Aquatic Therapy / Hydrotherapy

Lauren Robinson and Annette Turner
For more information see

What is Aquatic Therapy?

  • Aquatic Therapy (sometimes called hydrotherapy) is a method of rehabilitation which focuses on exercises performed in a warm pool of 34oC. The water’s properties can be used to alter the way you exercise, and can be graded to vary exercise intensity from completely passive to highly resisted.The water’s natural properties include:
  • Buoyancy
  • Being opposite to gravity this is a unique environment to exercise in, it can be used to unload joints, or even your whole body providing greater pain relief and increased freedom of movement. It can also be used to create resistance, and mobilise stiff joints.
  • Drag
  • This the property of resistance created by moving a body through water. Variation in speed and direction can be used to strength muscles, facilitate movements or to mobilise joints.
  • Turbulence
  • This is the property of water disturbance which can be used to retrain balance and stability.
  • Hydrostatic pressure
  • This promotes circulation and reduces swelling.
  • Warmth
  • As the water is warm this provides pain relief and can relax tight muscles and reduce muscle tone.
  • Is an Aquatic therapy pool specific?
  • Yes, an aquatic therapy pool differs from normal swimming pools firstly in temperature, being 340C, where as a swimming pool is usually around 280C .
  • There is usually easy access via a ramp or flight of stairs rather than a ladder, and the tiles on the bottom provide grip to allow walking and balance exercises more easily. There is also variable depth allowing for differences in weight bearing loads.
  • Your therapist should be trained specifically in Aquatic therapy and a member of Aquatic Therapy Association of Chartered Physiotherapists

Benefits of Aquatic Therapy

Aquatic therapy can be useful in treating a wide variety of conditions including soft tissue injury, bone injury, arthritis, neurological conditions and post –surgery or joint replacement. Aquatic therapy is appropriate for people of any age.

The benefits of aquatic therapy include: 

  1. Pain relief
  2. Reduction in muscle spasm
  3. Increased joint range of movement
  4. Muscle strengthening
  5. Improved circulation
  6. Retraining of balance and co-ordination
The buoyancy of the water allows many people to exercise where they struggle on land, be that due to reduced weight bearing status, or pain on weight bearing. Due to the reduced gravity environment this is less stress on joints, allowing more effective exercising.

Aquatic Therapy and its role in shoulder rehabilitation?

  • Aquatic therapy is rarely a standalone treatment; it should be used alongside specialist land based shoulder physiotherapy to improve range of movement and muscle strength. It can enable you to move your arm more freely, reducing pain and joint stiffness, as the buoyancy will support the weight of your arm.
  • It can help to restore the strength and stability in your shoulder. 
  • It can restore natural movement patterns after an injury.
  • Whether you have an acute problem or have been struggling for a long time, aquatic therapy can be tailored to your needs.

Do I need to be able to swim?

No, aquatic therapy can cater for all abilities within the water.If you are not comfortable floating, your treatment can be tailored to keep your feet firmly on the floor.
Most clients who begin nervous in the water gain confidence and grow to love being in the pool.


In a few circumstances, hydrotherapy is not recommended.
  • Inflammation - acute injuries where redness and heat are still present are not recommended for hydrotherapy treatment. (not within the 1st 48 hours of a significant injury or surgery)
  • Fever - whole body warming is not recommended if a temperature is present.
  • Kidney problems.
  • Allergy or marked sensitivity to Chlorine
  • Very low or high blood pressure
  • Any unstable medical conditions, such as heart problems, uncontrolled epilepsy or asthma (please discuss this with your aquatic therapist and your treatment may be able to be modified to accommodate you)
  • Wound infections or delayed/difficult wound healing (please discuss this, sometimes waterproof dressings can be warn)

For more information please see 
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As with all therapeutic research it is challenging to get the patient numbers and good randomised controlled trials is all areas, so more research is always required. There are some aspects that have been shown below:Following soft tissue injury, Aquatic Therapy can decrease pain, oedema, joint compression and improve flexibility, strength and proprioception (Ruoti et al 1997) 
With the increased cardiac output during immersion the increased blood flow is directed to the musculature (Bishop et all 1989). (Wilder & Brennan 1993) found this increase to be 100% if immersed up to the neck.
Aquatic therapy has been shown through electomyography to allow less muscle activation in shoulder forward , than performing the same movement on dry land. This is a much as 75% less. This means in the case of surgery, greater movement is allowed in the water without stressing a muscle repair, such as rotator cuff repair.
Immersion in the water has been shown to decrease the output of the sympathetic nervous system which increases relaxation and pain relief (Mano et al 1985)
Aquatic therapy has been found to be effective in reducing pain and increasing range of movement in patients with frozen shoulders. (Cautiero et al 2012)
Aquatic therapy ‘warms the neurological system up’ (Cools 1999). It does this by working on the balance system both in the longitudinal axis, but also in the transverse axis.



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  4. Bishop et al. ‘physiologic responses to treadmill and water running’ Physician and sports med 1989; 17:87-94
  5. Cautiero F. Russo R. Della Rotonda G. Di Domenico F.P ‘Non-operative management of shoulder adhesive capsulitis: Effectiveness of the Lyon hydrotherapy rehabilitation program’ Journal of Orthopaedics and Traumatology.13 (pp S39), 2012.
  6. Cool et al ‘Hydrotherapie: bewogen bewegen. Congresboek:hydrotherapie van, practice based naar evidence based’ 1999, Netherlands paramedisch instituut ISBN 90-73054-71-0
  7. CSP PA 39 Standards of good practice in Hydrotherapy
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  13. Jill, M. Thein, MPT, ATC*; Lori Thein Brody, ‘Aquatic-Based Rehabilitation and Training for the Shoulder’ Jill, ATC Journal of Athletic Training 2000;35(3):382-389 
  14. Kelly BT, Roskin LA, Kirkendall DT, Speer KP. ‘Shoulder muscle activation during aquatic and dry land exercises in non impaired subjects’ J Orthop Sports Phys Ther. 2000 Apr;30(4):204-10
  15. Mano T, Iwase S, Yamazaki Y, Saito M, Sympathetic Nervous Adjustments in Man to Simulated Weightlessness Induced by water Immersion JUEOH, 7, 215-217
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  17. Reid Campion MJ Hydrotherapy in paediatrics (1985) William Heinmann
  18. Reid Campion MJ Hydrotherapy Principles and Practice (2000) Butterworth Heinmann
  19. Ruoti, Morris, Becker ‘Aquatic Rehabilitation’ Philadelphia:Lippincott-Raven, 1997
  20. Wilder, Brennan ‘physiological responses to deep water running in athletes’ Sports medicine 1993; 16(6):374-80

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