Aquatic Neurorehabilitation

Neurocognitive disorder is a disease of a mental health due to which nerve cells – neurons – are damaged; as a result they are not able to function normally and die. People with this disease have troubles in everyday activities, because of decline in memory, behavior, bodily functions and other basic skills. Dementia, as a category of the neurocognitive disorder, maybe caused by depression, side effects from medications, delirium, using of alcohol, etc. According to Gaugler, James, Johnson, Scholz, and Weuve (2014) there are different types of dementia, such as Alzheimer’s disease, Parkinson’s disease, vascular dementia, Creutzfeldt -Jakob disease, dementia with Lewy bodies, Frontotemporal lobar degeneration, mixed dementia, pressure hydrocephalus, and others (p. 6-7).

Alzheimer’s disease is the most common type of dementia. It was first identified more than 100 years ago. According to statistic, about 5.2 million Americans of different ages have this disease in 2014 (p.16). In addition, “almost two-thirds of Americans with Alzheimer’s are women”(p. 17).  Alzheimer’s symptoms are “difficulty remembering recent conversations, names or events […]; apathy and depression […] impaired communication, disorientation, confusion, poor judgment, behavior changes and, ultimately, difficulty speaking, swallowing and walking” (p.6). However, “the brain changes of Alzheimer’s may begin 20 or more years before symptoms appear”. There are some risk factors. The first factor is age. People of 65 or older are susceptible to this disease. The second factor is family history. Individuals, who have parents or siblings with that disease, are at risk (p.9). Cardiovascular disease can be the other risk factor. “A healthy heart helps ensure that enough blood is pumped through these blood vessels, and healthy blood vessels help ensure that the brain is supplied with the oxygen and nutrient-rich blood it needs to function normally” (p.10). Scientist also discovered the link between education and the disease. “People with fewer years of formal education are at higher risk for Alzheimer’s and other dementias than those with more years of formal education” (p.11).

Parkinson’s disease is another type of dementia. It’s “a chronic and progressive movement disorder meaning that symptoms continue and worsen over time” (“What is Parkinson’s Disease?”, n.d.). There are about one million people with Parkinson’s disease in the US.  Zotz, T. G. G., Souza, E. A., Israel, V. L., and Loureiro, A. P. C. (2013) reported that:

With the clinical diagnosis of Parkinson’s disease, the individual may show an alteration in postural reactions such as straightening, balance, protective extension, difficulty in corporal rotation and reduced muscular strength. Such symptoms are accentuated when the patient is subjected to situations of stress, fatigue or pressure, which can exacerbate the freezing phenomenon and postural compromise, leading to a sudden loss of balance (p. 102).

According to Gaugler, James, Johnson, Scholz, and Weuve scientists reported two kinds of treatment for neurocognitive diseases: pharmacologic and non-pharmacologic. Pharmacologic treatment is based on drugs, which effectiveness may vary from patient to patient.”Non-pharmacologic therapies are those that employ approaches other than medication, such as physical therapy and reminiscence therapy (therapy in which photos and other familiar items may be used to elicit recall)” (p.14).

Physical activity plays a huge role in neurorehabilitation process. According to Bowes, Dawson, Jepson, and McCabe (2013) it positively affects “the cognition, activities of daily life and independence, functional ability, and mental health” (p.2). If physical activity is undertaken in a group then patients increase their social network, as a result, they don’t feel loneliness. It is also very important to choose the right type of physical activity:

For example, walking outdoors may help re-establish a connection with nature and the local community; dancing may provide enjoyment and feelings of wellbeing. Physical activity is also likely to have physical health benefits, helping maintain a normal lifestyle and reducing the risk of other disease (e.g. heart disease) (p.2).

Physical activity increases patients’ strength, improves their sleep quality, their balance becomes better too, and there are also significant reduction in falls and a reduction in wandering behavior. For example, “She’s developed a lot more strength and she now can get herself to the toilet and back. So that in itself is great. (Interview 9103)”. (p.7-8). Gardening, games and housework could also help patients to maintain or return skills:

I think it’s about maintaining skills as well, particularly with things like the gardening, which some of the men really enjoy. And they have a good workout sometimes… And it’s normality… and keeping the skills that they’ve got. (Interview 8682) (p.8).

Based on the researches made in Bowes, Dawson, Jepson, and McCabe it becomes clear that physical activity benefits patients and improve their overall quality of lives.  One of the best physical activities for patients with neurocognitive diseases is the aquatic therapy.

Water has a number of unique physical properties that are appropriate for various rehabilitation purposes. These properties include a relatively high specific thermal capacity and thermal conductivity, as well as the ability to provide resistance and the hydrostatical pressure on the body and its buoyancy. The two forces – the gravity and buoyancy act simultaneously on the human body in the water. Moreover, in the aquatic environment patients could perform movements in three dimensions, which are impossible in the air; it is a great social and psychological significance for people with disabilities. The buoyancy of the human body in the water is used in healing and rehabilitation practice for reducing stress, compression on joints, muscles, and connective tissue, as well as strain on the heart that is caused by the excessive body weight. The physical characteristics of the water allow patients to do a wide range of exercises more easily than it is possible on land. An important role for the recovery and rehabilitation does the hydrostatic water pressure. It increases proportionally to the depth of immersion of man. Immersion in water can be a supplement to circulation or peripheral edema due to venous or lymphatic insufficiency. Zotz, T. G. G., Souza, E. A., Israel, V. L., and Loureiro, A. P. C. reported that aquatic therapy can “improve the quality of life, reduce postural instability and the risk of falling in the elderly, and to enhance treatments for different disorders” (p.102).That is why hydrotherapy or aquatic therapy has positive effects on patients with neurologic and musculoskeletal conditions.

According to Myers, Capek, Shill, and Sabbagh (2013), “patients with decreased conditioning, cognitive impairments, reduced strength and endurance, head and spinal cord injuries, stroke, amputation, arthritis, osteoporosis, chronic back pain, and movement disorders may benefit from aquatic therapy”. There are also groups of patients for whom the aquatic therapy is contradicted. Such patients are persons with aquaphobia, fever, infections, cardiovascular disease, open wounds and incontinence. Patients with incontinence can be the “candidates for this therapy only if they are toileted before entering the pool and are provided with commercially available incontinence swim briefs” (p.4).

It is well known that the water influence positively on human’s body. Here emerges the question as to what effects the aquatic therapy has on patients with neurocognitive diseases? Because of the wide range of healing properties of water, the aquatic therapy benefits patients and can be an important part of the neurological rehabilitation.


First of all, it has the effect on the musculoskeletal system. Zotz, T. G. G., Souza, E. A., Israel, V. L., and Loureiro, A. P. C. mentioned that aquatic therapy “may be an excellent alternative to land exercise for individuals who lack confidence, have a high risk of falling, or have joint pain that limits their ability to practice center-of-gravity shifts beyond the limits of their base of support” (p.104). Myers, Capek, Shill, and Sabbagh also reported that “Buoyancy in the water and the viscosity of water compared with air enable nonambulatory persons and those at high risk of falls to practice balancing skills while strengthening their lower extremity musculature without the risk of falling”. Patients with neurocognitive diseases and problems with movements can move freely in the water without fear of falling. As a result, water exercisers improve their postural and motor skills. “This study implies that while gait, balance, and lower body strengthening activities reduce fall risk, aquatic exercises are more effective” (p. 5). Therapist should also be careful with some patients who have increased adipose tissue or hypotonicity, because such patients may become unstable. Moreover, according to Morris (1995) “decreased weightbearing through the joints may further diminish sensory input for clients with sensory deficits”. But if the appropriate water depth is used, these problems can be avoided (p. 22). In addition, when a patient immerses in the water to a level of the neck, hydrostatic pressure of the water increases his blood flow in the non-working muscles. This kind of increasing in the muscle blood flow improves the muscular performance by oxygen saturation and removal of metabolic products. Thus, muscle training becomes more effective.

Aquatic therapy exercises, their duration and frequency should be also prescribed individually for every patient. In that way, patient of 89-year-old with Alzheimer’s disease, in Myers, Capek, Shill, and Sabbagh, was prescribed aquatic therapy “twice weekly for 30 minutes over a period of 3 months”. As a result, his fall risk scores trended downward (p.3).

The second example of the aquatic therapy’s effects is the cardiovascular effect. In many ways, this effect is caused by the influence of hydrostatic pressure. It causes a change in the functional state of the cardiovascular system, even in a motionless person who stands in the water. According to Hall, Swinkels, Briddon, and McCabe (2008) these “mechanisms are based around the effects of hydrostatic pressure, which by virtue of its effect on the cardiovascular system may relieve pain by reducing peripheral edema and, centrally, by dampening sympathetic nervous activity” (p.873). When a patient is immersed in the water in an upright position of the body, the hydrostatic pressure on the lower limbs contributes the transferring of the venous blood from the periphery to the heart, but this effect will only occur if the patient is in the water up to the neck. In that position central venous pressure increases to about 60%, and the heart volume and the stroke volume to about 30% (p.877).

The respiratory effect is the third advantage of the aquatic therapy. Ide, Belini, and Caromano (2005) told that “the aquatic respiratory exercise strengthened aspiratory muscles. We believe that this improvement occurred because of the influence of the physical properties of water which increase the volunteers’ respiratory efforts compared to exercising in air” (p.155). Moreover, water immersion of the body results transferring of blood from the periphery, increasing blood flow in the organs of the thoracic cavity, and the increment of hydrostatic pressure on the chest increases the resistance of its chest excursions, thereby reducing the vital capacity and enhancing the muscle work of apparatus of external respiration. Reduced weight bearing due to buoyancy and increased support of abdominals which is provided by the hydrostatic pressure of water, can help patients with a weak breathing diaphragm. Consequently, the load that falling on respiratory system during exercises in water can be used to improve the respiratory function and strength of respiratory muscles.  According to Becker (2009) “A review in 2006 concluded that respiratory muscle training tended to improve expiratory muscle strength, vital capacity, and residual volume” (p.863).

There are different breathing results depending on the temperature of the water. Еhe breath-holding occurred at the first minutes of the cold hydroprocedure, than the breathing becomes more frequent and, finally, deepens and slows down. Warm water therapy treatments don’t not significantly change the quality of breathing, but speaking about hot water therapy, it speeds up and reduces the depth of breathing.

The most significant example of positive effects of the aquatic rehabilitation is psychophysiological effect. According to Broach and Dattilo (1996), “psychological benefits of participants in aquatic therapy have been identified to include improved mood, enhanced self-esteem and body image, and decreased anxiety and depression” (p.212). Water immersion forms a powerful sensory inflow from skin receptors of different modalities that can radically change the functional state of the central nervous system and vegetative nervous system, significantly increase the energy potential of the brain and its plasticity, enabling the higher nervous activity. Hot water, increasing the sensitivity of the mechanical and thermal receptors of the skin, and making more frequent the number of afferent impulses, has a stimulating effect. Cold hydro procedures (the first phase of the reaction) leads to the similar effect. Prolonged use of procedures with both cold and hot water follows by the development of the second phase of the reaction – the depression of central nervous system (p.215).

Psychological effects are also dependent on water temperature. Immersion in warm water causes a general relaxation and comfort. On the contrary, cold water gives a flow of energy for most people. The neutral effect of the warm water can be used to create a feeling of comfort and reassurance of overexcited or aggressive patients, whereas the activating effect of cold water is used to increase the activity during exercises for those who usually have little activity.

It is believed that the observed psychological effects including mood improvement may be caused by the activation process in the reticular formation. When a patient takes a hot bath, the concentration of endorphins in his blood plasma increases and as a result can cause his or her euphoric reaction. For example, in Myers, Capek, Shill, and Sabbagh, the stuff noticed that their 89-year-old patient “was smiling more and talking more clearly without his usual trouble finding words. He even joked with the staff” (p.4).

To sum up, it is known from ancient times that water has healing properties and influences positively on human’s body. Thus, the aquatic therapy is used in neurological rehabilitation of patients with neurocognitive diseases. The aquatic therapy benefits patients on musculoskeletal and cardiovascular systems. Patients also have the respiratory and psychophysiological effects after the aquatic therapy. Aquatic therapy is one of the most effective methods of recovery and rehabilitation, only in the case when it is taken into account the functional condition of a patient and met the security measures for its implementation.

Author: Ekaterina Nikitina


Becker, B. E. (2009). Aquatic therapy: scientific foundations and clinical rehabilitation applications. PM&R1(9), 859-872. Retrieved November 26, 2014, from

Bowes, A., Dawson, A., Jepson, R., & McCabe, L. (2013).  Physical activity for people with dementia: a scoping study, BMC Geriatrics, 13. Retrieved November 8, 2014, from

Broach, E., & Dattilo, J. (1996). Aquatic therapy: A viable therapeutic recreation intervention. Therapeutic Recreation Journal30, 213-229. Retrieved November 26, 2014, from

Gaugler, J., James, B., Johnson, T., Scholz, K., & Weuve, J. (2014).  2014 Alzheimer’s Disease Facts and Figures, Alzheimer’s & Dementia, 10 (2), 4-15. Retrieved November 9, 2014, from

Hall, J., Swinkels, A., Briddon, J., & McCabe C. S. (2008). Does aquatic exercise relieve pain in adults with neurologic or musculoskeletal disease? A systematic review and meta-analysis of randomized controlled trials, Archives of Physical Medicine and Rehabilitation, 89 (5), 873-883. Retrieved November 8, 2014, from

Ide, M. R., Belini, M. A. V., & Caromano, F. A. (2005). Effects of an aquatic versus non-aquatic respiratory exercise program on the respiratory muscle strength in healthy aged persons. Clinics60(2), 151-158. Retrieved November 27, 2014, from 10.1590/S1807-59322005000200012

Morris, D. M. (1995). Aquatic neurorehabilitation. Journal of Neurologic Physical Therapy19(3), 22-28. Retrieved November 8, 2014, from,

Myers, K., Capek, D., Shill, H., & Sabbagh, M. (2013). Aquatic therapy and Alzheimer’s disease. Annals of Long-Term Care: Clinical Care and Aging. Retrieved November 9, 2014, from

What is Parkinson’s Disease? (n.d). Parkinson’s Disease Foundation. Retrieved from

Zotz, T. G. G., Souza, E. A., Israel, V. L., & Loureiro, A. P. C. (2013). Aquatic physical therapy for Parkinson’s disease. Advances in Parkinson’s Disease, 2(4), 102-107. Retrieved November 9, 2014, from