or may need certification from a doctor, when there is heart or respiratory disease that is not yet stable, blood pressure that is not controlled, an infection that is currently present, an open wound that cannot be protected, seizures that are not controlled, acute illness, or a contraindication specific to the equipment and the facility. Immersion in water has an effect on the circulation and on breathing, so a shallow pool is not automatically of low risk.
There is also a risk of drowning and of injury while transferring. The supervision, the number of staff, the equipment for getting into and out of the pool, the water temperature, the emergency procedures, and the therapist's ability to help the patient should correspond with the risks that have been assessed. Patients should not enter the pool when acutely ill or while newly arisen neurological symptoms are being investigated.
What may one session of training consist of?
The training may consist of assisted standing, transferring weight, stepping, turning, moving the trunk, reaching, balance, aerobic exercise, or tasks related to daily routines according to the goals. The assistance and the resistance should be adjusted according to the capacity, not by using a fixed routine in water.
Training after cerebrovascular disease may emphasise the side that has been affected, body alignment, repeated function, or sensory perception. Training for Parkinson's may use larger movements, external cues, changes of direction, or strategies for starting to walk. These examples cannot be used interchangeably as instructions for training.
The role of the underwater treadmill
The underwater treadmill makes it possible to train stepping repeatedly, with the water level, the speed, the handrail support, and the assistance from the therapist all adjustable. It may help some patients train rhythm, endurance, or load-bearing in a controlled environment.
The equipment does not guarantee that the pattern of walking will become more normal, and there is not yet evidence that it is superior for every outcome of cerebrovascular disease or Parkinson's. The reasoning for using it, the measures, and the plan for transferring the training to land matter more than the name of the equipment.
Transferring the training to land
Most meaningful activities happen outside the pool. Training on land is necessary in order to assess how the patient copes with gravity, footwear, obstacles, doing several tasks at once, turning, transferring, and the surfaces at home and in the community.
Rehabilitation in water and on land may proceed alongside each other, or water may be used temporarily while endurance on land is developed. The proportion of the two should change according to progress that can be measured, not according to a set of services determined in advance.
How should progress be measured?
The measures should match the goals and the diagnosis. They may include the speed or the endurance of walking, balance, the level of assistance in transferring, the quality of the step, falls or near-falls, confidence, fatigue, and meaningful activities in daily life. Capacity in the pool alone is not enough.
Adverse effects and the response after getting out of the water should be recorded. If function does not improve, if working on land gets worse, or if the burden of the treatment is more than the benefit, the plan and the diagnosis should be reviewed rather than continuing automatically.
Signals of a new cerebrovascular event are an emergency
Therapy in water should not be done when a new or recurrent cerebrovascular event is suspected. Sudden loss of balance or of vision, a drooping face, weakness or numbness down one side, abnormal speech, or a severe headache unlike the usual one, require the facility's emergency response plan and an immediate medical assessment. Please see the guide to stroke warning signals
In Thailand, call the emergency medical system, 1669 (opens in a new tab); in other countries use the local emergency number. Note the last time the patient was still normal and follow the instructions of the person taking the call. Do not wait to see whether the symptoms will improve.
Questions that should be asked before beginning
- Which goals specific to the disease can be trained more easily or more safely in water?
- What evidence supports therapy in water for this disease and this stage?
- What risks of a medical kind, of transferring, of communication, and of water safety have already been assessed?
- How much assistance and supervision will be needed?
- Which measures will show that the programme is of benefit?
- How will the training in water connect with function on land?
- For what reasons should it be stopped, adjusted, or the plan assessed anew?
A supplement, not a short cut
Therapy in water may be a reasonable supplement for selected people after cerebrovascular disease or those who have Parkinson's disease. The possible value lies in an environment whose level can be adjusted in order to train meaningful activities, not in a promise that water will speed up the recovery of the nervous system.
A responsible plan distinguishes between the diseases, measures function in real life, screens the risks of immersion, and still gives importance to rehabilitation on land, training in specific activities, and medical treatment