Aquatic Therapy for Stroke Rehabilitation

Could an aquatic environment create the same results as other gait training methods?

Rehab professionals are more than familiar with the impacts of stroke — and the most common treatment plans. While the aftermath of a stroke clearly varies from patient to patient, the typical treatment plans are somewhat static.

Speech-language pathologists will use aphasia-centric methods; occupational therapists will help with meal preparation or home navigation; physical therapists will turn to gait training. But could there be an alternative to the popular treadmill-assisted gait training for these unique patients?

Though yet to take the lead in stroke therapy options, aquatic therapy holds much promise. Unlike traditional gait training, this alternative is low impact, less stressful on joints, safer and often more enjoyable for patients. A warm-water pool enables patients to move with more ease, increasing flexibility while decreasing muscle strain, and even stroke patients who are unable to stand on land may have success with aquatic therapy.1

Yet it seems logical to expect that the traditional route may hold more promise. After all, aquatic therapy isn’t new — variations of the technique date back thousands of years — and it still isn’t a preferred treatment for stroke patients. So why is aquatic therapy so frequently overlooked for these patients?

Lack of Research

Largely, the reluctance of physical therapists to use this technique for stroke patients can be attributed to a lack of research. Physical therapists who work with stroke patients have long relied on treadmills for treatment plans – and for good reason. There is no lack of research on the effectiveness of this type of therapy for stroke patients, and of course, clinicians are trained to trust what research has defended over what hasn’t yet been studied.

While treadmill training with bodyweight support has not necessarily been shown to be more effective than other physiotherapy treatments for increasing the chances of walking independently after stroke, it certainly is effective. Additionally, this specific training for stroke patients has shown to significantly increase walking velocity and walking endurance.2

Unlike bodyweight-supported treadmill training, aquatic therapy has been the subject of very few studies, none of which were focused on stroke. However, a lack of research does not indicate a lack of success.

“I use aquatic therapy in my practice and teach about it in my classes. I’ve seen it work,” said Chris McNamara, DPT, clinical assistant professor and clinical director of the department of physical therapy at Ithaca College, Ithaca, N.Y. “Many patients, many diagnoses, improve with aquatic therapy. Unfortunately, there’s a limited amount of evidence to support that.”

As an educator and clinician who specializes in aquatic therapy, McNamara has learned to trust the technique despite the lack of research-based evidence. However, she knows that other clinicians might be unwilling to utilize aquatic therapy for stroke treatment given the gap in research. So she has partnered with her colleague, Sarah Fishel, PT, assistant professor in the department of physical therapy at Ithaca College, to bridge that gap.

Opportunities for Growth

Fishel and McNamara are spearheading a new study that seeks to compare aquatic therapy for stroke survivors with treadmill training. In the study, eligible participants who have suffered a stroke more than six months ago and have been cleared for exercise will be randomly placed in one of three programs: treadmill training, aquatic therapy or a combination of the two. Participants will undergo one month of treatment followed by evaluations to measure progress.

Although neither researcher knows what the results of the study will be, they believe that the two therapies are more alike than different, as they provide bodyweight support and decrease the risk of falling.

Before beginning to set up the current study, Fishel and McNamara arranged a pilot study with just two participants. Both individuals showed improvements, but in different areas. With this new study being the first of its kind, the researchers are unsure of what to expect — but they do have some guesses.

“We expect all groups to improve with walking and balance,” said Fishel. “With the delivery of skilled, task-specific training, any patient with stroke is likely to improve. What we’re trying to see is how the impact of these interventions compares.”

Fishel and McNamara both acknowledge that their study alone won’t tell them everything there is to know about the possibilities of aquatic therapy for stroke treatment. However, as researchers, they find the process rewarding and worthwhile for physical therapy as a whole.

“To me, one of the exciting and frustrating things about research is how gradual the process is,” said McNamara. “There’s a vast amount of potential in the aquatic environment for patients who had a stroke six months ago, a year ago, or even two years ago. But the frustrating thing about research is that you need to look at one thing at a time, slowly and carefully, and it has to be that way.”

While the research process is tedious, it’s necessary in order to make aquatic therapy mainstream in stroke treatment. And, in McNamara’s eyes, that alternative will open a new world to stroke patients who may not have access to a practice with the proper equipment for weight-supported treadmill training.

“If we can demonstrate that aquatic therapy is beneficial in making improvements in walking and gait in patients with chronic stroke, my hope is that one day we can prove that aquatic therapy is a viable alternative intervention,” said McNamara. “We think that’ll happen.”


  1. Lewis P. Pool time: Stroke-friendly water rehabilitation. Stroke Smart. 2008.
  2. Mehrholz J, Pohl M, Elsner B. Treadmill training and body weight support for walking after stroke. Cochrane Database Syst Rev. 2014;Jan 23(1),CD002840.

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