Aquatic Physiotherapy

Aquatic physiotherapy is one of the oldest therapeutic modalities used in the treatment/management of physical dysfunction, but despite an extensive research base it remains underused in rehabilitation.
(Becker, 2009).

Aquatic physiotherapy is a therapy programme utilising the properties of water, designed by a suitably qualified physiotherapist specifically for an individual to maximise function, which can be physical, physiological or psychological. (ATACP, 2007).

Our Client – John

John suffered a life changing spinal cord injury when he was knocked from his bicycle in a road traffic accident in July 2019. He sustained a complicated fracture to his right shoulder and paralysis from T7. He underwent a spinal fixation from T4 to T10 and had shoulder surgery for an open reduction and internal fixation at Leeds General Infirmary, before being transferred to the Spinal Injuries Unit at Pinderfields Hospital. During a rehabilitation session, John began to feel unwell and was diagnosed with an extensive pulmonary embolism; treatment was commenced and continued over a period of 6 months.

In September 2019, John moved to STEPS Rehabilitation as a residential client.

On admission he presented with:

  • no motor power or sensation in lower limbs
  • normal power and sensation in upper limbs
  • T6 AIS A paraplegia
  • lower limb full passive range of movement (PROM)
  • limited PROM right shoulder – flexion approx. 20°, abduction approx. 40°

Following an initial medical and rehabilitation assessment, a unique care plan was drawn up for John using a combination of therapies; this included aquatic therapy that could be delivered in the on-site hydrotherapy pool at STEPS.

John’s aquatic therapy-based goals were to:

  • swim 10 lengths of the pool
  • complete a forward roll in the pool
  • swim a length of the pool underwater independently
  • be able to lift out of the pool (in the corner) and hold for 3 minutes
  • explore ways of increasing cardiovascular fitness without negatively affecting muscle tightness

Prior to aquatic therapy sessions taking place in the hydrotherapy pool, a full risk assessment was completed. Considerations were:

  • bowel management
  • skin integrity

The hydrotherapy pool at STEPS is fully accessible to wheelchair users and individuals with limited mobility via a ceiling hoist, which John used to transfer into and out of the pool. The changing rooms are also fully accessible, with the option of shower chairs or shower bed.

Summary of aquatic treatment used to help John achieve his goals

The focus of each sessions were:

  • to provide a safe environment to challenge John’s strength, shoulder range and cardiovascular fitness
  • to use the properties of the water to gain more independent movement, gradually increasing strength throughout range and to allow independent swimming/rolling
  • in supine (lying face upwards) with 2 x woggles in situ and neck collar to reduce trap activity
  • sea weeding – gentle movements through the water by the therapist to aid in relaxation and create gentle trunk movement using the effects of drag
  • metacentre work in supine with arms by side working through wrist extension, elbow flexion and attempts at shoulder flexion
  • in the pool corner: push ups x 5, adding in transferring weight to left and right, then rotations to left and right. Progressed to add pool jets to challenge stability
  • drag assisted should range of movement, progressed to strengthening shoulders through available range, utilising drag resistance.
  • rolling with assistance, progressed to independently
  • swimming, gradually removing assistance and increasing number of lengths. Once able to swim with his head above the water, he progressed to swimming with his head under the water to further challenge respiratory function/control.

The therapeutic benefits of Aquatic Therapy relate to the principles of hydrodynamics:

  • density
  • drag / turbulence
  • buoyancy
  • hydrostatic pressure
  • thermodynamics

During John’s aquatic therapy sessions, drag/turbulence were utilised in exercise choice and progression. The hydrostatic pressure and thermodynamic properties were beneficial in reducing pain, spasms and fatigue through the blocking of nociceptors by acting on thermal receptors and mechanopreceptors in exerting a positive effect on spinal segmental mechanisms (Mooventhan et al, 0214).

The properties of the water, aided in improving John’s cardiovascular function through increased hydrostatic pressure acting against his thoracic cage, this inversely impacts lung volume, The benefit of this is that it improves respiratory efficiency, positively impacting cardiometabolic profit (Ellapen T et al, 2018).

Evaluation of the effectiveness of aquatic therapy

John completed his aquatic based goals, and on discharge from STEPS, he was able to swim to touch the bottom of the pool, forward roll, complete 10 lengths of the pool independently, swim 1 length underwater and hold his body weight out of the water for 3 minutes.

The completion of these goals showed an improvement in core and upper body strength, endurance, control and cardiovascular fitness. These improvements also carried over into John’s land-based function in which his transfers, bed mobility and wheelchair skills progressed and allowed increased independence.

Research has shown that aquatic therapy improves mobility and quality of life, lessens spasticity and pain and is effective in promoting overall recovery from spinal cord injury. It is currently under-utilised, but recommendations have been made that people with spinal cord injury should be given access to aquatic therapy so that the benefits of skilled aquatic therapies can be more widely achieved. (Recio et al, 2017, Kesiktas et al, 2004).

For more information, please contact us on 0114 258 7769,


Becker, B.E., 2009, 'Aquatic therapy: Scientific foundations and clinical rehabilitation applications', Clinical Review: Current Concepts 1(9), 859-872.

Ellapen T et al, 2018. The benefits of hydrotherapy to patients with Spinal Cord Injury. African Journal of Disability, vol 7.

Kesiktas, N., Paker, N., Erdogan, N., Gulsen, G., Bicki, D. & Yilmaz, H., 2004, 'The use of hydrotherapy for the management of spasticity', The American Society of Neurorehabilitation and Neural Repair 18(4), 268-273.

Mooventhan A, Nivethitha L, 2014. Scientific evidence-based effects of hydrotherapy on various systems of the body. North American journal of medical sciences 6 (199-209).

Recio A, Steins S, Kubrova E, 2017. Aquatic based therapy in spinal cord injury rehabilitation, effective yet underutilized. Spinal cord injury Rehabilitation 5 (108-112).