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Aquatic-Based Therapy in Spinal Cord Injury Rehabilitation: Effective Yet

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Curr Phys Med Rehabil Rep
DOI 10.1007/s40141-017-0158-5
SPINAL CORD INJURY REHABILITATION (CL SADOWSKY, SECTION EDITOR)
Aquatic-Based Therapy in Spinal Cord Injury
Rehabilitation: Effective Yet Underutilized
Albert C. Recio 1 & Steven A. Stiens 2,3 & Eva Kubrova 4
# Springer Science+Business Media, LLC 2017
Abstract
Purpose of review The objective of this article is to review
aquatic therapy, a historically effective yet highly
underutilized therapeutic modality, in order to demonstrate
that it is a valuable therapeutic tool in patients with spinal cord
injuries (SCIs) and that it is an intervention that provides an
environment of support and resistance which elicits motor
performance improvements for patients with SCI.
Recent findings Aquatic therapy has been shown to improve
mobility and quality of life and lessen spasticity and pain. It is
highly effective in promoting overall recovery from SCI.
Recent research shows that more people with SCI, particularly
those who were perhaps previously excluded (colostomy
bags, incontinence, mechanical ventilators), can participate
in aquatic therapy interventions.
This article is part of the Topical Collection on Spinal Cord Injury
Rehabilitation
* Albert C. Recio
recio@kennedykrieger.org
Steven A. Stiens
steven.stiens@uw.edu
Eva Kubrova
kubrovaeva@gmail.com
1
The International Center for Spinal Cord Injury, Kennedy Krieger
Institute, 801 N. Broadway, Room 560, Baltimore, MD 21205, USA
2
Department of Rehabilitation Medicine, University of Washington
School of Medicine, Seattle, WA, USA
3
Spinal Cord Injury Unit, VA Puget Sound Health Care System,
Seattle, WA, USA
4
2nd Faculty of Medicine, Charles University,
Prague, Czech Republic
Summary Although the use of aquatic therapy has been
shown to improve function, more research is required to thor-
oughly investigate it and to develop protocols and safety mea-
sures that increase the variety of patients with access to this
therapy. Patients with spinal cord dysfunction should be given
access to aquatic therapy in their local communities and reha-
bilitation centers so that the benefits of skilled aquatic-based
therapies can be more widely achieved and integrated.
Accessible community pools provide a setting for recreation
and exercise with family and attendants, thus promoting im-
provement and maintenance of skills.
Keywords Aquatic therapy . Hydrotherapy . Spinal cord
injury . Rehabilitation . Spasticity . Rehabilitative
intervention . Environment . Disablement . Disability .
Community . Reintegration
Introduction: A Historically Effective
and Underutilized Therapeutic Modality
Water is the main ingredient for life and the essential medium
for growth, development, recovery, and reproduction of all
organisms on Earth. Medical hydrotherapy has been described
and prescribed since the fourth century BC when Hippocrates
wrote about water’s medicinal properties in his work On Airs,
Waters, and Places [1]. Later, during the Roman Empire,
Andrea Bacci wrote of water’s thermal therapeutic properties
in his treatise De Thermis [2]. In the late 1800s, Sebastian
Kneipp, the ‘father of hydrotherapy’, wrote extensively on
the healing, therapeutic effects of water in My Water Cure,
the effects of which were immediately recognized by patients
and clinicians [3]. Water has been studied as an environment
that not only promotes health but enhances quality of life.
Rehabilitation clinicians have utilized environmental

interventions for centuries with good success, and healers
have demonstrated the physical properties of water and their
potency for medical intervention. The buoyant environment is
so effective that simple independent activity in water produces
multisystem exercise, massage, hydration, and health benefits
and, as a result, the field of aquatic therapy has developed.
Spinal cord injury (SCI) in particular brings together a variety
of impairments and potential complications that can benefit
from hydrotherapy, but it is underutilized. Pools have been
installed widely in homes, rehabilitation facilities, churches,
schools, and communities, yet the pool is seldom recognized
as an ideal environment for recovery and rehabilitation. We
hope to unleash this great potential for patients with SCI while
enhancing the work of therapists.
There is a diverse collection of evidence indicating the
efficacy of aquatic therapy as a medical and rehabilitative
intervention for patients with SCI. The physical properties of
water, including buoyancy, resistance, turbulence and hydro-
static pressure, make it an ideal medium for increasing pa-
tients’ functional gains within a therapy program as it facili-
tates a variety of therapeutic techniques, including passive
range of motion (ROM), active range of motion (AROM),
progressive resistive exercises (PRE’s), and goal-based activ-
ity. All improve extremity strength, balance, walking perfor-
mance, and cardiovascular fitness in adults with incomplete
SCI, combating reduced levels of physical activity [4, 5, 6••,
7••]. The multiple therapeutic benefits of exercise facilitate
recovery and prevent complications. Although aquatic therapy
has been demonstrated to be an effective therapy in patients
with SCI, it remains an underused modality. This brief synop-
sis highlights the benefits of aquatic-based therapies for pa-
tients with SCI and aims to develop understanding and pro-
vide options for its greater utilization [8].
Benefits of Aquatic Therapy: Multisystem
Synergistic Effects
Approximately 300,000 people live with SCI in the USA
alone and there are 17,000 new injuries each year [9].
Typical impairments associated with SCI include spasticity,
contractures, weakness, and pain resulting in loss of functional
abilities. Skilled aquatic-based therapy is a known interven-
tion for patients with SCI that has widespread positive effects.
The physical properties of water act as a medium to improve
the effectiveness of skilled therapies and increase patients’
functional gains. Pediatric and adult patients with neurological
impairments have demonstrated improvements in strength,
ROM, balance, and coordination with aquatic therapy
[10–12]. One of the most famous people to utilize hydrother-
apy was none other than President Franklin Delano Roosevelt
who was paralyzed from the waist down from polio in 1921.
When visiting the therapeutic waters of Warm Springs,
Curr Phys Med Rehabil Rep
Georgia in 1924, he found immediate improvement.
Eventually he purchased a property and created the Warm
Springs Foundation in 1927 [13].
The wide variety and physical properties of water,
buoyancy, hydrostatic pressure, and temperature make
aquatic therapy a particularly suitable intervention for
people with SCIs as water facilitates a variety of thera-
peutic techniques. Buoyancy provides gravity-eliminated
support, hydrostatic pressure compresses tissues and
promotes lymphatic and venous return, the warm tem-
perature reduces muscle spasm, and viscosity/turbulence
provides velocity-dependent resistance-building strength.
In addition, stance and gait improve in water. People
with incomplete SCIs have reduced balance ability, are
prone to falling, and have difficulty advancing and bear-
ing weight on their paraplegic limbs. The aquatic envi-
ronment provides a less restrictive buoyant lift, viscous
resistance to movement (spasm and swing), and cutane-
ous dampening of sensations that may trigger spasms.
Stevens et al. showed that underwater treadmill training in
patients with incomplete SCIs was an effective therapy for
producing significant improvements in a variety of endpoints,
including lower-extremity strength, walking speed, 6-min
walking distance, and daily step activity [5, 6••]. These gains
translate into functional improvements in activities of daily
living, including transfers, toileting, feeding, dressing, and
bathing.
Gait training in water for paralysis has also been very ef-
fective. Other investigators have also examined the effect of
aquatic interventions in patients with chronic conditions such
as multiple sclerosis, chronic post-stroke paralysis,
Parkinson’s disease, osteoarthritis, and chronic pain in elderly
patients or cerebral palsy in pediatric patients. Evidence with-
in these populations demonstrates widespread benefits in
strength, flexibility, function, self-efficacy, affect, and balance
and a decrease in pain [11, 12, 14••, 15–17].
Spasticity is one of the most disabling conditions in pa-
tients with SCIs and other central neurological lesions.
Spasticity can lead to significantly decreased levels of func-
tional independence by maintaining contractures, limiting
movement, interrupting transfers, and triggering pain. Some
patients with SCIs present with increased spasticity, which
causes a variety of further secondary consequences such as
contortions that prevent seating, chronic pain, and pressure
ulcers. Kesiktas et al. found improvements to spasticity and
functional activities in adult SCI patients receiving aquatic
interventions for 20-min sessions three times per week. They
found decreased Ashworth scale scores, improved functional
independence measures, and decreased spontaneous spasm
severity and baclofen intake [14••]. Maintenance of these
achievements could come from an aggressive program of
home care combined with community pool therapy with the
patient’s family. When persons with SCI are floated in a pool,
Curr Phys Med Rehabil Rep
there are many advantages of the therapeutic environment.
The therapeutic pool is a rehabilitation intervention that spans
the patient’s immediate and intermediate environments and
complements other modalities within the same environmental
such as bracing and robotics (Fig. 1). Patients are able to float
on their backs, wearing flotation devices for safety, and im-
mediately propel themselves if they have any limb movement.
With a center of gravity just anterior to the sacral two verte-
brae, the pelvis sinks to leave the head and neck above the
surface, arms floating, and with gravity eliminated the patient
treads water against velocity-dependent turbulent resistance.
In addition to functional improvements, patients receiving
aquatic therapy demonstrate changes to ventilatory function.
Hydrostatic pressure covering the submerged patient provides
resistance for the chest to expand against with inspiration.
This leads to an increase in the strength of primary and acces-
sory muscles of inspiration. Ventilatory capacity has been
demonstrated by improvements in performance of vital capac-
ity, forced expiratory flow rate, forced expiratory volume at
1 s, and forced expiratory volume at 1 s/forced vital capacity
following 8 weeks of aquatic therapy [12, 17]. The pressure of
the water during buoyancy also surrounds the patient and
compresses like an abdominal binder, supporting the contents
of the abdominal organs as they are pushed up under the
relaxing dome of the diaphragm to complete exhalation [17].
Despite its documented benefits on ventilatory function,
very limited research exists to date to determine the safety
Fig. 1 Environmental adaptations: aquatic access for spinal cord
dysfunction. The person with spinal cord injury is at the center of the
sectors of the environment: the immediate environment, the water in the
therapeutic pool, is in contact with the person and moves with them. The
intermediate environment is the space in which they live and work and is
specifically adapted for them; a customized aquatic environment is made
and efficacy of aquatic therapy for persons with SCI requiring
mechanical ventilation. Felten-Barentsz et al. [18] and Taylor
[19] have successfully demonstrated aquatic therapy as a
proof of principle in mechanically ventilated patients. These
pioneering trials showed that critically ill patients in intensive
care units could tolerate hydrotherapy (60-min sessions) with
no adverse response or discomfort noted. Additional research
is warranted to establish the safety and efficacy of aquatic
therapy in patients requiring mechanical ventilation.
Unfortunately, aquatic therapy has not been consistently
available to all patients with SCI due to neurogenic bowel
dysfunction and co-morbidities that could potentially compli-
cate and produce barriers to their participation such as colos-
tomies with adherent collection bags. Commonly, patients
with SCIs are challenged with neurogenic bowel, a complica-
tion that often provokes functionally unpredictable involun-
tary incontinence [20]. In a 1996 study of outpatients with a
chronic SCI, Glickman and Kamm found that 95% of sur-
veyed patients required at least one therapeutic method to
initiate defecation, while half of the patients required attendant
assistance for toileting [21]. In the same survey, patients rated
their loss of mobility using the Hospital Anxiety and
Depression Scale (HADS) as a mean of 6.8 and their bowel
management as a mean of 5.1, where 0 is no perceived prob-
lem and a score of 10 is the maximum perceived problem.
Thus, neurogenic bowel is both a common and distressful
disorder in patients with SCIs. Placement of a colostomy has
possible by advances in technology and allows safe access. The
community environment includes communal spaces outside the home
that are adapted as societal laws specify for universal access. The
natural environment is unaltered by man and is as accessible as trails
and water access permit [26]

been demonstrated to be efficacious in both the treatment of
neurogenic bowel disease and recurrent pressure ulcers in pa-
tients with SCIs [21–24]. Recio and Cabahug recently dem-
onstrated the safety and efficacy of aquatic-based restorative
therapies in spinal cord patients with colostomy bags who had
their ostomy bag picture-frame taped to clean, dry skin with a
waterproof dressing before each pool session. A series of ses-
sions, over a period of years, were chart-reviewed, and only
one reported incident of stool leak occurred that required the
pool to be shock-treated with appropriate chemicals. No other
medical complications were noted with the patient [25].
Inclusion of patients with neurologic bowel in therapeutic
and community pools will come from the establishment of
evidence-based criteria, advances in containment technolo-
gies, and recovery protocols. [26]
In addition to neurogenic bowel, up to 85% of patients with
SCI develop pressure sores and a significant proportion re-
quire hospitalization for treatment. Recio and Cabahug also
reported on the safety and efficacy of aquatic-based restorative
therapy for spinal cord-injured patients who had pressure ul-
cers, tracheostomy tubes, and supra-pubic and Foley indwell-
ing urinary catheters [25]. Not only was the therapy effective
in producing significant improvements in a variety of end-
points including upper- and lower-extremity strength, the
Modified Ashworth Scale, 6-min walking distance, and func-
tional reach test, but no maceration or worsening of pressure
ulcers were noted. A requirement for patients with tracheos-
tomies was that they were able to tolerate capping for a min-
imum of 4 h and the water level needed to be maintained at the
nipple level. No desaturation or respiratory complications
were noted among the patients. Furthermore, no incidence of
a catheter being pulled was reported in patients with supra-
pubic and indwelling catheters [25–27].
Conclusion: Water Catalyzes Multiple Interventions
Aquatic therapy has been demonstrated to be a valuable ther-
apeutic tool in patients with SCIs. Aquatic therapy is an inter-
vention that provides an environment of support and resis-
tance that efficiently enables spontaneous movement with
gravity elimination and gentle velocity-dependent resistance
to movement to build strength and endurance. The physical
properties of water including buoyancy, resistance, turbu-
lence, and hydrostatic pressure all synergize to produce a com-
parable if not superior outcome over conventional land-based
therapies.
Continual Development
Hands-on integration of patients with families, friends, and
attendants is successful in achieving patient-centered goals
Curr Phys Med Rehabil Rep
in psychological adaptation, social role function, and commu-
nity reintegration. Further research is needed to encourage
aquatic-based therapies and to develop protocols and safety
measures that can be duplicated throughout the aquatic com-
munity to allow patients within this population to be given
access to aquatic therapy in their areas. The benefits of skilled
aquatic-based therapies in SCI rehabilitation must be further
studied.
Acknowledgments The authors thank Amy Kakitis-Fawley and
Gerald M. Koller for their invaluable input and support. The authors also
thank the Hugo W. Moser Research Institute at Kennedy Krieger,
Kennedy Krieger Institute Aquatics Program, the Virginia and Lee
Muhlhofer Fund, the VA Puget Sound Healthcare System Library,
the VA Puget Sound Healthcare System Medical Media Library, and
the SCI Therapy Department.
Compliance with Ethical Standards
Conflict of Interest Albert C. Recio, Steven A. Stiens, and Eva
Kubrova have no disclosures to declare.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
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