Pool Therapy, Aquatic Therapy or Hydrotherapy
Number: 0174
Table Of Contents
PolicyApplicable CPT / HCPCS / ICD-10 Codes
Background
References
Policy
Scope of Policy
This Clinical Policy Bulletin addresses pool therapy, aquatic therapy or hydrotherapy.
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Medical Necessity
Aetna considers aquatic therapy (hydrotherapy, pool therapy) medically necessary for.
- Osteoarthritis of the knee or hip; or
- Fibromyalgia: or
- Ankylosing spondylitis; or
- Rheumatoid arthritis; or
- Chronic low back pain; or
- Other musculoskeletal conditions when pain, weight-bearing restrictions or poor balance prevent the member from pursuing land-based therapeutic activities or exercises.
Aquatic therapy that is carried out to maintain a level of function (maintenance therapy), where the member is neither improving nor regressing, is considered not medically necessary.
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Experimental, Investigational, or Unproven
The following indications and modalities are considered experimental, investigational, or unproven because the effectiveness of these approaches has not been established (not an all-inclusive list):
- Combined hydrotherapy and Swedish massage for the treatment of endometriosis-related chronic pelvic pain;
- Crenobalneotherapy (spa therapy) for knee osteoarthritis, low back pain and all other indications;
- Marine therapy (ocean therapy) is considered experimental, investigational, or unproven for the treatment of musculoskeletal disorder/pain (including arthritis, fibromyalgia, and osteoarthritis);
- Nano-bubble hydrotherapy for the treatment of palmar plantar keratosis and all other indications;
- Passive hydrotherapy WATSU (WaterShiatsu) for the treatment of juvenile idiopathic arthritis, Parkinson's disease, and all other indications;
- Pool therapy for the treatment of post-stroke pain;
- Treatment of asthma and all other non-musculoskeletal indications (e.g., atopic dermatitis, autism, chronic obstructive pulmonary disease, developmental coordination disorder, end-stage dementia, reducing risk of falls in the elderly, lymphedema, management of individuals with cancer, neonatal brachial plexus palsy, peripheral artery disease, psoriasis, sickle cell anemia, stroke rehabilitation, and traumatic brain injury).
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Policy Limitations and Exclusions
Note: Pool, aquatic, or hydrotherapy is considered to be a physical therapy modality subject to the physical therapy guidelines and any applicable plan benefit limits for physical therapy (see CPB 0325 - Physical Therapy).
Note: Aetna covers only the professional charges of a physical therapist or other recognized, licensed providers (e.g., doctor of medicine, doctor of osteopathy, podiatrist, and physical therapy assistant), for physical therapy modalities administered in a pool, which require direct, one-on-one, patient contact. Charges for aquatic exercise programs, or separate charges for use of a pool, are not covered.
Note: Aquatic therapy must be carried out for restoring the member's level of function that was lost or reduced by injury or illness. The provider must have direct (one-to-one) patient contact when reporting aquatic therapy. Supervising multiple patients in a pool at one time and billing for each of these patients per 15 minutes of therapy time is inappropriate.
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Related Policies
Background
Aquatic therapy has been shown to provide relief from symptoms associated with various arthritides, traumatic injuries, and other musculoskeletal conditions. This procedure utilizes the therapeutic properties of water (e.g., buoyancy, resistance). Aquatic therapy may be necessary for individuals experiencing a loss or restriction of joint motion, strength, mobility, or function resulting from a specific disease or injury. The medical record should document objective loss of joint motion, strength, or mobility (e.g., degrees of motion, strength grades, levels of assistance). Standard treatment duration is typically 3 to 4 times per week for 2 to 4 weeks. It is not necessary to have more than one form of hydrotherapy during the same visit (NHIC, 2002). Other forms of exercise therapy may be required in addition to aquatic therapy when the member cannot effectively perform land-based exercises to treat their condition without first undergoing aquatic therapy, or when aquatic therapy facilitates progress to land-based exercise or increased function.
Harmer and colleagues (2009) compared outcomes between land-based and water-based exercise programs delivered in the early subacute phase, up to 6 months after total knee replacement (TKR). Two weeks after surgery (baseline), 102 patients were randomized to participate in either land-based (n = 49) or water-based (n = 53) exercise classes. Treatment parameters were guided by current clinical practice protocols. Thus, each study arm involved 1-hour sessions twice weekly for 6 weeks, with patient-determined exercise intensity. Session attendance was recorded. Outcomes were measured at baseline and at 8 and 26 weeks post-surgery. Outcomes included distance on the 6-minute walk test, stair climbing power (SCP), the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index (n = 85 English-proficient patients), visual analog scale for joint pain, passive knee range of motion, and knee edema (circumference). Planned orthogonal contrasts, with an intent-to-treat approach, were used to analyze the effects of time and time-group interactions. Compliance in both groups was excellent, with 81% attending 8 or more sessions. Loss to follow-up was 5%. Significant improvements were observed across time in all outcomes at 8 weeks, with further improvements evident in all variables (except WOMAC pain) at 26 weeks. Minor between-group differences were noted for 4 outcomes (SCP, WOMAC stiffness, WOMAC function, and edema), but these appeared clinically insignificant. The authors concluded that a short-term, clinically pragmatic program of either land-based or water-based rehabilitation delivered in the early phase after TKR was associated with comparable outcomes at the end of the program and up to 26 weeks post-surgery.
In a controlled trial with blinded 6-month follow-up, Rahmann and colleagues (2009) assessed the effect of inpatient aquatic physiotherapy in addition to usual ward physiotherapy on the recovery of strength, function, and gait speed after total hip or knee replacement surgery. Participants (n = 65) were individuals undergoing primary hip or knee arthroplasty (average age of 69.6 ± 8.2 years; 30 men). Subjects were randomly assigned to receive supplementary inpatient physiotherapy, beginning on day 4: aquatic physiotherapy, non-specific water exercise, or additional ward physiotherapy. Main outcome measures were strength, gait speed, and functional ability at day 14. At day 14, hip abductor strength was significantly greater after the aquatic physiotherapy intervention than after additional ward treatment (p = 0.001) or water exercise (p = 0.011). No other outcome measures were significantly different at any time point in the trial, but relative differences favored the aquatic physiotherapy intervention at day 14. No adverse events occurred with early aquatic intervention. The authors concluded that a specific inpatient aquatic physiotherapy program has a positive effect on early recovery of hip strength after joint replacement surgery. Moreover, they stated that further studies are needed to confirm these findings.
Hillier and colleagues (2010) stated that aquatic therapy is an intervention for children with developmental coordination disorder (DCD) that has not been formally investigated. In a pilot randomized controlled trial, these researchers investigated the feasibility and preliminary effectiveness of an aquatic therapy program to improve motor skills in children with DCD. A total of 13 children (mean age of 7 years 1 month; 10 males) with DCD were randomly allocated to receive either 6 sessions of aquatic therapy (once-weekly session of 30 minutes for 6 to 8 weeks) or to a wait-list (control group). The intervention and measures were demonstrated to be feasible, but barriers, such as limited appointment times and accessibility, were encountered. Analysis of covariance indicated that at post-test, mean scores on the Movement Assessment Battery were higher for children who received aquatic therapy compared to those on the wait-list (p = 0.057). Similar trends were noted on the physical competence portion of the Pictorial Scale of Perceived Competence and Social Acceptance (p = 0.058). However, these differences were not significant. These preliminary findings need to be validated by well-designed studies.
Tinti et al. (2010) noted that the process of hemoglobin polymerization and the consequent sickling of red blood cells that occurs in patients with sickle cell disease shortens the half-life of red blood cells. It causes vaso-occlusive complications as well as pain and pulmonary and cardiovascular dysfunction. In a case study, these researchers evaluated an aquatic rehabilitation program used for patients with sickle cell anemia and examined the possible benefits that exercise in warm water has for the circulatory system in relieving pain as well as for increasing lung capacity. The patient was a 32-year-old female. The parameters used in this study included respiratory muscle strength (calculated by measuring maximum inspiratory pressures and maximum expiratory pressures), the McGill and Wisconsin pain questionnaires (to evaluate the patients' characterizations and descriptions of their pain), and the SF-36 Health Survey. The treatment included warm water exercises, stretching, aerobic exercise, and relaxation, during 2 sessions of 45 minutes per week for 5 weeks. The patient experienced a significant decrease in pain, a significant increase in the strength of respiratory muscles, and improved quality of life. The authors concluded that aquatic rehabilitation can be used to improve the clinical condition of sickle cell anemia patients, and they stated that more research on this new treatment regime, in comparison with other types of therapies, should be encouraged.
Fibromyalgia (FM) is a debilitating condition characterized by the presence of widespread musculoskeletal pain. Moreover, there is inconsistent evidence regarding the effectiveness of various therapies developed so far, making FM a chronic disease that is difficult to treat.
The University of Texas, School of Nursing, Family Nurse Practitioner Program’s clinical guideline on “Management of fibromyalgia syndrome in adults” (2009) did not mention the use of aquatic therapy/hydrotherapy/pool therapy as a therapeutic option.
Thomas and Blotman (2010) examined the current evidence to support guidelines for aerobic exercise (AE) and FM in practice and outlined specific research needs in these areas. Data sources consisted of a PubMed search, a 2007 Cochrane Database Systematic Review, 2008 Ottawa panel evidence-based clinical practice guidelines, as well as additional references found from the initial search. Study selection included randomized clinical trials that compared an aerobic-only exercise intervention (land- or pool-based) with an untreated control, a non-exercise intervention, or other exercise programs in patients responding to the 1990 American College of Rheumatology criteria for FM. The following outcome data were obtained: pain, tender points, perceived improvement in FM symptoms such as the Fibromyalgia Impact Questionnaire (FIQ) total score, physical function, depression (e.g., Beck Depression Inventory, FIQ subscale for depression), fatigue, and sleep were extracted from 19 clinical trials that considered the effects of aerobic-only exercise in FM patients. Data synthesis showed that there is moderate evidence of an important benefit of aerobic-only exercise in FM on physical function and possibly on tender points and pain. It appears to be sufficient evidence to support the practice of AE as part of the multidisciplinary management of FM. However, the authors stated that future studies must be more adequately sized, homogeneously assessed, and monitored for adherence to draw definitive conclusions.
Winkelmann et al. (2012) noted that the scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften," AWMF; registration number 041/004) was planned starting in March 2011. The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie," DIVS), 9 scientific medical societies, and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest, and hierarchical position in the medical and scientific fields. Literature searches were performed using the MedLine, PsycInfo, Scopus, and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Center for Evidence-Based Medicine. The formulation and grading of recommendations were accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies. The authors concluded that low-to-moderate intensity aerobic exercise and strength training are strongly recommended. Chiropractic, laser therapy, magnetic field therapy, massage therapy, as well as transcranial current stimulation are not recommended. Aquatic therapy/hydrotherapy/pool therapy was not mentioned as a therapeutic option.
Lima et al. (2013) evaluated the effectiveness of aquatic physical therapy in the treatment of FM. The search strategy was undertaken using the following databases, from 1950 to December 2012: MEDLINE, EMBASE, CINAHL, LILACS, SCIELO, WEB OF SCIENCE, SCOPUS, SPORTDiscus, Cochrane Library Controlled Trials Register, Cochrane Disease Group Trials Register, PEDro, and DARE. The studies were separated into groups: Group I -- aquatic physical therapy × no treatment, Group II -- aquatic physical therapy × land-based exercises, and Group III -- aquatic physical therapy × other treatments. A total of 72 abstracts were found, 27 of which met the inclusion criteria. For functional ability (FIQ), 3 studies were considered with a treatment time of more than 20 weeks, and a mean difference (MD) of -1.35 [-2.04; -0.67], p = 0.0001 was found in favor of the aquatic physical therapy group versus no treatment. The same results were identified for stiffness and the 6-minute walk test, where 2 studies were pooled with an MD of -1.58 [-2.58; -0.58], p = 0.002 and 43.5 (meters) [3.8; 83.2], p = 0.03, respectively. The authors concluded that 3 meta-analyses showed statistically significant results in favor of aquatic physical therapy (FIQ, stiffness, and the 6-minute walk test) during a period of longer than 20 weeks. Moreover, they stated that due to the low methodological rigor, the results were insufficient to demonstrate statistical and clinical differences in most of the outcomes.
In a Cochrane review, McNamara et al. (2013) evaluated the effects of water-based exercise training in people with chronic obstructive pulmonary disease (COPD). A search of the Cochrane Airways Group Specialized Register of trials, which is derived from systematic searches of bibliographic databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED, and PsycINFO, was conducted (from inception to August 2013). Hand-searching was done to identify further qualifying studies from reference lists of relevant studies. Review authors included randomized or quasi-randomized controlled trials in which water-based exercise training of at least 4 weeks' duration was compared with no exercise training or any other form of exercise training in people with COPD. Swimming was excluded. These researchers used standard methodological procedures expected by The Cochrane Collaboration. A total of 5 studies were included, with a total of 176 participants (71 people participated in water-based exercise training and 54 in land-based exercise training; 51 completed no exercise training). All studies compared supervised water-based exercise training versus land-based exercise training and/or no exercise training in people with COPD (with average forced expiratory volume in one second (FEV1) % predicted ranging from 39% to 62%). Sample sizes ranged from 11 to 53 participants. A moderate risk of bias was due to a lack of reporting of randomization, allocation, and blinding procedures in some studies, as well as small sample sizes. Compared with no exercise, water-based exercise training improved the 6-minute walk distance (mean difference (MD) 62 meters; 95% confidence interval (CI): 44 to 80 meters; 3 studies; 99 participants; moderate quality evidence), the incremental shuttle walk distance (MD 50 meters; 95% CI: 20 to 80 meters; 1 study; 30 participants; high quality evidence), and the endurance shuttle walk distance (MD 371 meters; 95% CI: 121 to 621 meters; 1 study; 30 participants; high quality evidence). Quality of life was also improved after water-based exercise training compared with no exercise (standardized mean difference (SMD) -0.97, 95% CI: -0.37 to -1.57; 2 studies; 49 participants; low quality evidence). Compared with land-based exercise training, water-based exercise training did not significantly change the 6-minute walk distance (MD 11 meters; 95% CI: -11 to 33 meters; 3 studies; 62 participants; moderate quality evidence) or the incremental shuttle walk distance (MD 9 meters; 95% CI: -15 to 34 meters; 2 studies; 59 participants; low quality evidence). However, the endurance shuttle walk distance improved following water-based exercise training compared with land-based exercise training (MD 313 meters; 95% CI: 232 to 394 meters; 2 studies; 59 participants; moderate quality evidence). No significant differences were found between water-based exercise training and land-based exercise training for quality of life, as measured by the St George's Respiratory Questionnaire or by 3 of 4 domains of the Chronic Respiratory Disease Questionnaire (CRDQ); however, the fatigue domain of the CRDQ showed a statistically significant difference in favor of water-based exercise (MD -3.00; 95% CI: -5.26 to -0.74; 1 study; 30 participants). Only 1 study reported long-term outcomes after water-based exercise training for quality of life and body composition, and no significant change was observed between baseline results and 6-month follow-up results. One minor adverse event was reported for water-based exercise training (based on reporting from 2 studies; 20 participants). The impact of disease severity could not be examined because data were insufficient. The authors concluded that there is limited quality evidence that water-based exercise training is safe and improves exercise capacity and quality of life in people with COPD immediately after training. There is limited quality evidence that water-based exercise training offers advantages over land-based exercise training in improving endurance exercise capacity, but these investigators remained uncertain as to whether it leads to better quality of life. They noted that little evidence exists examining the long-term effect of water-based exercise training.
Mortimer et al. (2014) examined the effectiveness of hydrotherapy on social interactions and behaviors in the treatment of children with autism spectrum disorders (ASDs). A systematic search of Cochrane, CINAHL, PsycINFO, Embase, MEDLINE®, and Academic Search Premier was conducted. Studies of participants aged 3 to 18 years with ASDs at a high-functioning level were included if they utilized outcome measures assessing social interactions and behaviors through questionnaires or observation. A critical appraisal, using the McMaster Critical Review Form for Quantitative Studies, was performed to assess methodological quality. A total of 4 studies of varying research design and quality met the inclusion criteria. The participants in these studies were aged between 3 to 12 years. The duration of the intervention ranged from 10 to 14 weeks, and each study used varied measures of outcome. Overall, all the studies showed some improvements in social interactions or behaviors following a Halliwick-based hydrotherapy intervention. The authors concluded that few studies have investigated the effect of hydrotherapy on the social interactions and behaviors of children with ASDs. While there is an increasing body of evidence for hydrotherapy for children with ASDs, this is constrained by small sample sizes, lack of comparators, crude sampling methods, and the lack of standardized outcome measures. They stated that hydrotherapy shows potential as a treatment method for social interactions and behaviors in children with ASDs.
Marinho-Buzelli et al. (2015) summarized evidence on the effects of aquatic therapy on mobility in individuals with neurological diseases. MEDLINE, EMBASE, PsycInfo, CENTRAL, CINAHL, SPORTDiscus, PEDro, PsycBITE, and OT Seeker were searched from inception to September 15, 2014. Hand-searching of reference lists was performed in the selected studies. The search included randomized controlled trials (RCTs) and quasi-experimental studies that investigated the use of aquatic therapy and its effect on the mobility of adults with neurological diseases. One reviewer screened titles and abstracts of retrieved studies from the search strategy. Two reviewers independently examined the full texts and conducted the study selection, data extraction, and quality assessment. A narrative synthesis of data was applied to summarize information from included studies. The Downs and Black Scale was used to assess methodological quality. A total of 116 articles were obtained for full-text eligibility; 20 studies met the specified inclusion criteria: 4 RCTs, 4 non-randomized studies, and 12 before-and-after tests. Two RCTs (30 patients with stroke in the aquatic therapy groups), 3 non-randomized studies, and 3 before-and-after studies showed "fair" evidence that aquatic therapy increased dynamic balance in participants with some neurological disorders. One RCT (7 patients with stroke in the aquatic therapy group) and 2 before-and-after tests (20 patients with multiple sclerosis) demonstrated "fair" evidence of improvement in gait speed after aquatic therapy. The authors concluded that their synthesis showed "fair" evidence supporting the use of aquatic therapy to improve dynamic balance and gait speed in adults with certain neurological conditions.
Wang et al. (2023) stated that aquatic exercise (AE) is becoming increasingly popular as a physical therapy, while it is unclear what precise improvements it will produce and how effective it will be in comparison with other non-surgical therapies. In a systematic review and meta-analysis, these researchers examined whether AE would positively impact chronic musculoskeletal disorder patients in terms of pain, physical function, and quality of life (QOL). PRISMA guidelines were followed, and the study protocol was published online at PROSPERO. These investigators searched PubMed, Embase, Web of Science, and Cochrane library databases for English-language articles published before April 11, 2023, including studies from all relevant RCTs. After screening, these researchers included 32 RCTs with a total of 2,200 participants. They also carried out subgroup analyses for all included studies. This meta-analysis calculated standardized mean differences (SMD) with 95% confidence intervals (CI), and the variance was estimated using a random-effects model. The quality of the included studies was assessed using the Cochrane collaborative "risk of bias" assessment tool (version 2.0), ensuring that the literature included was of high quality. This meta-analysis entailed 32 studies with 2,200 subjects; these patients were all between the ages of 38 to 80 years. The study showed that compared to the no exercise (NE) group, patients in the AE group experienced a remarkable reduction in pain (SMD: -0.64, p < 0.001), a significant increase in physical function (SMD: 0.62, p < 0.001), and a statistically significant improvement in QOL (SMD: -0.64, p < 0.001). When compared to land-based exercise (LE), AE significantly relieved patients' pain (SMD: -0.35, p = 0.03). The authors concluded that this was the first systematic review and meta-analysis to study whether AE could improve chronic musculoskeletal disorders. The evidence suggested that AE benefited pain, physical function, and QOL in adults with chronic musculoskeletal conditions compared to NE. In addition, when compared to LE, AE continued to provide a better improvement in patient pain. Moreover, these researchers stated that further investigations with long-term clinical trials are needed to confirm AE's positive effects, improvement mechanisms, and the more existential advantages compared to LE.
The authors stated that this study had several drawbacks. First, this study only included RCTs published in English, and some high-quality articles published in languages other than English were excluded; therefore, future meta-analyses should include these excluded high-quality articles as well as some valuable studies that may not have been published yet. Second, because the number of included literature within some subgroups was found to be small when subgroup analysis was carried out in this study, this could have resulted in a large heterogeneity in some subgroup analyses and made the findings of the meta-analysis differ from the actual results. Hence, the number of included literature should be increased as much as possible in future studies to further improve the reliability of the study. Third, the intervention protocols were not identical across studies; thus, the intervention intensity, as well as the intervention period, could vary, both of which could have affected the final intervention effect. Fourth, there was a placebo effect for aquatic therapy, and most of the literature included in this paper lacked a placebo control; therefore, the placebo effect could not be excluded.
Benzo-Iglesias et al. (2023) stated that chronic obstructive pulmonary disease (COPD) is a progressive respiratory disease that, due to dyspnea, decreases patients' physical function and quality of life. The aim of the research was to evaluate the effectiveness of water-based exercise (WE) in improving functional capacity and respiratory muscle strength in patients with COPD. It consisted of a systematic review and meta-analysis of eight randomized clinical trials (RCTs) from the last 10 years, found in PubMed, PEDro, Scopus, and Web of Science databases. Methodological quality was analyzed using the PEDro scale and the Cochrane Collaboration Risk of Bias Tool. Regarding the evaluation of functional capacity, lung function, respiratory muscle strength, and maximal or aerobic exercise were primarily assessed. The results showed that WE improves functional capacity compared to a non-exercising control group (SMD: 73.42; 95% CI: 40.40 to 106.45; I²: 0%). There are no statistically significant differences between a WE treatment and a land exercise (LE) treatment (p = 0.24) in functional capacity, nor with respect to respiratory muscle strength (p = 0.97). These data should be interpreted with caution, as more RCTs with aquatic intervention in COPD patients are needed to elucidate whether there are differences between WE and LE according to patient characteristics and comorbidities.
In a systematic review and meta-analysis, Bravo et al. (2024) examined the effectiveness of aquatic therapy on pain, sleep quality, psychological symptoms, quality of life (QOL), and health status in individuals diagnosed with fibromyalgia. These investigators searched PubMed, CINAHL, the Cochrane Library, PEDro, and Scopus databases. Studies were eligible if they were RCTs examining the effects of aquatic therapy in adults diagnosed with fibromyalgia and published by October of 2022 in English or Spanish. The Cochrane Risk of Bias tool was used to perform the methodological quality assessment of the encompassed studies, and the overall quality of evidence for each comparison was determined using the GRADE approach. Of 375 articles found, 22 met the inclusion criteria. Forest plot analysis of the Pittsburgh Sleep Quality Index at short- and mid-term follow-up showed a trend in favor of aquatic therapy, although not statistically significant, with a weighted mean difference (WMD) = -1.71 (95% CI: -4.17 to -0.75, p = 0.17). Heterogeneity was substantial (χ² = 8.74, df = 5 (p < 0.000001; I² = 95%). Relating the pain outcome by the Fibromyalgia Impact Questionnaire (FIQ) short-term showed a trend in favor of the aquatic therapy group with WMD = -5.04 (95% CI: -9.26 to -0.82, p = 0.02) with heterogeneity χ² = 11.07, df = 4 (p = 0.03; I² = 64%). Great heterogeneity was found between trials in the medium term. The authors concluded that this systematic review and meta-analysis showed the effectiveness of aquatic therapy as an adjunctive treatment to usual care in individuals suffering from fibromyalgia. Aquatic therapeutic exercise improved the symptoms of sleep quality, pain, and QOL of adults with fibromyalgia. These investigators stated that further research on long-term outcomes may contribute to the currently available evidence.
The authors stated that, as with any meta-analysis, there is a potential for selection bias. First, screening references of identified studies may bring positive results because studies with positive results were more likely to be published than studies with negative outcomes. Second, almost all of the included studies were not blinded, and the researchers were not always blinded to the participants’ intervention. Studies involving active patient participation consistently exhibit a bias in blinding due to the inherent interactive nature of such interventions. Consequently, all studies concerning physical activity, physiotherapy, or similar interventions are prone to this bias unless comparison is possible with an active control group characterized by null effectiveness. Third, all studies included follow-up in the short- or medium-term; therefore, the long-term effect of aquatic therapy remains unclear.
Aquatic Therapy for Atopic Dermatitis and Psoriasis
Jazani et al. (2023) stated that atopic dermatitis (AD) and psoriasis are chronic inflammatory diseases that have significant skin complications. In a systematic study, these investigators examined the evidence obtained from human studies on the effectiveness of hydrotherapy, spa therapy, and balneotherapy in patients with atopic dermatitis and psoriasis. This systematic review was carried out according to the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statements. Furthermore, for this study databases such as Embase, PubMed, Scopus ProQuest, and sciences direct database were searched from the beginning to April 2021. All human studies that examined the effectiveness of balneotherapy, spa therapy, and hydrotherapy on atopic dermatitis and psoriasis were published in the form of a full article in English. A total of 22 (out of the 424) articles met the inclusion criteria for analysis. Most studies have shown that balneotherapy, spa therapy, and hydrotherapy may reduce the effects of the disease by reducing inflammation and improving living conditions. Furthermore, the results of the Downs and Black score showed that 7 studies received very good scores, 3 studies received good scores, 9 studies received fair scores, and 3 studies received poor scores. The authors concluded that the findings these studies showed that hydrotherapy resulted in an improvement in the PASI score index. Moreover, these researchers stated that more clinical trials are needed to determine the mechanism of action of hydrotherapy on these diseases.
Aquatic Therapy for Management of Individuals with Cancer
Reger et al. (2022) noted that water therapy such as hydrotherapy, balneotherapy or aqua therapy are often used in the relief of disease- and treatment-associated symptoms of cancer patients. However, a systematic review for the evidence of water therapy including all cancer entities has not been conducted to-date. These investigators stated that cancer patients often suffer from symptoms which in patients with other diseases are successfully treated with water therapy; they gathered more information regarding the risks and benefits of water therapy for cancer patients. In May 2020, a systematic search was conducted searching 5 electronic databases (Embase, Cochrane, PsychInfo, CINAHL and PubMed) to find studies concerning the use, effectiveness and potential harm of water therapy on cancer patients. Of 3,165 search results, 10 publications concerning 12 studies with 430 patients were included in this systematic review. The patients treated with water therapy were mainly diagnosed with breast cancer. The therapy concepts included aqua lymphatic therapy, aquatic exercises, foot bathes and whole-body bathes. Outcomes were state of lymphedema, QOL, fatigue, body mass index (BMI), vital parameters, anxiety and pain. The quality of the studies was assessed with the AMSTAR2-instrument, the SIGN-checklist and the IHE-Instruments. The studies had moderate quality and reported heterogeneous results. Some studies reported significantly improved QOL, extent of lymphedema, neck and shoulder pain, fatigue and BMI while other studies did not find any changes concerning these endpoints. The authors concluded that due to the very heterogeneous results and methodical limitations of the included studies, a clear statement regarding the effectiveness of water therapy on cancer patients is not possible.
The authors stated that this systematic review had several drawbacks. First, these researchers excluded studies concerning children or teenagers. Second, only studies in English or German language were included. Third, studies published before 1995 were excluded.
Aquatic Therapy for the Treatment of Chronic Obstructive Pulmonary Disease
Benzo-Iglesias et al. (2023) stated that chronic obstructive pulmonary disease (COPD) is a progressive respiratory disease that, due to dyspnea, decreases patients' physical function and quality of life (QOL). In a systematic review and meta-analysis, these investigators examined the effectiveness of water-based exercise (WE) in improving functional capacity and respiratory muscle strength in patients with COPD. The available evidence consisted of 8 randomized controlled trials (RCTs) from the past decade, found in the PubMed, PEDro, Scopus, and Web of Science databases. Methodological quality was analyzed using the PEDro scale and the Cochrane Collaboration Risk of Bias Tool. Regarding the evaluation of functional capacity, the main assessments included lung function, respiratory muscle strength, and maximal or aerobic exercise. The results showed that WE improved functional capacity compared to a non-exercising control group (SMD: 73.42; 95% CI: 40.40 to 106.45; I²: 0%). However, there were no statistically significant differences between WE treatment and land exercise (LE) treatment (p = 0.24) in functional capacity, nor with respect to respiratory muscle strength (p = 0.97). The authors stated that these findings should be interpreted with caution, as more RCTs with aquatic interventions in COPD patients are needed to examine whether there are differences between WE and LE according to patient characteristics and comorbidities.
The authors noted that the drawbacks of this systematic review included the lack of studies with high methodological quality and low risk of bias; specifically, there were 2 studies with low methodological quality and high risk of bias, which may compromise the quality of the evidence and affect the reliability of the conclusions and their clinical utility. Additionally, the studies included small sample sizes, variability in the characteristics of the participants and the aquatic environment, differences in the duration of the sessions and studies, and variations in the type of exercise performed. These issues made it difficult to reach a consensus on the results and increased the risk of bias in this review. All these factors, along with the small number of studies on the subject and the lack of certain information, limited the possibility of performing a more powerful meta-analysis of all the studies included in this review. Furthermore, potential drawbacks of this study included the exclusion of previous but still valuable research, especially when studying long-term outcomes. Emerging interventions may also have limited data within the specified time frame.
Cerebral Palsy
Ballington and Naidoo (2018) stated that cerebral palsy (CP) is the most common motor disability in childhood. Children with CP tend to have lower levels of physical activity compared to their peers, which negatively impacts their health. However, aquatic exercise can be utilized to enhance fitness levels among children with CP. The researchers investigated the carry-over effect of an aquatic-based program focused on postural control and balance on land activities (walking, running, and jumping) in children with CP following the aquatic intervention. The study employed a pretest-post-test, randomized group, crossover design, involving children aged 8 to 12 years (n = 10) who were divided into intervention (n = 5) and control (n = 5) groups. The intervention group participated in two 30-minute sessions per week, while the control group continued with their normal activities. Pre- and post-intervention testing was conducted using gross motor function measurement, and the 10-point program of the Halliwick Concept was implemented. Results indicated that aquatic therapy significantly improved gross motor function scores, with the aquatic program group showing enhanced motor function post-intervention compared to the control group (z = -2.803, p = 0.005). Additionally, the aquatic-based therapy improved the average score for gross motor function measurement after the intervention. The authors concluded that an 8-week aquatic-based intervention could lead to significant gains in gross motor function in children with CP, with a notable carry-over effect onto land. However, the study also revealed that after a month without aquatic activity, the gains in gross motor function were reversible. Therefore, it suggested that aquatic-based programs should be integrated and considered an essential continuous treatment modality for children with CP to ensure long-term improvements in gross motor function. Furthermore, aquatic therapy is an innovative approach for children with significant motor impairments, as land-based exercises may be restricted for this population.
The authors acknowledged several drawbacks of the study. First, the small number of participants (n = 5 in the treatment group) limited the ability to generalize findings to other populations. Second, the participants did not represent a broad range of severity levels, as none had gross motor function classified at Gross Motor Function Classification System (GMFCS) levels IV and V. Third, the study focused solely on aquatic-based exercise and assessed the carry-over effect from water to land, without evaluating the effects of land-based exercise alone. Fourth, the study was conducted over 8 weekly sessions for each participant, which constrained some participants from completing the entire 10-point program. Lastly, a questionnaire to assess participants' enjoyment and psychological status, which could have strengthened the overall study design, is recommended for future research.
Combined Hydrotherapy and Swedish Massage for the Treatment of Endometriosis-Related Chronic Pelvic Pain
In a randomized controlled trial (RCT), Rodríguez-Ruiz et al. (2024) examined the effectiveness of an integral HAMMAM experience, a 4-week therapeutic program that combined hydrotherapy and Swedish massage, employed in a multi-sensory immersive environment, on pain, well-being, and quality of life (QOL) in women with endometriosis-related chronic pelvic pain that is unresponsive to conventional treatment. This study included 44 women with endometriosis; subjects were randomly allocated to either the “HAMMAM” group (n = 21) or a control group (n = 23). The primary outcome, pain intensity, was examined using numeric rating scales (NRSs). The secondary outcomes included pain interference, pain-related catastrophic thoughts, pressure pain thresholds (PPTs), subjective well-being, functional capacity, and QOL, which were evaluated using the Brief Pain Inventory (BPI), the Pain Catastrophizing Scale (PCS), algometry, the Subjective Well-Being Scale-20 (EBS-20), the Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29), and the Endometriosis Health Profile-30 Questionnaire (EHP-30), respectively. The primary and secondary outcomes were measured at baseline and after the intervention. The statistical (between-group analyses of covariance) and clinical effects were analyzed by intention-to-treat (ITT) analysis. The adherence rate was 100.0%, and the mean (± standard deviation) satisfaction was 9.71 ± 0.46 out of 10. No remarkable health problems were reported during the trial. The “HAMMAM” intervention improved dysmenorrhea and dyspareunia following the intervention, with large and moderate effect sizes, respectively. Improvements in pain interference during sleep and PPTs in the pelvic region were also observed in women allocated to the “HAMMAM” group. No effects were observed in catastrophic thoughts, well-being, or QOL, except for the sleep subscale. The authors concluded that a 4-week program of an integral “HAMMAM” experience combining hydrotherapy and massage in a multi-sensory immersive environment was a feasible and effective intervention to alleviate pain during menstruation and sexual intercourse, as well as pain interference with sleep in women with endometriosis. Moreover, these researchers stated that further investigations using additional study arms (testing isolated therapeutic options) and larger sample sizes should be performed to validate these findings.
The authors noted that the key drawback of this study was the absence of study groups treated with isolated therapeutic tools (hydrotherapy or Swedish massage), which prevented them from elucidating the beneficial effect of each therapeutic approach used. Moreover, intra- and inter-variability in the professionals who conducted the massages could not be prevented, which might also have influenced the results observed. Furthermore, this RCT had a limited sample size (n = 21 in the HAMMAM group). Although the researchers completed the estimated sample size to detect differences in the primary outcome (pain intensity), the size may have hindered the identification of subtle differences between groups in secondary outcomes such as well-being or QOL. In addition, the simple randomization methodology followed for this small sample size resulted in an unequal distribution of individuals across groups. Nevertheless, a slight imbalance in group sizes due to simple randomization was unlikely to have introduced bias, especially when baseline characteristics remained balanced and appropriate statistical adjustments were used. Additionally, the eligibility criteria may have limited the generalizability of these findings to women with endometriosis. Furthermore, the variety of pharmacotherapies prescribed to women with endometriosis prevented the authors from homogenizing both groups based on this aspect. Therefore, although there were no differences in the use of oral contraceptives between the groups and all women reported full compliance with the prescribed treatment, potential differences in the current treatment of the patients assigned to each group could also have influenced these findings.
Crenobalneotherapy
In a systematic review, Forestier and Francon (2008) examined the effectiveness of crenobalneotherapy for the treatment of limb osteoarthritis and discussed the study methods used to evaluate this treatment modality. These investigators searched Medline using the following keywords: "spa therapy," "mud," "radon," "balneotherapy," and "hydrotherapy" in combination with "osteoarthritis," "arthrosis," and "gonarthrosis." They also reviewed the reference lists of articles retrieved by the Medline search. Studies that compared crenobalneotherapy to any other intervention or to no intervention were selected, and a checklist was used to examine their internal validity. Furthermore, external validity and the quality of the statistical analysis were evaluated. Crenobalneotherapy was associated with improvements in the evaluation criteria (pain, function, and quality of life [QOL]) compared to baseline; however, inadequate internal validity precluded the establishment of a causal link between these improvements and crenobalneotherapy. External validity was often poorly defined. Some studies found no significant differences with the control group but failed to include a sample-size calculation, suggesting inadequate statistical power as a possible explanation for the result. In several studies, the use of multiple evaluation criteria and measurements led to a high risk of Type I error. The authors concluded that although the consistency of the results suggested a therapeutic effect of crenobalneotherapy in limb osteoarthritis, available studies were methodologically inadequate and sample sizes too small to allow definitive conclusions. These researchers suggested a number of solutions to these shortcomings, stating that carefully designed studies in larger patient populations are needed to determine the role of crenobalneotherapy in knee osteoarthritis.
Forestier et al. (2022) stated that crenobalneotherapy is a treatment commonly used in Europe and the Middle East. It employs mineral water, sometimes combined with different hydrotherapy techniques. Most patients treated in spa centers suffer from low back pain (LBP). These investigators identified clinical trials on crenobalneotherapy for LBP. Publication research was carried out using the Medline, Cochrane, and PEDRO databases. Clinical trials were analyzed for internal validity, external validity, quality of statistical analysis, and quality of collection of adverse events. These investigators presented the best level of evidence. Bibliographic research identified 21 clinical trials, and the co-authors added 5 references. The 26 studies represented 2,695 patients. Some exhibited good methodological quality and allowed for considering crenobalneotherapy as a potential treatment for LBP, even if the role of mineral water remains uncertain. The authors concluded that the methodological quality of therapeutic trials should be improved, and these trials should be analyzed in future guidelines on LBP.
End-Stage Dementia
Becker and Lynch (2018) reported on the case of a 54-year old woman who retired due to progressive cognitive decline, and was diagnosed with early-onset Alzheimer dementia (AD). Conventional medication therapy for dementia had proven futile. Initial evaluation revealed a non-verbal female seated in a wheelchair, dependent on 2-person assist for all transfers and activities of daily living (ADL). She had been either non-responsive or actively resistive for both ADL and transfers in the 6 months before assessment. After a total of 17 1-hour aquatic therapy sessions over 19 weeks in a warm water therapy pool, she achieved the ability to tread water for 15 minutes, transfers improved to moderate-to-maximum assist from seated, and ambulation improved to 1,000 feet with minimum-to-moderate assist of 2 persons. Communication increased to appropriate "yes", "no", and "okay" appropriate responses, and an occasional "thank you" and "very nice". The authors proposed that her clinical progress may be related to her aquatic therapy intervention. Level of evidence: To be determined. These preliminary findings need to be further investigated.
Improvement of Balance in the Elderly
Shariat and colleagues (2022) stated that balance is a key component of movement for daily activities, especially in the elderly. Previous studies examining aquatic therapy as an effective way for improving balance have yielded inconsistent findings. In a systematic review and meta-analysis, these investigators examined the effectiveness of aquatic therapy on balance among the elderly. Sources include Cochrane Central Register of Controlled Trials, Medline, ISI Web of Science, EBSCO, Embase, Cumulative Index to Nursing and Allied Health Literature, and Scopus. Randomized controlled or cross-over trials published by February 2020 were included following pre-determined search and selection criteria. Data extraction was carried out by 2 researchers independently using a pre-determined data extraction form. Methodological quality was evaluated by 2 reviewers using the PEDro scale that was used to rate trials according to criteria such as concealed allocation, blinding, and ITT analysis. Furthermore, meta-analysis was conducted where possible. A total of 15 trials with 385 healthy subjects aged 50 or over were included. Results showed that aquatic therapy had a significant effect on dynamic balance (SMD, - 1.13; 95% CI: - 1.45 to - 0.82]; I2 = 77%). The analysis indicated that aquatic therapy improved balance ability compared to controls. The authors concluded that aquatic therapy had a positive impact on dynamic balance in the elderly; however, further high-quality and appropriately powered studies are needed to confirm this conclusion.
Improvement of Predisposing Risk Factors to Falls in the Elderly
Martínez-Carbonell Guillamon and associates (2019) stated that, according to the World Health Organization (WHO), the elderly are at the highest risk of injury or death from falls. Age-related changes in strength, balance, and flexibility are degenerative factors that may increase this risk, and aquatic training may provide a favorable environment to improve these modifiable risk factors. The investigators conducted a systematic review to evaluate the potential preventative role of aquatic exercise in reducing the risk of falls among the elderly by improving predisposing risk factors. They searched electronic databases and reference lists of relevant articles published between 2005 and 2018, including randomized controlled trials (RCTs) that directly or indirectly examined the effect of aquatic exercise on fall prevention in healthy subjects aged 60 to 90 years without exercise-affecting comorbidities. Data related to subject demographics, study design, methodology, interventions, and outcomes were extracted by one reviewer, while methodological quality assessment was independently performed by two reviewers using the PEDro (Physiotherapy Evidence Database) scale. A total of 14 trials met the inclusion criteria, with exercise intervention durations and frequencies varying from 2 to 24 weeks, 2 to 3 times per week, and 40 to 90 minutes per session. Although the fall rate was not reported in any of the analyzed studies, aquatic exercise improved key modifiable physical fitness components that are internal risk factors for falling. The authors concluded that there is limited, low-quality evidence to support the use of aquatic exercise for improving physiological components that are risk factors for falls. They emphasized that, despite the limited evidence and poorly described interventions, these findings should be considered by health and exercise professionals when making evidence-based clinical decisions regarding training programs aimed at reducing fall risk. They also noted that further research is needed to develop an evidence-based, replicable protocol for aquatic training specifically designed to improve commonly reported predisposing risk factors for falls.
The authors acknowledged that there is some evidence supporting the use of aquatic exercise to improve predisposing, modifiable risk factors for falls; however, the quality of this evidence is low, and many interventions were poorly described. The lack of consistency in study methodologies made it difficult to compare interventions. Furthermore, the findings did not establish a statistically significant relationship between training variables and falls. Resistance equipment was not included to enhance exercise intensity, and few studies emphasized the importance of execution speed during aquatic exercises. Most exercises referred to general movements of the upper and lower limbs, but they should be described in detail to help professionals achieve the desired outcomes. Although flexibility was included in programs directed at older adults, it was not discussed as a significant variable. The importance of pelvic musculature in gait disturbances and fall risk was overlooked. Researchers should avoid superficial and uncritical methodologies to design specific and valid aquatic programs aimed at reducing the most modifiable predisposing risk factors for falls in the elderly.
Lymphedema
Yeung and colleagues (2018) stated that aquatic therapy has several proposed benefits for people with lymphedema. These researchers performed a systematic review of the evidence for aquatic therapy in lymphedema management. Five electronic databases were searched to identify RCTs of people with lymphedema, which compared aquatic therapy with other lymphedema interventions. Qualitative analysis was undertaken where quantitative analysis was not possible. Study quality was assessed using physiotherapy evidence database (PEDro) scores. The strength of evidence was evaluated using the Grades of Recommendations Assessment, Development and Evaluation (GRADE) approach; 4 RCTs of moderate quality (average PEDro score of 6.5/10) were included in the review; 2 studies provided results for inclusion in meta-analysis. There was moderate-level evidence of no significant short-term differences in lymphedema status (as measured by lymphedema relative volume) between patients who completed aqua lymphatic therapy (ALT) compared to land-based standard care (standardized mean difference [SMD]: 0.14; 95% CI: -0.37 to 0.64, I2 = 0%, p = 0.59); and low-quality evidence of no significant difference between ALT and standard care for improving upper limb (UL) physical function (SMD -0.27, 95% CI: -0.78 to 0.23, I2 = 0%, p = 0.29). No adverse events (AEs) were reported. The authors concluded that current evidence indicated no significant benefit of ALT over standard land-based care for improving lymphedema status or physical function in people with UL lymphedema. Moreover, they stated that further research is needed to strengthen the evidence from 4 studies in people with UL lymphedema, and to establish the effectiveness of this intervention in people with lower limb lymphedema.
Marine Therapy / Ocean Therapy
In a systematic review with meta-analysis, Shim et al. (2023) examined the effectiveness of marine-derived resources for treating specific diseases and identified the most effective methods for applying such resources in therapeutic applications. These investigators searched bibliographic databases (PubMed, Embase, and Cochrane) from their inception until May 2023 using Medical Subject Headings terms and text keywords related to seawater, mineral water, or ocean therapy. A total of 15 eligible studies were included, entailing 1,325 subjects aged 42.7 to 63.0 years. In the subgroup analysis based on treatment type, the mean difference (MD) was -1.581 (95% CI: -1.889 to -1.274) for seawater with sun exposure, and -1.210 (95% CI: -1.417 to -1.002) for seawater with sun exposure, mud pack application, and sulfur pool therapy. The pooled standardized mean difference (SMD) was calculated for different outcomes; the results were -1.110 (95% CI: -3.028 to 0.806) for osteoarthritis (OA) severity, -0.795 (95% CI: -0.982 to -0.607) for arthritis pain, -1.623 (95% CI: -2.036 to -1.209) for fibromyalgia pain, and -1.498 (95% CI: -1.888 to -1.108) for quality of life (QOL). The authors concluded that marine therapy is a promising approach for treating chronic skin issues, easing musculoskeletal discomfort, and enhancing the QOL among patients with musculoskeletal pain.
The authors noted that this study had two main drawbacks. First, most of the research was carried out in the Dead Sea, which may introduce regional bias and restrict the scope to chronic skin diseases and musculoskeletal pain. Second, although the study was prospective, it only compared marine therapy using seawater with basic marine-derived resources. These researchers stated that in the future, it is important to expand research efforts beyond the scope of the Dead Sea environment; this includes performing randomized controlled trials (RCTs) in different settings to broaden the understanding of this approach. There is a significant need for research that delves into various health conditions and symptoms, especially in the context of public healthcare. Being primarily supplementary, marine therapy often demands prolonged application and the development of more effective approaches tailored to specific health needs, including appropriate therapy duration. The key lies in carrying out well-designed systematic studies that carefully consider these factors to ensure the best outcomes for individuals seeking such therapies.
Nano-Bubble Hydrotherapy
Nanobubble hydrotherapy entails the infusion of compressed air into water to form a cloud of tiny bubbles, allowing for a form of hydrotherapy. Some manufacturers purport that nanobubble hydrotherapy enhances the growth of skin cells, improves the functioning of blood vessels, and stimulates the body's immune system.
Paknahad et al. (2021) stated that the use of bulk nanobubbles in biomedicine has been increasing in recent years, which is attributable to the array of therapeutic and diagnostic tools promised by developing bulk nanobubble technologies. From cancer drug delivery and ultrasound (US) contrast enhancement to malaria detection and the diagnosis of acute donor tissue rejection, the potential applications of bulk nanobubbles are broad and diverse. Developing these technologies to the point of clinical use may significantly impact the quality of patient care. These researchers summarized a representative collection of the current applications, fabrication techniques, and characterization methods of bulk nanobubbles in biomedicine. Current state-of-the-art generation methods are not designed to create nanobubbles of high concentration and low polydispersity, both of which are important characteristics for several bulk nanobubble applications. Currently, microfluidics has not been widely considered as a tool for generating nanobubbles, although the small-scale precision and real-time control offered by microfluidics may overcome the aforementioned challenges. The authors suggested possible uses of microfluidics for improving the quality of bulk nanobubble populations and proposed ways of leveraging existing microfluidic technologies, such as organ-on-a-chip platforms, to expand the experimental toolbox of researchers working to develop biomedical nanobubbles.
Lu et al. (2022) noted that low-frequency (20 to 100 kHz) US-assisted drug delivery has been widely examined as a non-invasive method to enhance the permeability and retention effect of drugs. The functional micro-/nanobubble loaded with drugs could provide an unprecedented opportunity for targeted delivery. Then, US with higher intensity would locally burst bubbles and release agents, thus avoiding side effects associated with systemic administration. In addition, US-mediated destruction of micro/nanobubbles could effectively increase the permeability of vascular membranes and cell membranes, thereby not only increasing the distribution concentration of drugs in the interstitial space of target tissues but also promoting the penetration of drugs through cell membranes into the cytoplasm. These advancements have transformed US from a purely diagnostic utility into a promising theragnostic tool. The authors discussed the structure and generation of micro-/nanobubbles, US parameters and mechanisms of therapeutic delivery, and potential biomedical applications of micro-/nanobubble-assisted US. Finally, these investigators discussed the challenges and future directions of US combined with micro-/nanobubbles.
Furthermore, an UpToDate article on “Palmoplantar keratoderma” (Kubo, 2022) does not mention nanobubble hydrotherapy management. The authors state that palmoplantar keratoderma (PPK) is a heterogeneous group of inherited or acquired disorders characterized by excessive epidermal thickening of the palms and soles. Patients with certain types of PPK will benefit from daily to weekly bath soaks followed by gentle mechanical scale removal with tools that are chosen according to patient preference. Examples of useful tools include a pumice stone, a synthetic polyurethane pumice bar (which is softer), or a callus file. Professional foot and hand care may be appropriate for some patients, and frequent and liberal use of emollients is advisable.
Neonatal Brachial Plexus Palsy
In an integrative literature review, Frade and colleagues (2019) analyzed the scientific literature aimed at identifying and describing existing rehabilitation treatments/therapies for neonatal brachial plexus palsy (NBPP). The data collection was carried out in January 2019, in the EBSCOhost and BVS (Biblioteca Virtual em Saúde) platforms, in the CINAHL Complete, Medline Complete, LILACS and PubMed databases. A total of 13 articles were included in this integrative literature review, based on a literature search spanning title, abstract and full text, and considering the inclusion criteria. Two main treatments/therapies for NBPP rehabilitation were identified: conservative treatment and surgical treatment. Conservative treatment includes teamwork done by physiatrists, physiotherapists and occupational therapists. These professionals use rehabilitation techniques and resources in a complementary way, such as electro-stimulation, botulinum toxin (BTX) injection, immobilizing splints, and constraint induced movement therapy (CIMT) of the non-injured limb. Professionals and family members work jointly. Surgical treatment includes primary surgeries, indicated for children who do not present any type of spontaneous rehabilitation in the first 3 months of life; and secondary surgeries, recommended in children who after primary surgery have some limitation of injured limb function, or in children who have had some spontaneous recovery, yet still have significant functional deficits. Treatment options for NBPP are defined by clinical evaluation/type of injury, but regardless of the type of injury, it is unanimous that conservative treatment is always started as early as possible. The authors stated that it should be noted that there was no evidence in the literature of other types of rehabilitation and techniques used in clinical practice, such as preventive positioning of contractures and deformities, hydrotherapy/aquatic therapy (from the age of 6 months), among others, thus, these researchers considered there is a need for further studies at this level in this area.
Passive Hydrotherapy WATSU (WaterShiatsu)
Ramirez and associates (2019) stated that juvenile idiopathic arthritis (JIA) is a rheumatologic disease in children under 16 years of age, which causes early physical disability. The use of a form of passive hydrotherapy in chest-deep thermo-neutral water (WATSU [WaterShiatsu]; 35° C = 95° F = 308.15 K) in these patients was proposed. WATSU combines elements of myofascial stretching, joint mobilization, massage, and shiatsu. These researchers examined the effectiveness of WATSU compared with conventional hydrotherapy on health-related quality of life (HR-QOL), functional health status, pain, and ranges of joint motion in patients with acute or subacute JIA. In a single-blind, parallel controlled clinical trial, 46 patients with acute and subacute JIA between 8 to 18 years of age were randomized in a 1:1 manner to the WATSU group (n = 24) and to the conventional hydrotherapy group (n = 22). Subjects participated in 10 sessions of 45 minutes once weekly. Pediatric Quality of Life Inventory 4.0 (PedsQL4.0), Childhood Health Assessment Questionnaire (CHAQ), and 10-joint Global Range of Motion Score (GROMS) assessments were measured at the beginning, post-treatment, and at 3-month follow-up. WATSU therapy showed statistically significant improvements in physical functioning – HR-QOL (p = 0.041), disability index (p = 0.015), distress index (p = 0.015), and functional health status – CHAQ (p = 0.013) after treatment compared to conventional hydrotherapy. The authors concluded that WATSU therapy improved HR-QOL, pain sensation, and functional health status compared to conventional hydrotherapy. Moreover, these researchers stated that methodological adaptations are needed in future studies to improve the external validity of these findings.
The authors noted that the limited number of subjects (n = 24 in the WATSU group) and the heterogeneity of their baseline clinical condition hindered the external validity of these findings. For future studies, it is proposed to increase the intervention period with WATSU therapy, to perform randomized sampling stratified by type of JIA and sex, and to add instruments that measure the barriers to adherence to treatment perceived by children and their families, in order to improve the methodological level of the studies, promote adherence to treatment, and favor long-term remission status.
In a systematic review and meta-analysis, Schitter and colleagues (2020) examined the applications, indications, and effects of WATSU to form a basis for future studies. They conducted a search for "WATSU OR watershiatsu OR (water AND shiatsu)" without any restrictions in 32 databases. Peer-reviewed original studies addressing WATSU as a stand-alone hydrotherapy were examined for risk of bias. Quantitative data on effects related to pain, physical function, and mental issues were processed in random model meta-analyses with subgroup analyses by study design. Effect sizes were expressed as Hedges's g (± 95% CIs). Of 1,906 unique citations, 27 articles, regardless of study design, were evaluated for risk of bias. WATSU has been applied to individuals of all ages. Indications covered acute (e.g., pregnancy-related low back pain [LBP]) and chronic conditions (e.g., chronic pain) with beneficial effects of WATSU regarding relaxation or sleep quality. Meta-analyses suggested beneficial effect sizes of WATSU on pain (overall Hedges's g = -0.71, 95% CI: -0.91 to -0.51), physical function (overall Hedges's g = -0.76, 95% CI: -1.08 to -0.44), and mental issues (overall Hedges's g = -0.68, 95% CI: -1.02 to -0.35). The authors concluded that various applications, indications, and beneficial effects of WATSU were identified. The grade of this evidence is estimated to be low to moderate at best. These researchers stated that high-quality RCTs are needed to strengthen the findings of this study. They noted that the presented meta-analyses are suited to assist future researchers in designing trials and sample size calculations to further examine the effect of WATSU on pain, physical function, and mental issues.
The authors stated that this systematic review was limited by the quality of findings, as only 7 of the studies evaluated for risk of bias had control groups. The assessment revealed that not only the studies’ designs but also poor reporting hampered accurate judgment in several studies. In subgroup analyses, however, the effect sizes of the meta-analyses were consistently confirmed with minimal heterogeneity, indicating that the inclusion of trials with lower methodological rigor led to an increase in noise without major over- or under-estimation of the effect size as observed in RCTs. The weighted effect sizes provided in the current article warrant attempts to reproduce the reported results and may support future researchers in designing adequately powered RCTs regarding the effectiveness of WATSU.
Loureiro and colleagues (2022) noted that sleep disorders are one of the most frequent non-motor symptoms of Parkinson's disease (PD). In a randomized controlled trial (RCT), these researchers examined whether adding WATSU to land-based therapy would result in additional beneficial therapeutic effects regarding quality of sleep and quality of life (QOL) in individuals with PD. Participants completed 9-week interventions. The control group (CG) received land-based therapy, while the intervention group (IG) received the same land-based therapy along with WATSU. Sleep quality and QOL were measured at baseline and post-interventions using the Pittsburgh Sleep Quality Index and Nottingham Health Profile, respectively. A total of 28 subjects completed the study. In contrast to the CG, the IG showed significant improvements in both quality of sleep and QOL (p < 0.001). The authors concluded that WATSU has the potential to be an attractive adjunctive therapy for producing positive health impacts regarding sleep quality, which may translate to an overall improvement in QOL for individuals with PD. These preliminary findings need to be validated by well-designed studies.
Schitter and associates (2022) examined if and how frequently scientifically studied application areas and effects of WATSU occur in practice, whether similar effectiveness of WATSU is observed in trials and practice, and whether practitioners could contribute additional application areas and effects of WATSU. Application areas and effects of WATSU reported in a recent systematic review were extracted verbatim to be evaluated in a worldwide multilingual cross-sectional online survey, generating quantitative and qualitative data. A pre-test and re-test were carried out to ensure quality and evaluate the questionnaire's psychometric properties; answers from 191 respondents were processed. All proposed 26 application areas and 20 effects were confirmed, each with relatively high ratings of observed effectiveness of WATSU. WATSU was frequently used in healthy individuals (including during pregnancy) and individuals with various pain-related (e.g., LBP, neck pain, myofascial pain, fibromyalgia) and stress-related (e.g., stress, depression, sleep disorders, fatigue, anxiety disorders) conditions. Frequently confirmed effects included physical relaxation, relief of physical tension, pain relief, increased mobility and flexibility, improved QOL, spiritual experiences, and increased psychological health. Respondents contributed 73 additional application areas and effects (both mental and physical) of WATSU. The authors concluded that application areas and effects of WATSU are consistently employed both practically and scientifically. Respondents' ratings of the effectiveness of WATSU matched tentative research efforts. These researchers stated that WATSU is cautiously recommended for use in pain-related as well as stress-related conditions; moreover, the short-term and long-term effectiveness of WATSU needs to be examined in high-level intervention studies.
Peripheral Artery Disease
Park and colleagues (2019) noted that peripheral artery disease (PAD) is an atherosclerotic disease that is associated with attenuated vascular function, cardiorespiratory capacity, physical function, and muscular strength. It is essential to combat these negative effects on health by incorporating lifestyle interventions to slow disease progression, such as exercise. In a randomized clinical trial, these researchers examined the effects of aquatic walking exercise on cardiovascular function, cardiorespiratory capacity [maximal volume of oxygen consumption (V̇o2max)], exercise tolerance [6-min walking distance (6MWD)], physical function, muscular strength, and body composition in patients with PAD. Patients with PAD (n = 72) were randomly assigned to a 12-week aquatic walking training group (AQ, n = 35) or a control group (CON, n = 37). The AQ group performed walking and leg exercises in waist-to-chest-deep water. Leg arterial stiffness [femoral-to-ankle pulse wave velocity (legPWV)], heart rate (HR), blood pressure (BP), ankle-to-brachial index (ABI), V̇o2max, 6MWD, physical function, muscular strength, body composition, resting metabolic rate (RMR), and flexibility were measured before and after 12 weeks. There were significant group × time interactions (p < 0.05) after 12 weeks for legPWV and HR, which significantly decreased (p < 0.05) in AQ, and V̇o2max, 6MWD, physical function, and muscular strength, which significantly increased (p < 0.05) in AQ, compared with no changes in CON. There were no significant differences (p > 0.05) for BP, ABI, RMR, or flexibility after 12 weeks. Interestingly, there was relatively high adherence (84%) to the aquatic walking exercise program in this population. These findings suggested that aquatic walking exercise was an effective therapy to reduce arterial stiffness and resting HR and improve cardiorespiratory capacity, exercise tolerance, physical function, and muscular strength in patients with PAD. The authors concluded that the findings of this study revealed for the first time that aquatic walking exercise could decrease arterial stiffness and improve exercise tolerance, cardiorespiratory capacity, and muscular strength in patients with PAD. These researchers stated that aquatic walking exercise training demonstrated relatively high exercise adherence in this population; it may be a useful therapeutic intervention for improving physical function in patients with PAD. These preliminary findings need to be validated by well-designed studies.
Pool Therapy for the Treatment of Post-Stroke Pain
Saragih et al. (2025) stated that pain is a frequent post-stroke health concern, and several non-pharmacological interventions are commonly used to manage it. However, few reviews have examined the effectiveness of such interventions, making it difficult to draw conclusions regarding their usefulness. In addition, subgroup analysis based on post-stroke pain level or intervention characteristics is rarely carried out. In a systematic review and meta-analysis, these investigators examined the effectiveness of non-pharmacological interventions and assessed the significant factors associated with post-stroke pain through subgroup analysis. Relevant studies were obtained from seven databases, from their commencement up to March 2024, as well as from the gray literature. The PICOS (patient/population, intervention, comparison, and outcomes) approach was used to examine the eligibility criteria of the studies. The RoB-2 tool was employed to determine the risk of bias in each randomized trial. Pooled estimations of SMD and heterogeneity (quantified with I²) were obtained using a random-effects model. The stability of the pooled result was then assessed using the leave-one-out approach. STATA 17.0 was used to run the meta-analysis. Non-pharmacological interventions were effective in reducing pain immediately after intervention (pooled SMD: -0.79; 95% CI: -1.06 to -0.53; p < 0.001). The approach involving acupuncture, aquatic therapy, or laser therapy combined with rehabilitation training was effective for post-stroke hemiplegic shoulder pain. A pooled analysis of non-pharmacological interventions showed that both interventions lasting less than 4 weeks and those lasting more than 4 weeks were effective in alleviating pain in stroke patients. The authors concluded that non-pharmacological approaches appeared to be beneficial for reducing post-stroke pain. Moreover, these researchers stated that these findings merit further investigations. In addition, to avoid overestimation of intervention effectiveness, future randomized trials should consider blinding approaches to the interventions delivered.
Stroke Rehabilitation
In a pilot study, Morer and colleagues (2017) examined the effect of an intensive program of thalassotherapy and aquatic therapy in stroke patients. This quasi-experimental prospective study involved a specific program assessed pre- and post-3 weeks of treatment for 26 stroke patients with mild to moderate disability. The outcomes measured included the Berg Balance Scale (BBS), Timed Up and Go test, Comfortable 10-meter Walking Test (CWT), 6-minute walking test, and pain visual analog scale (VAS). After the intervention, participants showed significant improvements in all measured outcomes. The authors concluded that these findings suggest that an intensive program of thalassotherapy and aquatic therapy could be beneficial during stroke rehabilitation to improve balance, gait, and pain. However, these preliminary findings need to be validated by well-designed studies.
Lee and associates (2017) determined the efficacy of aquatic treadmill training (ATT) as a new modality for stroke rehabilitation by assessing changes in gait symmetry, balance function, and subjective balance confidence for both the paretic and non-paretic leg in stroke patients. A total of 21 subacute stroke patients participated in 15 intervention sessions of ATT. Spatiotemporal gait parameters, BBS, CWT, and Activities-specific Balance Confidence scale (ABC) were assessed pre- and post-intervention. Statistically significant improvements were observed from pre- to post-intervention in the CWT (0.471 ± 0.21 to 0.558 ± 0.23, p < 0.001), BBS (39.66 ± 8.63 to 43.80 ± 5.21, p < 0.001), and ABC (38.39 ± 13.46 to 46.93 ± 12.32, p < 0.001). Step-length symmetry (1.017 ± 0.25 to 0.990 ± 0.19, p = 0.720) and overall temporal symmetry (1.404 ± 0.36 to 1.314 ± 0.34, p = 0.218) showed improvement without statistical significance. The authors concluded that ATT improved the functional aspects of gait, including CWT, BBS, and ABC, as well as spatiotemporal gait symmetry, though without statistical significance. They stated that further studies are needed to examine and compare the potential benefits of ATT as a new modality for stroke therapy with other modalities.
In a systematic review and meta-analysis, Iliescu and colleagues (2020) examined the effectiveness of aquatic therapy in improving mobility, balance, and functional independence following stroke. Data sources included articles published in Medline, Embase, CINAHL, PsycINFO, and Scopus up to August 20, 2019. Studies met the following inclusion criteria: English language, adult stroke population, randomized controlled trial (RCT) or non-randomized prospectively controlled trial (PCT) study design, the experimental group received more than one session of aquatic therapy, and included a clinical outcome measure of mobility, balance, or functional independence. Subject characteristics, treatment protocols, between-group outcomes, point measures, and measures of variability were extracted. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) tool, and pooled mean differences (MD) ± standard error (SE) and 95% confidence intervals (CI) were calculated for the Functional Reach Test (FRT), Timed Up and Go Test (TUG), gait speed, and Berg Balance Scale (BBS). A total of 19 studies (17 RCTs and 2 PCTs) with a mean sample size of 36 subjects and a mean PEDro score of 5.6 (range of 4 to 8) were included. Aquatic therapy demonstrated statistically significant improvements over land therapy on FRT (MD = 3.511 ± 1.597; 95% CI: 0.381 to 6.642; p = 0.028), TUG (MD = 2.229 ± 0.513; 95% CI: 1.224 to 3.234; p < 0.001), gait speed (MD = 0.049 ± 0.023; 95% CI: 0.005 to 0.094; p = 0.030), and BBS (MD = 2.252 ± 0.552; 95% CI: 1.171 to 3.334; p < 0.001). The authors concluded that while the effect of aquatic therapy on mobility and balance was statistically significant compared to land-based therapy, the clinical significance was less clear, highly variable, and dependent on the outcome measure.
In a systematic review, Moritz and co-workers (2020) examined whether the combination of aquatic therapy (AT) with usual care would result in greater improvements in activity limitations and neurological-related impairments in individuals with neurological conditions than usual care physiotherapy alone. These researchers conducted a systematic review of controlled trials to compare usual care physiotherapy with usual care physiotherapy combined with AT for adults with any neurological condition; standardized mean differences (SMDs) and 95% CIs were calculated from post-intervention means and standard deviations (SDs). A total of 10 studies with 490 subjects met the inclusion criteria. Of the included trials, combined aquatic and usual care physiotherapy was evaluated in individuals with stroke in 8 trials and in patients with Parkinson's disease (PD) in 2 trials. Trial and outcome heterogeneity prevented the completion of meta-analyses. Data from 5 trials (n = 259) in individuals with stroke suggested that AT improved measures of balance, walking, mobility, and activities of daily living (ADL). No significant differences were detected in measures of activity limitation for patients with PD or measures of impairment for patients with stroke or PD. The authors concluded that this review provided preliminary evidence that the combination of AT with usual care physiotherapy may improve activity limitations in individuals with stroke. However, this review found no evidence to support the combination of AT with usual care physiotherapy to improve activity limitations in PD or other neurological populations. These investigators stated that these findings should be interpreted with caution due to the mixed quality of the included trials.
Nayak and associates (2020) stated that the evidence on aquatic therapy (AT) for improving balance and gait deficits post-stroke is unclear. These researchers examined the effect of AT on balance and gait in stroke survivors. They searched CINAHL, PubMed, Web of Science, Aqua4balance, Ewac, Cochrane, and Embase databases from inception to November 1, 2019. A total of 11 studies with 455 subjects were included in the review. Meta-analysis showed that AT was effective for improving balance (MD 3.23, 95% CI: 1.06 to 5.39; p = 0.004; I² = 61%) and gait speed (MD 0.77, 95% CI: 0.25 to 1.29; p = 0.004; I² = 0%) when delivered alone. AT was also effective in improving cadence (MD 4.41, 95% CI: 0.82 to 8.00; p = 0.02; I² = 68%) when delivered as an adjunct to land-based therapy. The authors concluded that AT may be used to improve balance and gait after stroke; however, the evidence to support its use is still low.
Perez-de la Cruz (2020) noted that stroke survivors face severe problems affecting their mobility, such as balance impairments and an increased risk of falls. In a pilot study, these researchers examined the effects of 12 sessions of Halliwick AT for the treatment of balance in patients with chronic stroke. A total of 29 individuals with stroke participated in this single-group, experimental trial. Sessions were conducted three times weekly for a total of 12 sessions. A stable-metric assessment was performed using a computerized platform. Evaluations were conducted at baseline, at 4 weeks, and 1 month after completing the aquatic program. The results revealed significant differences in postural stability values (p < 0.001) and single-leg stable-metric assessment. However, no significant differences were observed in values within the limits of stability, such as forward (F = 0.339, p = 0.676), backward (F = 0.449, p = 0.644), forward right oscillations (F = 1.637, p = 0.21), and the anterior/posterior instability index (F = 0.614, p = 0.55). The author concluded that these findings suggest that Halliwick AT may potentially improve balance impairments in stroke patients.
The author stated that one of the limitations of this study was the relatively small sample size (n = 29). This was a non-randomized, single-group trial; thus, no conclusions could be drawn regarding the effectiveness of the intervention. The intervention (Halliwick method) is difficult to standardize between subjects. Future studies should increase the number of subjects to more safely extrapolate the results obtained in this pilot study. Furthermore, this study also lacked a control group for comparison and examination of possible differences between treatments. It would also have been interesting to re-evaluate the subjects over a longer period after completing therapy to verify the duration of the changes that occurred. Additionally, this study was not blinded.
In a systematic review and meta-analysis, Veldema and Jansen (2020) evaluated the available evidence of AT in stroke rehabilitation and examined the effect of this intervention in supporting stroke recovery. The PubMed, Cochrane Central Register of Controlled Trials, and PEDro databases were searched from their inception through May 31, 2020, for RCTs examining the effect of AT on stroke recovery. Subject characteristics, methodological aspects, intervention descriptions, and outcomes were extracted. Effect sizes were calculated for each study and outcome. Overall, a total of 28 appropriate studies (n = 961) were identified. A comparison with no intervention indicated that AT was effective in supporting walking, balance, emotional status, health-related quality of life (HR-QOL), spasticity, and physiological indicators. In comparison with land-based interventions, AT showed superior effectiveness on balance, walking, muscular strength, proprioception, HR-QOL, physiological indicators, and cardiorespiratory fitness. Only for independence in activities of daily living (ADL) did land-based and water-based exercise induce similar effects. Established concepts of water-based therapy (such as the Halliwick, Ai Chi, Watsu, or Bad Ragaz Ring methods) were the most effective, while aquatic treadmill walking was the least effective. The current evidence on balance and walking ability is good. In contrast, the evidence on emotional status and spasticity is very limited. No evidence exists on cognitive abilities; future studies should fill this gap. These investigators stated that these findings suggest that the effectiveness of AT depends on the technique used. Standardized concepts were more effective than both aquatic treadmill walking and water-based walking, balance training, strengthening, and stretching. Future research should further examine these technique-induced differences. The authors concluded that the available evidence is insufficient to support AT within evidence-based rehabilitation; however, the available data indicate that AT can significantly improve a wide range of stroke-induced disabilities. These researchers stated that future research should devote more attention to this highly potent intervention.
The authors noted that this was the first meta-analysis to examine the potential of water-based therapy on reducing cognitive and emotional decline as well as spasticity following a stroke. This was also the first meta-analysis to compare the effectiveness of different water-based therapy methods. A limitation of this meta-analysis was the inconsistency of studies regarding their methodological design (parallel, crossover), interventions (different AT methods, different control interventions, and different intervention durations), and outcomes (more than 50 outcomes were pooled in 8 areas). This may explain the high inconsistency of effect sizes detected. Another limitation of this study was the high inconsistency of the methodological quality of the studies analyzed. The three most frequent methodological deficiencies were: first, the absence of blinding for subjects, therapists, and/or assessors; second, the absence of a statement regarding the number of subjects from whom key outcomes were obtained; and third, the absence of intention-to-treat (ITT) analysis. These issues may impede the interpretation of the data. Furthermore, no data exist regarding the long-term effects of AT in this cohort; therefore, these investigators could not render any explicit statements on the persistence of the positive effects of this form of therapy.
In a systematic review with meta-analysis, Najafabadi and colleagues (2022) examined the evidence of the effects of aquatic therapy on lower limb disability compared to land-based exercises in post-stroke patients. Medline, PsycInfo, CENTRAL, SPORTDiscus, PEDro, PsycBITE, and OT Seeker were searched from inception to January 2019. The search included only randomized clinical trials. Two reviewers independently examined the full text and conducted study selection, data extraction, and quality assessment. Data synthesis was applied to summarize information from the included studies. The quantitative analysis incorporated fixed-effect models. Of the 150 studies identified in the initial search, 17 trials (629 subjects) satisfied the eligibility criteria. Aquatic therapy improved balance based on the Berg Balance Scale (BBS) (SMD, 0.72; 95% CI: 0.50 to 0.94; I² = 67%) compared with land-based exercises (control). Furthermore, aquatic therapy had a small positive effect on walking speed (SMD, -0.45; 95% CI: -0.71 to -0.19; I² = 57%), based on the results of the 10-meter walking test, compared to controls. Aquatic therapy also had a small positive effect on mobility (based on the Timed Up and Go test) (SMD, -0.43; 95% CI: -0.7 to -0.17; I² = 71%) compared to land-based exercise (control). The authors concluded that aquatic therapy had a more positive effect on walking speed, balance, and mobility than land-based exercises. Moreover, these researchers stated that further research is needed to confirm the clinical utility of aquatic therapy for patients following stroke in the long term.
Traumatic Brain Injury
In a 2-arm RCT, Curcio and colleagues (2020) examined the effectiveness of an AT in patients with severe traumatic brain injury (sTBI) on balance. The secondary objectives were to examine the effects on gait, ADL, and QOL, comparing to a land-based conventional protocol. A total of 20 inpatients with sTBI, Glasgow Coma Scale score of less than or equal to 8, and Level of Cognitive Functioning of greater than or equal to 7 were recruited and randomly assigned to the AT group (ATG) or to the conventional training group (CTG). Patients underwent 12 individual rehabilitation sessions (3 days/week, 4 weeks), in a rehabilitation pool during the post-acute intensive neuro-rehabilitation. The primary outcome measure was the Berg Balance Scale (BBS); secondary outcome measures were the Modified Barthel Index (MBI), Disability Rating Scale (DRS), Tinetti Gait Balance Scale (TBG) and QOL After Brain Injury (QOLIBRI). All the evaluations were carried out at baseline and after 4 weeks of training. The within-subjects analysis showed a significant improvement both in ATG and CTG in MBI, BBS, TBG, and QOLIBRI. The authors concluded that these findings may support the use of AT during post-acute phase to improve motor functions and QOL in patients with sTBI. These preliminary findings need to be validated by well-designed studies.
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