Topics in Stroke Rehabilitation

ISSN: 1074-9357 (Print) 1945-5119 (Online) Journal homepage: https://www.tandfonline.com/loi/ytsr20

The effect of aquatic physical therapy in patients

with stroke: A systematic review and meta-
analysis

Sara Giuriati, Annamaria Servadio, Giulia Temperoni, Andrea Curcio,

Donatella Valente & Giovanni Galeoto

To cite this article: Sara Giuriati, Annamaria Servadio, Giulia Temperoni, Andrea Curcio,
Donatella Valente & Giovanni Galeoto (2020): The effect of aquatic physical therapy in patients
with stroke: A systematic review and meta-analysis, Topics in Stroke Rehabilitation, DOI:
10.1080/10749357.2020.1755816

To link to this article: https://doi.org/10.1080/10749357.2020.1755816

Published online: 27 Apr 2020.

Submit your article to this journal

Article views: 2

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=ytsr20
TOPICS IN STROKE REHABILITATION
https://doi.org/10.1080/10749357.2020.1755816

The effect of aquatic physical therapy in patients with stroke: A systematic

review and meta-analysis
Sara Giuriatia, Annamaria Servadiob, Giulia Temperonic, Andrea Curcioc, Donatella Valented,
and Giovanni Galeoto e
a
Tor Vergata University of Rome, Rome, Italy; bTor Vergata University of Rome and UniCamillus University of Rome, Rome, Italy; cI.R.C.C.S.
Foundation Santa Lucia, Rome, Italy; dDepartment Human Neurosciences, Sapienza- University of Rome, Rome, Italy; eDepartment of Public
Health and Infectious Disease, Sapienza University of Rome and UniCamillus University of Rome, Rome, Italy

ABSTRACT ARTICLE HISTORY

Objective: The purpose of this study was to evaluate the literature reports of qualitative and Received 11 January 2020
quantitative results of physical therapy treatments in the alternative aquatic setting for individuals Accepted 9 April 2020
affected by strokes. KEYWORDS
Method: PRISMA guidelines were used to carry out the systematic review and meta-analysis. Aquatic therapy; aquatic
Three bibliographic databases were searched: MEDLINE, PEDro, and the Cochrane Library. Papers exercise; hydrotherapy;
included in the study were required to: (a) have a randomized controlled trial (RCT) design of aquatic treatment; quality of
research; and (b) be published in English; (c) be published during the last 10 years (2008–2018). life; outcome measure;
Only randomized controlled trials were employed in the study. The quality of the clinical trials to stroke
be included was evaluated according to the Jadad scale. The internal validity was assessed
according to the PEDro scale.
Results: Eleven RCTs were initially identified in the systematic review. Eight of these were involved
in the meta-analysis comparing outcomes and follow-up. Eight studies received a Jadad score of
three, indicating a high level of quality. The remaining three studies achieved a lower score which
indicated lower qualitative level. Nearly all of the results of the quantitative analysis were
statistically significant (P < 0,05) and most of them favored of the experimental group subject
to aquatic treatment.
Conclusion: Aquatic physical therapy may be a valid means for the rehabilitation of people
affected by stroke. The integration of this methodological approach with conventional physical
therapy should be considered. However, more studies; a larger number of participants; and
varying lengths of follow-up times are necessary.

1. Introduction neurological disease. The biological effects of

Acute cerebrovascular disease is the third-leading
cause of death and the second-leading cause of dis-
ability throughout the world.1 Even though mortality
due to stroke has decreased in the last 20 years, the
burden of stroke is still extreme. A report of the Stroke
Alliance for Europe (SAFE) points out that every 20
s a person has a stroke. The data collection of their last
report “Burden of Stroke” predicts a future increase of
34% in the total number of acute cerebrovascular
events annually in Europe, from the 613.148 cases
that occurred in 2015 to 819.771 expected for. 20352
35% of strokes are followed by serious enduring dis-
abilities necessitating neurorehabilitation.
Aquatic therapy plays an important role in the
rehabilitation protocols for patients affected by
water immersion involve essentially all the homeo-
static systems of the human body.3 These effects
are ascribable to the hydrodynamic principles.
Each immersed body reacts to specific physical
laws that influence its behavior in static and
dynamic conditions. The intrinsic characteristics
of water (hydrostatic pressure, buoyancy, viscosity,
density, and temperature) and the dynamic char-
acteristics (flow resistance and turbulent flow) act
as facilitators: they permit a person immersed in
water to practice balanced and coordinated
movements.4
The hydrostatic pressure and viscosity of water
provide proprioceptive and sensory feedback dif-
ferent from those experimented on land. Buoyancy
is a force that provides support making it possible

CONTACT Giovanni Galeoto giovanni.galeoto@uniroma1.it Piazzale Aldo Moro 5, Rome 00185, Italy
© 2020 Taylor & Francis Group, LLC
2 S. GIURIATI ET AL.
for patients to realize movements that cannot be
done on land.5,6 The microgravity environment
allows patients to actively take part in exercise
because of the relief of the body weight. With the
absence of a stationary position of the body in
water, muscles are continuously activated to stabi-
lize the body. This makes possible the acquisition
of strength, flexibility, and balance.7,8
Viscosity slows movements, so, the response
time to re-acquire a balanced state after postural
perturbations is extended, thus reducing falls.6
With less fear of falling, the aquatic environ-
ment is less traumatic, making it easier rehabilita-
tion task such as balance training.9 Additionally,
the thermodynamic properties of water cause
a decrease of pain and a relaxation of muscles
with an increased muscle tone. Muscle relaxation
and the reduction of algic symptomatology allow
patient to move more easily.9
The interaction between body systems and
a microgravity setting influences biomechanical
behavior. It causes the re-organization of sensor-
imotor connections stimulating of central nervous
system’s functional chain of command and can
modify motor patterns.10 A study achieved by
Sato et al. (2012)11 demonstrates the effect of
water immersion on cortical activities. In particu-
lar, different areas underline an increased cerebral
activity during the aquatic treatment. It suggests
that water immersion may increase motor learning
for the re-acquisition of motor skills.
Somatosensory inputs derive by hydrostatic pres-
sure and temperature may reinforce the elabora-
tion of motor and sensitive informations.Water
could be a tool of facilitation.
The purpose of neuromotor rehabilitation is to
support the best possible functional recovery.
Aquatic physical therapy may facilitate rehabilita-
tion by stimulating coordination, developing resi-
dual abilities, allowing recovery of an appropriate
cardiovascular fitness and global and analytic
movements in simplifying conditions. The aquatic
physical therapy takes place in a setting that
involves proprioceptive feedback and sensorial
stimulus.12
The aim of this study was to conduct a systematic
literature review of randomized controlled trials to
evaluate the results of aquatic physical therapy on
patients affected by strokes.
2. Materials and methods
2.1. Search methods
PRISMA guidelines were used to carry out the
systematic review and meta-analysis. Three elec-
tronic databases were searched: MEDLINE, the
Cochrane Library, and PEDro.
Keywords used for the literature’ search were
“aquatic therapy,” “aquatic treatment,” “aquatic
exercise,” and hydrotherapy” related to the key-
word “stroke” through the Boolean operator
“AND.” The bibliographical search was performed
with a due date set to November, 2018.
2.2. Type of studies
Only studies with randomized controlled trials
(RCTs) were included in the review. These types
of clinical trials involve the random assignment of
participants to one of two types of treatment,
including the experimental group and control
group. Studies that employed a conventional phy-
sical therapy treatment in the control group were
considered.
2.3. Type of participants
The studies included non-acute patients affected
by stroke. The duration of the acute rehabilitation
phase lasted until clinical stabilization of the
patients was reached. During this phase, it is
important to minimize the risk of secondary inju-
ries, so challenging rehabilitation should be
avoided. For this reason, the target group included
only those patients who were medically stable, and
therefore, low-impact aquatic therapy was selected.
It is important to note that where no restric-
tions with respect to the age of the participants.
2.4. Type of interventions
This research focused on all possible forms of
aquatic physical therapy treatments. Interventions
used in Aquatic Physical Therapy include, but are
not limited to therapeutic exercise, functional
training, manual therapy, breathing strategies,
physical agents, and mechanical modalities using
the properties of water and techniques unique to
the aquatic environment.

2.5. Selection of studies
The prerequisites for a study to be considered
included following three core criteria: (a) studies
designed with randomized controlled trials; (b)
studies published in English; and (c) studies pub-
lished at some point in the last 10 years
(2008–2018).
2.6. Data extraction and risk of bias
The methodological quality of each study was
evaluated using the Jadad scale and the
Physiotherapy Evidence Database (PEDro) Scale.
Each article was subjected to evaluation using the
Jadad score, which employs a scoring system from
0 to 5 based on the expected criteria associated
with the scale. The score related to the adminis-
tration of the PEDro Scale is obtained summing 11
criteria, which depend on whether such criteria are
met by studies examined.
2.7. Data in the included studies
The following data from each article were analyzed
and included in our review: (1) participant details
(e.g. age, type of stroke, side of weakness, time
since stroke); (2) intervention (i.e. control group
and experimental group); (3) treatment rates; (4)
outcomes measurement tools; (5) follow-up exam-
inations; (6) conclusions and (7) Jadad scale and
PEDro Scale.
3. Results
3.1. Search result
Figure 1 represents the selection process of the
study. A total of 323 records were identified, with
119 duplicate records being excluded, while the
remaining 204 records were screened. After read-
ing the titles of all 204 studies, 149 were excluded.
After the exclusion of 44 records due to inap-
propriate design of the research and/or publication
of the study in a language other than English, 11
studies were included in the qualitative analysis
and only 8 of the 11 studies examined were
included in the quantitative analysis. The last
three articles were excluded due to the absence of
TOPICS IN STROKE REHABILITATION 3
outcomes that were comparable with those ana-
lyzed using meta-analysis.
3.2. Characteristics of included studies
Table 1 contains information regarding the char-
acteristics of each included study. Based on the
synthesis, the most commonly used therapies in
the intervention group included the following:
aquatic treadmill training, Halliwick therapy and
Ai-Chi. Only one trial employed the Bad Ragaz
Ring Method (BRRM). The rehabilitation sessions
were organized differently.
3.3. Trial quality
The Jadad score is used for the qualitative analysis of
the trials included in the systematic review. This eva-
luation revealed that eight studies had a score of three,
which also displayed a relatively good level of quality.
The remaining three studies achieved a score that
characterized them as low-quality studies13 (Table 2.)
The quality of the clinical trials was also
assessed using the PEDro Scale. This scale assesses
the internal validity of randomized controlled
trials. The assessment indicated that the studies
had a relatively good level of internal validity.
Scoring was between 7 and 10, and the study was
allocated if the characteristics of the studies met
the criteria considered by the scale. The score is
are presented in Table 3.
3.4. Meta-analysis
Quantitative analysis was performed by comparing
outcomes. The follow-up included in the studies
was pooled and taken into account.
This pool was based on comparable outcomes
and time’s affinity (the same time frame expected
by each study) associated with the follow-up which
allowed for the consideration of eight studies in
the performance of meta-analysis.
3.4 (a) Comparison of aquatic physical therapy
vs. conventional physical therapy for outcome 1:
Berg Balance Scale (BBS), 2–4 weeks.
The studies of Lee et al.14 and Zhu et al.15 were
considered. The meta-analysis revealed statistically
4 S. GIURIATI ET AL.

Records identified through Additional records identified

database searching through other sources

Identification
(n=323) (n=0)

Records after duplicates removed

(n=204)
Screening

Record screened Record excluded

(n=204) (n=149)

Record excluded
articoli full-text valutati per l’eleggibilità
Eligibility

(n=44)
(n=55)

Studies included in the qualitative

synthesis
(n=11)
Included

Studies included in the quantitative

synthesis (meta-analysis)
(n=8)

Figure 1. Flow-chart.

significant results (P = .03) in favor of the experi- aquatic therapy compared to the control group
mental group compared to the control group. that was subjected to conventional physical ther-
(mean difference = 3.56; 95% CI = 0.41, 6.71) as apy. (mean difference = 7.01; 95% CI = 3.37,
shown in Figure 2. 10.65), as shown in Figure 3.

3.4 (a.1) Comparison of aquatic physical ther- 3.4 (b) Comparison of aquatic physical therapy
apy vs. conventional physical therapy for outcome vs. conventional physical therapy for outcome 2:
1: Berg Balance Scale (BBS), 4–6 weeks. Timed Up and Go (TUG), 4–6 weeks.

The studies of Chan et al.16 and Eyvaz et al.17 were The studies of Cha et al.18, Chan et al.16 and Eyvaz
considered. The quantitative analysis revealed sta- et al.17 were considered. Meta-analysis revealed
tistically significant results (P = .0002) in favor of statistically significant results (P = .004) in favor
Table 1. Characteristics of the studies.
Intervention Rates of Control Follow- Jaded
Author Participants details (SG) treatment groups (CG) Outcomes measurement tools up Conclusions Score
Aidar F.J. et al., N = 43; SG = 22, CG = 21 Aquatic 45–60 min Land therapy BDI, IDATE (STAI), TUG, timed 7.62 12 weeks The practice of aquatic therapy promotes 3
2018 therapy × 2 sessions Meters Walk, Getting up from improvements in the levels of depression and anxiety
for week a sitting position, BBS. in people who suffered an ischemic stroke.
× 12 weeks
Cha H.G. et al., N = 22; SG = 11, CG = 11 Aquatic 1h×3 Land therapy BI, EMG lateral gastrocnemius and 6 weeks Bad Ragaz Ring method may be beneficial for 2
2017 Age: therapy sessions for tibialis anterior, TUG improving balance and muscle activation in chronic
SG = 64.0 ± 12.1, (Bad Ragaz week stroke patients.
CG = 63.3 ± 12.2 Ring; PNF) × 6 weeks
Stroke type +
(Ischemic/Hemorragic): Land
SG = 7/4, CG = 9/2 therapy
Time since stroke:
SG = 16.6 ± 4.0,
CG = 18.9 ± 5.1
Chan K. et al., N = 32; SG = 17, CG = 15 Aquatic 1h×2 Land therapy BBS, CBM, TUG, 2MWT 6 weeks A combination of water and land-based exercise has 3
2016 Age: therapy sessions for potential for improving balance.
SG = 66 ± 10, + weeks ×
CG = 64 ± 12 Land 6 weeks
Side of weakness (left/ therapy
right):
SG = 8/5; CG = 7/5
Time since stroke (days):
SG = 96 ± 27;
CG = 97 ± 34
Eyvaz N. et al., N = 60; SG = 30, CG = 30 Aquatic 1 h ×5 Land therapy BBS, FIM, SF-36, QoL assessment 6 weeks Applying aquatic therapy with the conventional 3
2018 Age: therapy sessions for questionnaire; SBI, DBI, TUG, therapy in patients with hemiplegia did not make any
SG = 58.5 ± 6.27, + week × additional contribution to the application of land
CG = 58.3 ± 5.43 Land 6 weeks therapy alone.
Stroke type therapy
(Ischemic/Hemorragic):
SG = 27/3, CG = 23/7
Side of weakness (left/
right):
SG = 12/18,
CG = 16/14
Time since stroke
(month):
SG = 23.4 ± 15.1,
CG = 24.2 ± 15.1
TOPICS IN STROKE REHABILITATION

(Continued )
5
 6

Table 1. (Continued).
Intervention Rates of Control Follow- Jaded
Author Participants details (SG) treatment groups (CG) Outcomes measurement tools up Conclusions Score
Funari A. et al., N = 40; SG = 20, CG = 20 Aquatic 1h×3 Land therapy mRS, BI, FIM, MAS, TT, 8 weeks Hydrokinesitherapy may be considered a promising 0
2014 Age: therapy sessions for Baropodometric evaluation treatment in improving gait and balance in individuals
SG = 68.3 ± 3, + week × following stroke.
CG = 72 ± 5 Land 8 weeks
S. GIURIATI ET AL.

Time since stroke therapy

(month):
SG = 7 ± 1.6,
CG = 6 ± 1.4
Lee S.Y. et al., N = 37; SG = 19, CG = 18 Aquatic 30 min × 5 Land therapy FMA, BBS, MBI, EQ-5D index; 4 weeks Water-based aerobic exercise performed on 3
2018 Age: therapy sessions for + baPWV test, isometric muscle a motorized
SG = 57.58 ± 13.98, week × Occupational strength measures (torque values, aquatic treadmill had beneficial effect on isometric
CG = 63.67 ± 11.37 4 weeks therapy Nm) muscle strength in the lower limb.
Stroke type
(Ischemic/Hemorragic):
SG = 11/8, CG = 9/9
Side of weakness (left/
right):
SG = 10/9, CG = 9/10
Time since stroke (days):
SG = 30.37 ± 21.92,
CG = 29.22 ± 19.94
Noh D.K. et al., N = 25; SG = 13, CG = 12 Aquatic 1h×3 Land therapy CMSA, 8 weeks Postural balance and knee flexor strength were 3
2008 Time since stroke (years): therapy sessions for BBS, Weight-bearing ability, improved after aquatic therapy based on the Halliwick
SG = 2.8 ± 3.8, week × Modified Motor Assessment Scale, and Ai Chi methods in stroke survivors.
CG = 1.6 ± 1.7 8 weeks muscle strength measures (peak
Stroke type torque values, Nm)
(Ischemic/Hemorragic):
SG = 6/7, CG = 7/5
Side of weakness (left/
right):
SG = 6/7, CG = 7/5
Park H.K. et al., N = 30; SG = 15, CG = 15 Aquatic 1h×5 Land therapy TIS, BBS-3 L, FRT, MBI 4 weeks The result of this study suggest that LATE program can 3
2018 Stroke type therapy sessions for help improve trunk control, balance and activities of
(Ischemic/Hemorragic): + week × daily living in chronic stroke patients.
SG = 7/7, CG = 8/7 Land 4 weeks
Side of weakness (left/ therapy
right):
SG = 9/5, CG = 8/7
Time since stroke,
(month):
SG = 9.21 ± 4.95,
CG = 12.93 ± 6.05
(Continued )
Table 1. (Continued).
Intervention Rates of Control Follow- Jaded
Author Participants details (SG) treatment groups (CG) Outcomes measurement tools up Conclusions Score
Tripp F. et al., N = 30; SG = 14, CG = 16 Aquatic 45 min × 5 Land therapy BBS, FR, FAC, RMI, CI 2 weeks This study indicates that Halliwick-Therapy is safe and 3
2014 Age: therapy sessions for well tolerated in stroke patients in post-acute
SG = 64.89 ± 15.0, + week × rehabilitation and has positive effects upon some
CG = 65.0 ± 15.1 Land 2 weeks aspects of mobility.
Side of weakness (left/ therapy
right):
SG = 4/10, CG = 6/10
Stroke type
(Ischemic/Hemorragic):
SG = 12/2, CG = 15/1
Time since stroke (days):
SG = 51.9 ± 37.7,
CG = 39.0 ± 27.9
Zhang Y. et al., N = 36; SG = 18, CG = 18 Aquatic 40 min × 5 Land therapy MAS, FAC, BI, MIVC strenght 8 weeks Aquatic therapy enhanced muscle strength in paretic 3
2016 Age: therapy sessions for (torque values, Nm) lower limbs are improved muscle cocontraction
SG = 56.3 ± 8.18, week × without increasing spasticity in subacute stroke
CG = 54.7 ± 7.59 8 weeks patients.
Side of weakness (left/
right):
SG = 8/10, CG = 7/11
Time since stroke (years):
SG = 0.34 ± 0.07,
CG = 0.37 ± 0.08
Zhu Z. et al., N = 28; SG = 14, CG = 14 Aquatic 45 min × 5 Land therapy FRT, BBS, TUG, 2MWT 4 weeks A relatively short programme of hydrotherapy exercise 0
2015 Age: therapy sessions for resulted in a large improvement in a small group of
SG = 56.6 ± 6.9, week × individuals with relatively high balance and walking
CG = 57.1 ± 8.6 4 weeks function following a stroke.
Stroke type
(Ischemic/Hemorragic):
SG = 10/4, CG = 11/3
Side of weakness (left/
right):
SG = 8/6, CG = 11/3
Time since stroke (days):
SG = 247.4 ± 56.6,
CG = 262.1 ± 55.4
2MWT: 2 Minute Walking Test; BBS: Berg Balance Scale; BBS-3 L: 3-level Berg Balance Scale, BDI: Beck Depression Inventory; BI: Barthel Index; CBM: Community Balance and Mobility Test; CMSA: Chedoke-Mc
Master Stoke Assessment; DBI: Dynamik Balance Index; FAC: Functional Ambulation Categories; FMA: Fugl-Meyer Assessment; FR: Functional Reach; FRT: Functional Reach Test; IDATE (STAI): State-Train
Anxiety Inventory, FIM, Functional Independence Measure; MAS: Modified Ashworth Scale; MBI: Modified Barthel Index; mRS: modified Ranking Scale; RMI: Rivermead Mobility Index; SBI: Statik Balance
TOPICS IN STROKE REHABILITATION

Index; SF-36: Short-Form 36; TT: Tinetti Test; TIS: Trunk Impairment Scale; TUG: Timed Up and Go Test.
7
8 S. GIURIATI ET AL.

Table 2. Qualitative analysis through Jadad Score.

Randomization
Aidar et al., 2018
Cha et al., 2017
Chan et al., 2016
Eyvaz et al.,2018
Furnari et al., 2014
Lee et al., 2018
Noh et al., 2008
Park et al., 2018
Tripp et al., 2014
Zhang et al., 2016
Zhu et al., 2015
Method of Double Method of double
randomization blinding blinding
1 1 0 X
1 1 0 X
1 1 0 X
1 1 0 X
1 −1 0 X
1 1 0 X
1 1 0 X
1 1 0 X
1 1 0 X
1 1 0 X
1 −1 0 X
Description of withdrawals and Total
dropouts score
1 3
0 2
1 3
1 3
0 0
1 3
1 3
1 3
1 3
1 3
1 0

of the experimental group compared to the control 3.4 (e) Comparison aquatic physical therapy
group. (mean difference = −3.79; 95% CI = – 6.39, vs. conventional physical therapy for outcome 5:
−1.19). (Figure 4.) Functional Reach Test (FRT), 2–4 weeks.

3.4 (c) Comparison of aquatic physical therapy
vs. conventional physical therapy for outcome 3:
Muscle strength (Nm), 6–8 weeks.
The studies of Noh et al.8 and Zhang et al.19 were
considered for quantitative analysis of the recruit-
ment of motor units during the movements of the
flexion and extension in the affected lower limb.
Even when the results were relatively small, meta-
analysis revealed that they are statistically significant
(P = .007) in favor of the experimental group that
was subjected to aquatic therapy about the recruit-
ments of motor units during movement of flexion.
(mean difference = 4.03, 95% CI = 1.12, 6.93) (Figure
5). By contrast, statistically significant results were
not obtained (P = .82) for the recruitment of motor
units during the extension of the knee in favor of the
control or the experimental group. (mean differ-
ence = 0.24, 95% CI = – 1.79, 2.27), as shown in
Figure 6 These results suggest that aquatic physical
therapy and conventional physical therapy may be
equally important in rehabilitation.
3.4 (d) Comparison of aquatic physical therapy
vs. conventional physical therapy for outcome 4:
Modified Barthel Index (MBI), 6–8 weeks.
The studies of Lee et al.14 and Park et al.20 were
considered. Meta-analysis revealed statistically sig-
nificant results (P = .03) in favor of the experi-
mental group subjected to aquatic therapy
compared to the control group. (mean differ-
ence = 9.49, 95% CI = 0.74, 18.24). (Figure 7)
Studies of Park et al.20 and Zhu et al.15 were consid-
ered. Meta-analysis revealed statistically significant
results (P = .0007) in favor of aquatic physical ther-
apy compared to conventional physical therapy.
(mean difference = 4.19, 95% CI = 1.76, 6.63) as
shown in Figure 8.
4. Discussion
The meta-analysis performed in this study indicated
that aquatic therapy could be a valid alternative to
the conventional rehabilitative treatments.
The quantitative analysis produced statistically
significant results (P < .05) for the level of func-
tional disability in the activity of daily living based
on the Modified Barthel Index (MBI). It has been
demonstrated that water immersion once a week
can improve activities associated with daily living
in patients with hemiplegia.11 The meta-analysis
also revealed also positive results (P < .05) con-
cerning the balance outcomes (BBS, TUG, FRT).
The performance of activities daily living (ADL)
is made difficult by deficits in static and dynamic
balance. These types of deficits are also related to
an increased risk of fallings. This risk and the fear
of falling are lower in an aquatic setting. Even
though this positive emotional and psychological
perception was not object of evaluation in the
studies of Chan et al.16, Noh et al.8, Furnari et al.21
and Park et al.20 it is very likely that the greater
safety of the aquatic setting compared to land-
based therapies, may have a positive influence on
 TOPICS IN STROKE REHABILITATION 9

the results obtained from the trials with respect to

score
Point measures and Total

7
9
7
7
8
9
7
7
7
7
7
balance conditions. The aquatic setting allows
patients to practice balance, improve the symmetry

variabilità data
of the body even in unbalanced conditions.
Water-based therapies have a significant poten-

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
tial because they make it easier to perform con-
trolled movements and weight balancing
movements. Due to water’s viscosity, movements
Between-groups

are slower than those made on land. In this way,

comparisons
statistical

patients have at their disposal more time to cope

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
with postural disturbances. This likely represents
an advantage in the initial phase of rehabilitative
treatment. Accordingly, aquatic physical therapy
should be considered as a first approach to addres-
treat analysis
Intention-to-

sing balance deficits, which can then be subse-

Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes

quently followed by conventional land-based

physical therapy.
The positive results in favor of the experimental
Less than

dropouts
15%

Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes

group obtained by the quantitative analysis con-

cerning the BBS test were confirmed by the meta-
analysis performed by Iatrodu et al.22 In their
Assessor
blinding

study, nine randomized controlled trials (RCTs)

Yes
Yes

Yes
Yes

Yes
Yes
No
No
No

No
No

concerning balance in patients with hemiplegia

were considered. Aquatic physical therapy has
Therapist
blinding
No
No
No
No
No
No
No

No
No
No
No

proved to be more effective (P < .05) than physical

therapy on land. Based on their review and meta-
analysis, Mehrolz.23 did not find any differences
blinding
Concealed Groups similar Subject

Yes
Yes

Yes
No
No
No
No

No

No
No
No

between the two approaches, and thus, further

studies are necessary. Conflicting results emerge
at baseline

from the meta-analysis of the outcomes concern-

Yes
Yes
Yes
Yes
Yes

Yes
No

No
No

No
No

ing the recruitment of motor units. Aquatic phy-

sical therapy may be more effective for the
recruitment of motor units during the movement
allocation

of the knee flexion. But no differences between

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

conventional physical therapy and aquatic physical

therapy were found with respect to the recruit-
Table 3. Qualitative analysis through Pedro Scale.

allocation
Random

ment of motor units during the knee extension

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

movement.
The aquatic setting allows the therapist to carry
out training exercise focused on the recruitments
Eligibility

specified
criteria

Yes
Yes
Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
No

of motor units by exploiting the resistance gener-

ated by water’s viscosity. This resistance increases
as the body moves faster. During the training ses-
sions, patients can adjust the speed of their move-
Furnari et al., 2014

Zhang et al., 2016

ments to match their residual abilities and

Aidar et al., 2018

Tripp et al., 2014

Chan et al., 2016
Eyvaz et al.,2018

Park et al., 2018

Noh et al., 2008

Zhu et al., 2015

Cha et al., 2017

Lee et al., 2018

potential. In other words, water makes it possible

for patients to regulate the resistance by simply
changing the speed of their movement which has
a corresponding effect on the difficulty of the
10 S. GIURIATI ET AL.

Figure 2. Comparison of aquatic physical therapy vs. conventional physical therapy about outcome 1: BBS (Berg Balance Scale),
2–4 weeks.

Figure 3. Comparison of aquatic physical therapy vs. conventional physical therapy about outcome 1: BBS (Berg Balance Scale),
4–6 weeks.

Figure 4. Comparison of aquatic physical therapy vs. conventional physical therapy about outcome 2: TUG (Timed Up and Go),
4–6 weeks.

Figure 5. Comparison of aquatic physical therapy vs. conventional physical therapy about outcome 3: Muscle strength (Nm),
6–8 weeks.
Flexion affected lower limb

Figure 6. Comparison of aquatic physical therapy vs. conventional physical therapy about outcome 3: Muscle strength (Nm),
6–8 weeks.
Extension affected lower limb.

exercise. This ability to modulate the difficulty of The qualitative analysis of 11 RCTs included in
motor tasks may encourage patients pursue out- the systematic review provides interesting results
comes that are better than land-based outcomes.19 regarding the effects on depression, anxiety levels,

Figure 7. Comparison of aquatic physical therapy vs. conventional physical therapy about outcome 4: MBI (Modified Barthel
Index),6–8 weeks.
Figure 8. Comparison of aquatic physical therapy vs. conventional
physical therapy about outcome 5: FRT (Functional Reach Test), 2–
4 weeks.
quality of life, and the cardio-respiratory fitness.
After a cerebrovascular event, a person’s cardio-
respiratory fitness decreases, so aerobic training
must be part of the rehabilitation program in
patients affected by stroke. The causes of
a reduction in a person’ cardio-respiratory capacity
in neurological patients are not fully understood. It is
thought that there are numerous contributing fac-
tors, such as cardiovascular and respiratory dysfunc-
tion and neuromuscular deficits.24
In this regard, aquatic treadmill training seems to
be a valid tool, and it is able to improve blood pressure
reactivity to physical stress.9 In a study by Lee et al.14
that was included in the systematic review, the cardio-
respiratory fitness of the patients belonging to the
experimental group improved without any significant
differences with the control group. Arterial stiffness
was among the clinical parameters investigated in
their study. Based on their review and meta-analysis
Vlachopoulos et al.25 found that an improvement in
arterial stiffness can decrease the risk of relapses and/
or mortality and morbidity associates with stroke.
In the study included in the systematic review
mentioned above, an improvement of this para-
meter was recorded in both groups.
Therefore, aquatic treadmill training may be
a valid tool for the aerobic training in patients who
TOPICS IN STROKE REHABILITATION 11
have suffered a stroke26 and it could be a valid alter-
native to conventional land-based therapies. The
underwater treadmill reduces a person’s body weight
due to water’s buoyance force, which is generated
because water is denser than body fat. Water essen-
tially creates the same effect that is employed in Body
Supported Weight Treadmill Training (BWSTT)
which is very frequently used in the rehabilitation
of patients recovering from a stroke.
In addition to facilitating aerobic training, the
aquatic treadmill makes it possible to begin working
on gait and balance impairments early in the reha-
bilitation process.27 It has been shown to improve
gait speed, body coordination, balance, and patient
awareness. It offers the combination of the positive
health effects associated with water immersion and
the advantages associated with gait training by pro-
viding a form of regular and continuous activity.26
Improvement of a person’s aerobic skills and their
global motor conditions, including gait, balance and
motor unit recruitment often results in an increase in
motivation and the pursuit of a social life.27
Therefore, water not only has positive physical
repercussions, but it also has psychological, motiva-
tional, and emotional effects. Often times, physical
disabilities lead to psychological and emotional
issues, including depression and anxiety. This is
a very common reality for people who suffer
a stroke. In a study of 104 patients affected by stroke,
it was found that 23% had elevated levels of anxiety,
and 19% reported high levels of depression.28
Some studies have demonstrated that aquatic
therapy can be employed to combat complex psy-
cho-emotional conditions in a manner that is similar
or greater than land-based physical therapy.29,30
Hence, patients’ feeling of anxiety and depres-
sion decrease and their perception of well-being
increase, which was supported by the study con-
ducted by Aidar et al.31 which was included in the
systematic review.
12 S. GIURIATI ET AL.
4.1. Study limits
The limits of this study concern the small sample
size of patients in the trials, the heterogeneity of
the phase of illness, the lack of intermediate fol-
low-up examinations, the small number of RCTs
in the literature and the lack of double-blind stu-
dies. This last limit is closely correlated to the
nature of the study considered.
5. Conclusions
The present study was conducted by health profes-
sionals from Sapienza University in Rome and the
Rehabilitation & Outcome Measures Assessment
Association (ROMA). The research group has car-
ried out many outcome-based measures in
Italy.32–48
In conclusion, the qualitative and quantitative
analysis conducted in this study supported the
potential and validity of aquatic therapy for reha-
bilitation of people affected by stroke. The integra-
tion of aquatic physical therapy with conventional
physical therapy may represent an optimal
approach to neuromotor rehabilitation of patients
who have suffered neurological damage. The ben-
efits associated with water immersion due to its
unique properties are well known. However, more
studies are needed that include a larger number of
participants and less heterogeneity in organization
of therapy sessions and the phase of the illness.
Moreover, short, medium, and long term follow-
up examinations are essential. However, the sys-
tematic review and meta-analysis performed in
this study did not identify any major issues asso-
ciated with aquatic treatment of patients recover-
ing from the consequences of stroke. On the
contrary, this study supports the value of water-
based rehabilitative therapy.
Statement of human and animal rights
All procedures performed in this study were in accordance
with the ethical standards of the responsible committee on
human experimentation (institutional and national) and the
Helsinki Declaration of 1975, as revised in 2008. Informed
consent was obtained from all participants prior to being
included in the study.
Statement of ethics
We certify that all applicable institutional and governmental
regulations concerning the ethical use of human volunteers
were followed during the course of this research.
ORCID
Giovanni Galeoto http://orcid.org/0000-0002-9043-5686
References
1. Hojaghihaghighi S, Vahdat SS, Mikaeilpour A,
Ramouz A. Comparison of neurological clinical mani-
festation in patients with hemorrhagic and ischemic
stroke. World J Emerg Med. 2017;8:34–38. doi:10.5847
/wjem.j.1920-8642.2017.01.006.
2. The Burder of Stroke in Europe http://strokeeurope.eu/
data-comparison/ Accessed October 15, 2018
3. Becker BE. Aquatic therapy: scientific foundation and
clinical rehabilitation applications. Am Acad Phys Med
Rehab, 859. 2009.
4. Kim EK, Lee DK, Kim YM. Effects of aquatic PNF lower
extremity patterns on balance and ADL of stroke patients.
J Phys Ther Sci. 2015;27:213–215. doi:10.1589/jpts.27.213.
5. Alikhaejeh Y, Hossein SRA, Moghaddam A. Effect of
hydrotherapy in static and dynamic balance among
elderly men. Soc Behav Sci. 2012;46:220–2224.
6. Jung JH, Lee J, Chung EJ, Kim K. The effect of obstacle
training in water on static balance of chronic stroke
patients. J Phys Ther Sci. 2014;26:437–440. PMID:
24707102. 2014. doi:10.1589/jpts.26.437.
7. Park J, Roh H. Postural balance of stroke survivors in
aquatic and land environments. J Phys Ther Sci.
2011;23(6):905–908. 201. doi:10.1589/jpts.23.905.
8. Noh DK, Lim JV, Shin HI, Paik NJ. The effect of
aquatic therapy on postural balance and muscle
strength in stroke survivors: a randomized controller
pilot trial. Clin Rehabil. 2008;22:966–976. doi:10.1177/
0269215508091434.
9. Lambert BS, Greene NP, Carradine AT. et al. Aquatic
treadmill training reduces blood pressure reactivity to
physical stress. Med Sci Sports Exer. 2014;46:809–816.
PMID: 24056269. doi:10.1249/MSS.0000000000000167.
10. Barassi G, Bellomo RG, Ancona E, Trivisano L, Saggini R.
The role of water environment rehabilitation in patients
with neurological and cognitive disabilities. Biophilia.
2017;2017(1):28–34. doi:10.14813/ibra.2017.28.
11. Sato D, Onishi H, Yamashiro K, Iwbe T, Shimoyama Y,
Maruyama A. Water immersion to the femoral level
affects cerebral cortical activity in humans: functional
near-infrared spectroscopy study. Brain Topogr.
2012;25:220–227. doi:10.1007/s10548-011-0204-z.
12. Benelli P, Zanazzo M. Idrochinesiterapia Manuale Di
Riabilitazione in Acqua;Edi Ermes, 260. 2015.

13. Clark HD, Wells GA, Huët C, et al. Assessing the
quality of randomized trials: reliability of the Jadad
scale. Control Clin Trials.1999;20(5):448–452.
14. Lee SY, Young HE, Kim BR, Im SH. The effects of
a motorized aquatic treadmill exercise program on mus-
cle strength, cardiorespiratory fitness, and clinical func-
tion in subacute stroke patients: a randomized controlled
trial. Am J Phys Med Rehabil. 2018;97:533–540.
doi:10.1097/PHM.0000000000000920.
15. Zhu Zhizhong Z, Cui L, Yin M, Yu Y, Zhou X,
Wanghongtu Y. Hydrotherapy vs. Conventional
land-based exercise for improving walking and balance
after stroke: a randomized controlled trial. Clin Rehab.
2015;30:587–593. doi:10.1177/0269215515593392.
16. Chan K, Phadke CP, Stremler D. et al. The effect of
water-based exercises on balance in person post-stroke:
a randomized controlled trial. Top Stroke Rehab.
2016;24:228–235. PMID: 27808012. doi:10.1080/
10749357.2016.1251742.
17. Eyvaz N, Dundar U, Yesil H. Effects of water-based and
land-based exercise on walking and balance functions of
patients with hemiplegia. Neurorehabilitation.
2018;42:237–246. doi:10.3233/NRE-182422.
18. Cha HG, Shin YJ, Kim MK. Effects of the Bad Ragaz
Ring method on muscle activation on the lower limbs
and balance ability in chronic stroke: a randomised
controlled trial. Hong Kong Physiother J.
2017;37:39–45. doi:10.1016/j.hkpj.2017.02.001.
19. Zhang Y, Wang YZ, Huang LP. et al. Aquatic therapy
improves outcomes for subacute stroke patients by
enhancing muscular strength of paretic lower limbs
without increasing spasticity: a randomized controlled
trial. Am J Phys Med Rehabil. 2016;95:840–849. PMID:
27088480. doi:10.1097/PHM.0000000000000512.
20. Park HK, Lee HJ, Lee SJ, Lee WH. Land-based and
aquatic trunk exercise program improve trunk control,
balance and activities of daily living ability in stroke:
a randomized clinical trial. Eur J Phys Rehabil Med.
2018. doi:10.23736/S1973-9087.18.05369-8.
21. Furnari A, Calabrò RS, Gervasi G. et al. Is hydrokinesither-
apy effective on gait and balance in patients with stroke?
A clinical and baropodometric investigation. Brain Inj.
2014;28:1109–1114. doi:10.3109/02699052.2014.910700.
22. Iatridou G, Pellidou HS, Varvarousis D. et al. The
effectiveness of hydrokinesitherapy on postural balance
of hemiplegic patients after stroke: a systematic review
and meta-analysis. Clin Rehabil. 2017;32(5):583–593.
doi:10.1177/0269215517748454.
23. Mehrholz J1, Kugler J, Pohl M. Water-based exercises
for improving activities of daily living after stroke.
Cochrane Database Syst Rev. 2011; Jan 19 1:
CD008186. 10.1002/14651858.CD008186.pub2.
24. Han EY, Im SH. Effect of a 6-week aquatic treadmill
exercise program on cardiorespiratory fitness and
walking endurance in subacute stroke patients.
J Cardiopulm Rehabil Prev. 2018;38:314–319.
doi:10.1097/HCR.0000000000000243.
TOPICS IN STROKE REHABILITATION 13
25. Vlachopoulos C, Aznaouridis K, Stefanadis C.
Prediction of cardiovascular events and all-cause mor-
tality with arterial stiffness: a systematic review and
meta-analysis. J Am Coll Cardiol. 2010;55:1318–1327.
doi:10.1016/j.jacc.2009.10.061.
26. Yoo J, Lim KB, Lee HJ, Kwon YG. Cardiovascular
response during submaximal underwater treadmill
exercise in stroke patients. Ann Rehabil Med.
2014;38:628–636. doi:10.5535/arm.2014.38.5.628.
27. Lee ME, Jo GY, Do HK, Choi HE, Kim WJ. Efficacy of
aquatic treadmill training on gait symmetry and bal-
ance in subacute stroke patients. Ann Rehabil Med.
2017;41:376–386. doi:10.5535/arm.2017.41.3.376.
28. Sagen U, Vik TG, Moum T, Mørland T, Finset A,
Dammen T. Screening for anxiety and depression
after stroke: comparison of the hospital anxiety and
depression scale and the Montgomery and Asberg
depression rating scale. J Psychosom Res.
2009;67:325–332. doi:10.1016/j.jpsychores.2009.03.007.
29. Robiner WN. Physiological and physical reactions to
whirlpool baths. J Behav Med. 1990;13:157–173.
doi:10.1007/BF00844996.
30. Watanabe E, Takeshima N, Okada A, Inomata K.
Comparison of water-based and land-based exercise in
the reduction of state anxiety among older adults. Perc
otor Skills. 2000;91:97–104. doi:10.2466/pms.2000.91.1.97.
31. Aidar JF, Jacò de Oliveira R, Gama de Matos D,
Chilibeck PD, de Souza RF, Carneiro AL.
A Randomized trial of the effect of an aquatic exercise
program on depression, anxiety levels, and functional
capacity of people who suffered an ischemic stroke.
J Sports Med Phys Fitness. 2018;57:1171–1177.
32. Galeoto G, Berardi A, De Santis R. et al. Validation and
cross-cultural adaptation of the Van Lieshout test in an
Italian population with cervical spinal cord injury:
a psychometric study. Spinal Cord Ser Cases. 2018;15
(4):49. PMID: 29928515. doi:10.1038/s41394-018-0083-6.
33. Massai P, Colalelli F, Sansoni J. et al. Reliability and
validity of the geriatric depression scale in Italian subjects
with Parkinson’s disease. Parkinsons Dis. 2018;2018:1–6.
PMID: 30155239. doi:10.1155/2018/7347859.
34. Galeoto G, Colalelli F, Massai P. et al. Quality of life in
Parkinson’s disease: italian validation of the
Parkinson’s Disease Questionnaire (PDQ-39-IT).
Neurol Sci. 2018;39:1903–1909. PMID: 30088166.
doi:10.1007/s10072-018-3524-x.
35. Galeoto G, Sansoni J, Scuccimarri M. et al.
A psychometric properties evaluation of the Italian
version of the Geriatric depression scale. Depress Res
Treat. 2018:PMID: 29686898. 10.1155/2018/1797536.
2018. 1–7.
36. Galeoto G, Colucci M, Guarino D. et al. Exploring
validity, reliability, and factor analysis of the quebec
user evaluation of satisfaction with assistive technology
in an italian population: a cross-sectional study. Occup
Ther Heal Care. 2018; 32:380–392 PMID:30596451.
doi:10.1080/07380577.2018.1522682.
14 S. GIURIATI ET AL.
37. Covotta A, Gagliardi M, Berardi A. et al. Physical
activity scale for the elderly: translation, cultural adap-
tation, and validation of the Italian version. Curr
Gerontol Geriatr Res. 2018;2018:1–7. PMID: 30224917.
doi:10.1155/2018/8294568.
38. Tofani M, Candeloro C, Sabbadini M. et al. The psy-
chosocial impact of assistive device scale: italian valida-
tion in a cohort of nonambulant people with
neuromotor disorders. Assist Technol. 2018;25:1–6.
PMID: 29694271. doi:10.1080/10400435.2018.1469553.
39. Berardi A, Biondillo A, Màrquez MA. et al. Validation
of the short version of the Van Lieshout Test in an
Italian population with cervical spinal cord injuries: a
cross-sectional study. Spinal Cord. 2018;57:339–345.
doi:10.1038/s41393-018-0226-4.
40. Berardi A, De Santis R, Tofani M. et al. The
Wheelchair Use Confidence Scale: italian translation,
adaptation, and validation of the short form. Disabil
Rehabil Assist Technol. 2018;13:575–580. PMID:
28758517. doi:10.1080/17483107.2017.1357053.
41. Parente M, Tofani M, De Santis R, Esposito G,
Santilli V, Galeoto G. The role of the occupational
therapist in disaster areas: systematic review. Occup
Ther Int. 2017;2017:1–8. doi:10.1155/2017/6474761.
42. Nobilia M, Culicchia G, Tofani M. et al. Italian version
of the Jebsen-Taylor hand function test for the assess-
ment of hand disorders: a cross-sectional study. Am
J Occup Ther. 2019;73(3):1–6. PMID: 31120838.
doi:10.5014/ajot.2019.030080.
43. Tofani M, Nobilia M, Culicchia G. et al. The Italian
version of rheumatoid arthritis pain scale (IT-RAPS):
psychometric properties on community and clinical
samples. Reumatismo. 2019;71:13–18. PMID:
30932438. doi:10.4081/reumatismo.2019.1043.
44. Galeoto G, Iori F, De Santis R. et al. The outcome
measures for loss of functionality in the activities of
daily living of adults after stroke: a systematic review.
Top Stroke Rehabil. 2019;26:236–245. PMID: 30774018.
doi:10.1080/10749357.2019.1574060.
45. Berardi A, Dhrami L, Tofani M, Valente D, Sansoni J,
Galeoto G. Cross-cultural adaptation and validation in
the Italian population of the wolf motor function test
in patients with stroke. Funct Neurol. 2018 Oct/Dec;33
(4):229–253. PMID:30663971.
46. Dattoli S, Colucci M, Soave MG. et al. Evaluation of
pelvis postural systems in spinal cord injury patients:
outcome research. J Spinal Cord Med. 2018;18:1–13.
PMID: 29668375. doi:10.1080/10790268.2018.1456768.
47. Attanasio G, Camerota F, Ralli M. et al. Does focal
mechanical stimulation of the lower limb muscles
improve postural control and sit to stand movement
in elderly? Aging Clin Exp Res. 2018;30:1161–1166.
PMID: 29468616. doi:10.1007/s40520-018-0909-x.
48. Murgia M, Bernetti A, Delicata M. et al. Inter- and
intra-interviewer reliability of Italian version of
Pediatric Evaluation of Disability Inventory (I-PEDI).
Ann Ig. 2018;30:153–161. PMID: 2946511. doi:10.7416/
ai.2018.2206.