In this , we have covered what is aquatic therapy, what are properties of water, how it works on different body systems, types, therapeutic effects, contraindications and few recent advances.

1. AQUATIC THERAPY
-Simran Narang
Department of Musculoskeletal PT

2. CONTENTS
 Introduction
 How it emerged
 Physical properties of water
 Therapeutic effects
 Contraindications
 Design of exercise program
 Techniques
 Effect on different systems
 Recent Advances

3. INTRODUCTION
 Aquatic therapy, utilizing swimming and exercise activity to
improve function, is believed to have beneficial consequences for
physiological and psychological well-being (Campion, 1990;
Davis & Harrison, 1988; Hurley & Turner, 1991; Skinner &
Thomson 1989).
Aquatic Physical Therapy (APT) is defined as ‘‘the special
practice of physiotherapy, with therapeutic intent toward the
rehabilitation or attainment of specific physical and functional
goals of individuals using the medium of water”
 Aquatic exercise refers to the use of multidepth immersion pools
or tanks that facilitate the application of various established
therapeutic interventions, including stretching, strengthening, joint
mobilization, balance and gait training, and endurance training.
 Rehabilitation commonly focuses on improving the physical
function associated with illness, injury, or disability.

4. HOW IT EMERGED
 In 1911, Dr. Charles Leroy Lowman, the founder of the Orthopaedic Hospital in
Los Angeles, began using therapeutic tubs to treat spastic patients and those with
cerebral palsy after a visit to the Spaulding School for Crippled Children in
Chicago, where he observed paralyzed patients exercising in a wooden tank.
 The invention of the Hubbard Tank, developed by Leroy Hubbard, launched the
evolution of modern aquatic therapy and the development of modern techniques.
 Dr. Lowman's Technique of Underwater Gymnastics: A Study in Practical
Application, published in 1937, introduced underwater exercises that were used to
help restore muscle function lost by bodily deformities.
 The National Foundation for Infantile Paralysis began utilizing corrective
swimming pools and Lowman's techniques for treatment of poliomyelitis in the
1950s.
 In 1992, The American Physical Therapy Association (APTA) recognized the
aquatic therapy section within the APTA .

5. PHYSICAL PROPERTIES OF WATER
1) Density
2) Specific gravity
3) Buoyancy
4) Hydrostatic pressure
5) Viscosity
6) Surface tension

6. Density
 Density (ϱ) is the ratio between the mass of a substance (kg) and
the space it occupies (m3).
 Although the human body is mostly water, the body’s density is
slightly less than that of water and averages a specific gravity of
0.974
 The density (specific weight) of water at 1 atmosphere pressure
and 4 °C is 1000 kg/m3 for freshwater and the mean density of
the human body is 950 kg/m3
 Due to its density, water acts as a counterbalance to the effects
of gravity, such that a body submerged in it will float.
 The force of gravity also acts on this body, which means that if
the body is to remain in static equilibrium (neutral buoyancy)
these two forces must counterbalance one another, that is, the
buoyant force must be equal to the weight (∑F=0) if the body is
to remain suspended in the fluid

7.  When comparing exercise performed in the aquatic and dry land
environment, research has found that when an exercise involves
a horizontal movement at submaximal speeds (e.g., aquatic
treadmill, walking or jogging), at a depth shallow immersion,
oxygen uptake (VO2) and muscle (electromyographic; EMG)
activity are greater than when performing the same exercise at
the same speed on land (Becker, 2009).
 Conversely, when the exercise is static or involves a vertical
movement the metabolic cost, the cardiovascular responses and
neuromuscular activity are reduced in comparison with the same
exercise on land, this being due to the reduction in body weight
produced by the effect of buoyancy (Alberton et al., 2011;
Reilly et al., 2003).

8. Specific Gravity
 Specific gravity is defined as the ratio of the density of a substance to the
density of water
 The human body displaces a volume of water weighing slightly more than the
body, forcing the body upward by a force equal to the volume of the water
displaced.
 Water has a specific gravity of 1.0: any object with a specific gravity less than
1.0 will float in water and anything with a density greater than 1.0 will sink.
 The human body has a density slightly less than that of water and averages a
specific gravity of 0.974, therefore we float.
 Lean body mass, or the mass of the body minus the fat, has a typical density
near 1.1, whereas fat mass has a density of about 0.9. Therefore, an individual
who has a high percentage of lean body mass may require floatation devices.
 In contrast, an obese individual will have a specific gravity considerably less
than 1.0 and will float more easily.

9. Buoyancy
 As the body is gradually immersed, water is displaced, creating
the force of buoyancy.
 Definition: Buoyancy is the upward force that works opposite to
gravity.
 Archimedes 'principle states that an immersed body experiences
upward thrust equal to the volume of liquid displaced.
As the mass of the submerged body increases, the buoyancy force
increases proportionally
Buoyancy will be positive when a body tends to rise within the
fluid and negative when it tends to sink

10. Weight bearing with
immersion at different
level

11. Clinical Significance:
Buoyancy provides the patient with relative weightlessness and
joint unloading, allowing performance of active motion with
increased ease and also allows the practitioner three-dimensional
access to the patient.
Buoyancy can be assistive and resistive at the same time.
A person’s body mass index (BMI), adipose tissue vs. muscle
mass, is the primary determining factor in the degree to which a
person sinks or floats.
Muscle mass has a greater density than water, causing it to sink.
Adipose tissue is less dense, causing it to float.
Each individual’s unique level of buoyancy requires appropriate
flotation devices or weights, depending upon the desired effects of
treatment.

12. Hydrostatic Pressure
 Definition: Hydrostatic pressure is the pressure exerted on
immersed objects.
 Pascal’s law states that the pressure exerted by fluid on an
immersed object is equal on all surfaces of the object.
 A human body immersed to a depth of 48 inches is subjected to a
force equal to 88.9 mm Hg.
 Depends upon depth of submerged water and density of liquid. A
human with specific gravity of 0.97 reaches floating equilibrium
when 97% of his or her volume is submerged.
As the body is gradually immersed, water is displaced, creating
the force of buoyancy and this takes the weight off the immersed
joints progressively. Immersion till pubis symphysis has
effectively off-loaded 40% of his or her body weight, and when
further immersed to the umbilicus, approximately 50% of body
weight is off-loaded. Xyphoid immersion off-loads body weight
by 60% or more, depending on whether the arms are overhead or
beside the trunk

14. Clinical Significance:
1) Exercising in water produces an increase in cardiac output, in
the blood flow to muscles, and in the diffusion of metabolic
waste products from muscle to blood, as well as a reduction in
the time it takes to transport oxygen, nutrients, and hormones to
fatigued muscles (Versey et al., 2013)
2) The proportionality of depth and pressure allows patients to
perform exercise more easily when closer to the surface

15. Viscosity
 Definition: Viscosity is friction occurring between molecules of
liquid resulting in resistance to flow.
 The viscous resistance is directly proportional to the force
exerted against the fluid.
 It is a quality that makes water a useful strengthening medium
and resistance increases as more force is exerted against it.
 Doubling the speed of an arm moving through water requires 8
times the power.
 As soon as movement ceases and the exerted force on the
water disappears, the viscous resistance drops immediately
to zero, resulting in no further resistance on the body.

16.  Thus, when a rehabilitating person feels pain and stops
movement, the force drops very steeply and water viscosity damps
(progressively reduce) movement almost instantaneously. This
allows great control of strengthening activities within the envelope
of patient comfort.
 Clinical Significance:
1) Water’s viscosity creates resistance with all active movements.
2) A shorter lever arm results in increased resistance.
3) Increasing the surface area moving through water increases
resistance.

17. Surface Tension
 Definition: The surface of a fluid acts as a membrane under
tension. Surface tension is measured as force per unit length.
 Properties:
1) The attraction of surface molecules is parallel to the surface.
2) The resistive force of surface tension changes proportionally to
the size of the object moving through the fluid surface.
 Clinical Significance:
1) An extremity that moves through the surface performs more
work than if kept under water.
2) Using equipment at the surface of the water increases the
resistance

18. HYDROMECHANICS
 Hydromechanics comprise the physical properties and
characteristics of fluid in motion.
It is the force created when moving through water, causing
resistance in front of the object
 Components of Flow Motion:
1) Laminar flow
2) Turbulent flow
3) Drag / Resistance

19. Laminar flow: Movement where all molecules move parallel to
each other, typically slow movement.
Turbulent flow: Movement where molecules do not move parallel
to each other, typically faster movements.
Drag: The cumulative effects of turbulence and fluid viscosity
acting on an object in motion.
 Clinical Significance of Drag:
1) As the speed of movement through water increases, resistance
to motion increases.
2) Moving water past the patient requires the patient to work
harder to maintain his/her position in pool.
3) Application of equipment (glove/paddle/boot) increases drag
and resistance as the patient moves the extremity through water.

20. Thermodynamic
 Water temperature has an effect on the body and, therefore,
performance in an aquatic environment.
 Specific heat is the amount of heat (calories) required to raise the
temperature of 1 gram of substance by 1o C.
 Properties: The rate of temperature change is dependent on the
mass and the specific heat of the object.
 Water retains 1000 times more heat than an equivalent volume of
air does.
 Water is an efficient conductor, transferring heat 25 times faster
than air. This thermal conductive property, in combination with the
high specific heat of water, makes the use of water in
rehabilitation very versatile.

21.  Clinical Significance:
1) Differences in temperature between an immersed object and
water equilibrate with minimal change in the temperature of the
water.
2) Heat transfer increases with velocity. A patient moving through
the water loses body temperature faster than an immersed
patient at rest.

23. Cold plunge tanks are often used in athletic training at
temperatures of 10°–15°C to produce a decrease in muscle pain
and speed recovery from overuse injury.
Most public and competitive pools operate in the range of 27°–
29°C, which is often too cool for general rehabilitative
populations, because these populations are usually less active in
the water.
Typical therapy pools operate in the range of 34°–35°C,
temperatures that permit lengthy immersion durations and exercise
activities sufficient to produce therapeutic effects without chilling
or overheating.
Hot tubs are usually maintained at 37.5°– 41°C, although the latter
temperature is rarely comfortable for more than a few minutes,
and even the lower typical temperature does not allow for active
exercise

24. Therapeutic Effects
 Relieves pain and muscle spasm
 Facilitates ROM exercises
 Re-educate paralyzed muscles
 Initiate resistance training
 Facilitate weight bearing activities
 Facilitate CVS exercise
 Improve circulation ( trophic condition of the skin )
 Enhance patient relaxation
 Minimize risk of injury and reinjures during rehab
 Gives the patient encouragement and confidence in carrying out his
exercises

25. CONTRAINDICATIONS
 Unstable angina and cardiac
failure
 Respiratory dysfunction
 Severe peripheral vascular
disease
 Urinary tract infection
 Bowel and bladder incontinence
 Open Wounds
 Severe kidney disease
 Recently Surgery
 Contagious diseases / skin
infections
 Uncontrolled seizures
 Fever
 Cold
 Chemical allergies (Chlorine)
 Hydrophoby

26. Design of Exercise Program
 All sessions should begin with a proper warm-up, such as
walking, biking, or calisthenics, and end with a cool-down that
includes stretching techniques.
 General recommendations suggest exercising for 25 to 30 min a
day 5 times a week to maintain cardiovascular fitness levels.
 Typical water temperatures of therapeutic pools are between 34°C
and 35°C but can be increased or decreased depending on the goal
of the therapy session and the individual.
 Aquatic therapy aimed at maintaining or improving
cardiovascular endurance can include deep water or hydrotrack
running, cross-country skiing, waist-deep aqua running, or water
cycling

27. Techniques
Ai – Chi : uses diaphragmatic breathing and active progressive
resistance training in water to relax and strengthen the body.
Aqua running : a form of cardiovascular conditioning, involving
running or jogging in water, useful for injured athletes and those
who desire a low-impact aerobic workout.
Burdenko method : Originally it is an integrated land-water
therapy approach that develops balance , coordination
, flexibility , endurance , speed , and strength using the same
methods as professional athletes. The water-based therapy uses
buoyant equipment to challenge the center of buoyancy in vertical
positions, exercising with movement in multiple directions, and at
multiple speeds ranging from slow to fast

28. Watsu : in which an aquatic therapist continuously supports and
guides the person receiving treatment through a series of flowing
movements and stretches that induce deep relaxation and provide
therapeutic benefit.
Bad Ragaz Ring Method : focuses on rehabilitation of
neuromuscular function using patterns of therapist-assisted
exercise performed while the patient lies horizontal in water, with
support provided by rings or floats around the neck, arms, pelvis,
and knees. BRRM is an aquatic version of Proprioceptive
Neuromuscular Facilitation (PNF) developed by physiotherapists
at Bad Ragaz, Switzerland,
Halliwick Concept : focuses on biophysical principles of motor
control in water, in particular developing sense of balance
(equilibrioception) and core stability

29. Effect on different
systems

30. Effect on Cardiovascular and Cardiopulmonary System
An individual immersed in water is subjected to external water
pressure in a gradient, blood is displaced upward through the
venous and lymphatic systems, first into the thighs, then into the
abdominal cavity vessels, and finally into the great vessels of the
chest cavity and into the heart.
 Central venous pressure rises with immersion to the xyphoid and
increases until the body is completely immersed. There is an
increase in pulse pressure as a result of the increased cardiac
filling and decreased heart rate.
 Pulmonary blood flow increases with increased central blood
volume and pressure.

31. 1) Central blood volume
increases by
approximately 0.7 L
(60%)
2) Cardiac volume
increases 27% to 30%
3) Mean stroke volume
increases 35% on
average
4) Heart rate drops and
typically at average
pool temperatures the
rate lowers by 12% to
15%
5) Cardiac output
increases by about
1500 mL/min during
clavicle depth
immersion, of which
50% is directed to
increased muscle blood
flow (age and
temperature
dependent).

32.  As cardiac filling and stroke volume increase with progress in
immersion depth from symphysis to xyphoid, the heart rate
typically drops and typically at average pool temperatures the rate
lowers by 12% to 15%. This drop is variable, with the amount of
decrease dependent on water temperature.
 In deep water running, oxygen consumption (VO2) is 3 times
greater at a given speed of running (53 m/min) in water than on
land. Thus, looking at the reverse effect, during water walking and
running, only one half to one third the speed is required to achieve
the same metabolic intensity as on land.
 Caution is taken when working with people with severe valve
insufficiency, because cardiac enlargement can mechanically
exacerbate this problem during full immersion.
 A summary published in 2008 has concluded that aquatic and
thermal therapies may be a very useful rehabilitative technique in
individuals with mild to moderate heart failure.

33.  Warm water immersion can increase heart rate and thus cardiac
output, with cardiac output increasing 1500 mL/min of clavicle
depth immersion.
 Fifty percent of this increase in cardiac output is increased blood
muscle flow.
Patients with high blood pressure need to be closely monitored
when exercising because systolic blood pressure increases with
increasing workload.
For patients with cardiac disease resulting in higher-than normal
heart rates and cardiac output, aquatic therapy in colder water may
be more beneficial because immersion in colder water can
decrease the heart rate by 12% to 15%, which decreases cardiac
output.

34.  Aquatic therapy with pool temperatures ranging from 31°C to
38°C has proved to be a safe and effective rehabilitation
alternative for hypo-, hyper-, and normotensive individuals with
cardiac impairments.
 Patients with pulmonary dysfunction such as those with chronic
obstructive pulmonary disease (COPD) or congestive heart failure
can use aquatic therapy as a form of inspiratory muscle training in
addition to the regular aquatic strength training.
It is recommended that patients with COPD begin aquatic therapy
at waist-deep levels to decrease the amount of pressure placed on
the thorax and progress to deeper levels as their strength,
respiratory capacity, and tolerance improve.

35. Effect on Musculoskeletal System
 The effects are caused by the compressive effects of immersion as
well as reflex regulation of blood vessel tone.
During immersion, it is likely that most of the increased cardiac
output is redistributed to skin and muscle.
Resting muscle blood flow has been found to increase from a dry
baseline of 1.8 mL/min/100 g tissue to 4.1 mL/min/100 g tissue with
neck immersion
Muscle blood flow increased 225% above dry land flow. It is
reasonable to conclude that oxygen delivery is significantly increased
during immersion at rest.
The hydrostatic effects of immersion, possibly combined with
temperature effects, have been shown to significantly improve
dependent edema and subjective pain symptoms in patients with
venous varicosities.

36. Muscle blood
flow during
immersion

37. Effect on Respiratory System
The pulmonary system is profoundly affected by immersion of the
body to the level of the thorax. Part of the effect is due to shifting
of blood into the chest cavity, and part is due to compression of
the chest wall itself by water.
 Vital capacity decreases by approximately 6% to 9% when
compared with xyphoid-submerged controls due to increased
thoracic blood volume and half due to hydrostatic forces that
counteract inspiratory musculature.
 The combined effect of all of these changes is to increase the total
work of breathing when submerged to the neck.

38. The total work of breathing
at rest for a tidal volume of
1 L increases by 60%
during submersion to the
neck

39.  Most of the increased work occurs during inspiration.
 Inspiratory muscle weakness is an important component of many
chronic diseases, including congestive heart failure and chronic
obstructive lung disease.
Because viscosity and flow rates under turbulent conditions enter
into the elastic workload component of breathing and perhaps into
the dynamic component as respiratory rate increases, there is an
exponential workload increase with more rapid breathing, as
during high-level exercise with rapid respiratory rates.
For an athlete used to land-based conditioning exercises, a
program of water-based exercise results in a significant workload
demand upon the respiratory apparatus, primarily in the muscles
of inspiration.
 Because inspiratory muscle fatigue seems to be a rate- and
performance-limiting factor even in highly trained athletes,
inspiratory muscle strengthening exercises have proven to be
effective in improving athletic performance in elite cyclists and
rowers.

40. Effect in Geriatric
Morris defines balance as “the ability to control one’s body
position for stability and orientation” (2010, p. 104).
People with reduced balance control are at higher risk for falling
and as people age, their body alignment changes so that their body
weight is no longer centered over their base of support.
Also, older adults also have weaker muscles, which makes it
harder for them to hold an upright posture.
The aquatic environment is safe for older adults to exercise in
because of buoyancy (Becker, 2009). Since the direction of the
buoyant force is upward, it offloads (or removes) a percentage of a
person’s weight, or the force of gravity on the body (Gangaway,
2010).

41. Receptors in the spine detect the proper posture and learn how to
hold the body in correct postural position.
Therapists can add a turbulence to create an intentional balance
threat to build core strength.
During aquatic exercise, the buoyant force offloads weight from
the joints, which reduces pain in the affected joints. Warm water
can also help reduce joint pain.
A submerged body also experiences the effects of hydrostatic
pressure.
The pressure difference increases circulation in the body.
 As more blood returns to the heart, cardiac preload increases.
Gulick explains that stimulation of venous return starts the
Starling reflex: the muscle fibers in the heart stretch more due to
the increased preload, and as a result they contract more, which
increases the amount of oxygenated blood that the heart can pump
out to the body.

42. Effect on Renal System

43. Recent
Advances

44. Musculoskeletal Conditions
 Usmary S. Siqueira et al (2017) carried out a study on 133 women suffering
from RA, aged between 40 to 65 years, to compare the effectiveness of land-
based (LB) and water-based (WB) aerobic exercises. Intervention was done
thrice a week for 16 – week. The level of immersion was adjusted to allow the
water therapy patients to maintain a sitting position in the chair during the
execution of 10 of the 11 movements of the exercise protocol. Muscle strength
(MS) using an isokinetic dynamometer, Disease activity (DAS-28) and
functional ability (health assessment questionnaire) were measured. Results
revealed that after 16 weeks, there were no significant changes of knee MS
neither body composition among the groups. However, there was a significant
improvement in disease activity and functional ability in the WB after 8 and 16
weeks.
 Natalia Pérez Ramírez (2019) evaluated the effectiveness of Watsu compared to
conventional hydrotherapy on health-related quality of life (HRQoL), functional
health status, pain, and ranges of joint motion in patients with acute or subacute
JIA. 46 patients aged between 8-18 years old were recruited, duration of 10
sessions, once a week, with 45-minute sessions and results revealed that Watsu
therapy showed statistically significant improvements in physical functioning –
HRQoL, disability index, distress index, and functional health status – CHAQ
after treatment compared to conventional hydrotherapy

45.  Billy C.L. So et al.(2019) investigated the efficacy of a 4-week community aquatic
physiotherapy program with Ai Chi or the Bad Ragaz Ring Method (BRRM) on
pain (VAS) and disability (Roland-Morris Disability Questionnaire) in 44 adults
with chronic low back pain (CLBP). Other outcome were single leg stand test,
prone and supine bridge maneuvers, modified Schober test, Rehabilitative
ultrasound imaging (Transverse abdominis muscle thickness). Results revealed
significant pre – to post – treatment improvement in disability and global core
muscle endurance. Ai Chi appeared to have an additional benefit of improving
single leg standing balance and BRRM an additional benefit of reducing pain.
 L. Linton et al.(2017) evaluated muscle activity in people (18-45 year) with CLBP
(n=20) and controls (n=20) in water and on land when they perform exercises
involving dynamic upper and lower limb movements with a stable trunk and
pelvis. Waterproof wireless surface electromyography synched with video analysis
measured 7 muscles bilaterally (multifidus, erector spinae, internal oblique,
external oblique, rectus abdominis, gluteus maximus and gluteus medius). Results
showed no significant differences in mean and peak activity for any muscle or
exercise between both group in both land and aquatic exercises. For exercises with
the same movement patterns on land and in water, several significant differences in
muscle activity were found such as higher mean gluteal activity on land (P<0.01)
for unilateral hip movements. The incidence of pain was lower (2.8%) during
water exercises, but up to 3 times higher during some exercises on land (7.5%).
Lower incidences of pain in water suggest it may be an appropriate environment
for rehabilitating individuals with even higher levels of chronic disability..

46. Neurological Impairments.
Individuals suffering from a variety of neurological diseases often
have impairments such as hemiparesis, decreased balance,
decreased proprioception, decreased ROM, and difficulty with
ambulation.
Buoyancy allows for decreased weight bearing and reduces the
effort needed to support the body.
Aidar F.J. et al. in 2018 conducted a 12 – week study on 43 stroke
patients and concluded that 43 minute session done twice a week
promotes improvements in the levels of depression and anxiety in
people who suffered an ischemic stroke

47. In a study by Lee et al.(2018), the cardiorespiratory 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. Vlachopoulos et al.(2010) found that an improvement in
arterial stiffness can decrease the risk of relapses and/ or mortality
and morbidity associates with stroke.
Sevda Adar et al.(2017) carried out a study on 32 CP children aged
between 4 to 17 years to compare the effects of aquatic exercises
and land-based exercises on spasticity, quality of life, and motor
function and also assessed the morphology of spastic muscle using
ultrasonography. 30 minutes session were given five times per
week for six weeks and results revealed that aquatic exercise
produced a higher improvement in quality of life scores than the
land-based exercises. Also, post-treatment ultrasonographic
assessment of spastic gastrocnemius muscle showed a significant
improvement in the compressibility ratio in the aquatic exercise
group

48. Bolarinwa Isaac Akinola et al. in 2019, investigated the effect of a
10-week aquatic exercise training program on gross motor
function in children with 30 spastic CP aged 1 – 12 years and
found that only the experimental group showed significant
improvement (P < .05) in all dimensions of gross motor function
except for walking, running, and jumping
In 2019, Priya C et al. conducted a study to analyze the aquatic
therapy session in comparison with the regular physiotherapy
session in toddler’s with Down Syndrome. 21 children were aged
between 6 months to 4 years and participated in aqua therapy
twice a week with conventional therapy 5 days a week. Study
results stated most of the parameters studied on the Down’s
syndrome children namely sitting, creeping, standing, crawling,
pushing, moving, walking and kicking improved significantly
(p<0.01) on Down’s Syndrome children who underwent both
exercise and aqua therapy as compared to children who underwent
only land exercise.

49. Geriatric
 Li-Jung Chen et al. (2015) examined the effects of an 8 week aquatic exercise
program on objectively measured sleep parameters among 67 older adults (55–70
years of age) with mild sleep impairment. Participants wore wrist actigraphs to
assess seven parameters (seven indices of sleep quality: sleep onset latency, sleep
efficiency, total sleep time (TST), wake after sleep onset (WASO), total activity
counts, and number and length of awakenings) of sleep for 1 week before and after
the intervention. Physical fitness was assessed by the 8-ft up-and-go test and the 2-
min step test. Results showed that exercise group reported significantly less time
on sleep onset latency and greater sleep efficiency.
 B. Rhett Rigby (2018) compared the effect of aquatic treadmill exercise (ATM) to
land treadmill exercise (LTM) in 10 adults (mean age = 51± 6) with and without
type 2 diabetes (T2d). Heart rate, systolic and diastolic blood pressure, absolute
and relative oxygen consumption, and energy expenditure were measured at rest
and during steady-state exercise at each intensity. A major finding from this study
was the dBp value was higher in the T2d versus the group without T2d
independent of treadmill mode or stage. Other noteworthy findings were all
variables, including DBp, increased as speed increased independent of group or
treadmill mode. When comparing those with and without T2D, cardiorespiratory
and metabolic variables are similar in both groups during locomotion on land and
in an aquatic environment.

50.  Pilot trial by Stefano Masiero et al. (2019) assessd thermal hydrokinesiotherapy
efficacy on pain, mood, and quality of life and enrolled 11 participants (mean age
of 70.55±14 years) with total hip replacement (THR) after early hospital discharge.
standardized combined land-based and hydrokinesiotherapy rehabilitation program
was designed for 2 consecutive weeks. Data was collected at admission, discharge,
3 and 6 months from surgery. Functional outcome scores improved and were
maintained at 6-month follow-up. Results support the hypothesis of a contribution
of aquatic thermal therapy in the rehabilitation process of this population.
 A pilot study was conducted by Michal Nissim et al (2020) to examine the effects
of an aquatic physical intervention program on balance, gait, fall risk and working
memory among 42 community-dwelling older individuals (65–89 years) and
secondary objective was to examine the effects of an aquatic physical intervention
program on safety of street–crossing among community-dwelling older
individuals. Participants had to score below 10 on the Geriatric Depression Scale.
Protocol included 30-min sessions twice a week for 12 weeks. Results revealed
The differences in Tinetti balance ,fall risk, digit span forward and Corsi blocks
forward and backward scores after 12 weeks between the groups were significant.
The API group showed improved scores. The differences in hazard perception test
for pedestrians scores after 12weeks of intervention between the groups were
marginally significant.

51. Cardiovascular Conditions
 In 2018, a study conducted in Pune, aimed to explore and compare the effects
of aquatic exercise on the heart rate, blood pressure, rate of perceived exertion
(Modified Borg score ) and VO2 max, between normal and overweight
persons(18-35 years). 20 individuals attended the protocol for 6 weeks. Study
concluded that Underwater treadmill training helps reduce heart rate, blood
pressure, rate of perceived exertion in normal as well as overweight men. Also
there is an increase in the maximal oxygen consumption for both groups.
Therefore, no statistical difference was seen in both groups. (National Journal
of Integrated Research in Medicine)
 Julie Adsett et al. (2016) determined the feasibility and efficacy of aquatic
exercise training during a maintenance phase for 51 clinical heart failure
population. Six-minute walk test (6MWT), grip strength, walk speed, and
measures of balance were compared for the two training protocols within 12
weeks. However improvements in 6MWT were greater in the land-based
training group (p=0.038), by a mean difference of 10.8 metres. No significant
difference was observed for other parameters when the two training protocols
were compared. It is feasible for aquatic exercise training to be undertaken in
stable HF patients during a maintenance phase in a clinical setting. Attending
one session per week was sufficient to maintain functional performance
throughout the study duration.

52. Song-Young Park et al. (2019) examined the effects of 12 week
aquatic walking exercise on cardiovascular function,
53 cardiorespiratory capacity (VO2max), exercise tolerance
(6MWD), physical function, muscular strength, and body
composition in 72 patients with peripheral arterial disease. There
were significant group by time interactions after 12 weeks for
legPWV (Femoral-to-ankle pulse wave velocitY) and HR
which significantly decreased, and VO2max, 6MWD, physical
function, and muscular strength, which significantly increased in
aquatic group. There 64 were no significant differences (p>0.05)
for BP, ABI, resting metabolic rate, or flexibility after 12 weeks.

53. THANK YOU