The unique physical properties of water create a therapeutic environment impossible to replicate on land. Buoyancy reduces body weight by up to 90%, hydrostatic pressure improves circulation, and warmth promotes muscle relaxation. For those living with chronic pain conditions or recovering from surgery, these properties can make the difference between struggling with exercise and thriving through rehabilitation.
Aquatic Therapy: Proven Benefits for Pain Relief and Rehabilitation
How water-based rehabilitation delivers measurable improvements for osteoarthritis, fibromyalgia, and balance disorders
Key finding: Water-based rehabilitation delivers measurable improvements in pain, function, and quality of life across a broad spectrum of conditions. A 2023 meta-analysis of 32 randomised controlled trials involving 2,200 participants found aquatic therapy improved balance by 6.36cm on functional reach tests compared to land-based alternatives—a clinically meaningful difference for fall prevention.
At CK Physio, we understand that effective rehabilitation requires matching the right treatment approach to each patient's unique circumstances. For many conditions—particularly osteoarthritis, fibromyalgia, and balance disorders in older adults—the evidence strongly supports aquatic therapy as part of a comprehensive treatment plan.
The Scientific Case for Water-Based Rehabilitation
Recent systematic reviews have substantially strengthened the evidence base for aquatic therapy. Wang and colleagues' 2023 meta-analysis demonstrated positive impacts on pain, physical function, and quality of life across chronic musculoskeletal disorders. For knee osteoarthritis specifically, research published in 2024 reported that hydrotherapy significantly improved pain relief within one week, with no serious adverse events across all trials analysed.
The comparison between aquatic and land-based therapy reveals nuanced advantages for each approach. For chronic low back pain, aquatic therapy proved superior at 3, 6, and 12-month follow-ups in a study published in JAMA Network Open. For fibromyalgia, a 2025 network meta-analysis ranked aquatic exercise as the most effective therapeutic exercise for short-term pain reduction.
Why Water Works: The Physics of Hydrotherapy
What makes water uniquely therapeutic relates to its fundamental physics. At chest depth, patients experience approximately 75% body weight reduction; at neck depth, this reaches 90%. This allows individuals who struggle with weight-bearing exercises on land to move freely and build strength without excessive joint stress.
Hydrostatic pressure creates uniform 360-degree compression, enhancing venous return and reducing peripheral oedema. Water conducts heat 25 times faster than air, allowing warm pools maintained at 32-34°C to promote muscle relaxation, increase tissue extensibility, and activate the parasympathetic nervous system—creating conditions ideal for healing.
Conditions with the Strongest Evidence
Osteoarthritis of the Knee and Hip
Osteoarthritis commands the most robust evidence base for aquatic therapy. The Cochrane review established moderate-quality evidence for clinically relevant effects on pain, disability, and quality of life. A 2025 network meta-analysis comparing 12 physical therapy options ranked hydrotherapy second only to knee bracing for effectiveness.
Patients typically report significantly reduced pain and stiffness after structured programmes combining underwater treadmill work with targeted exercises. If you're managing osteoarthritis, our physiotherapy treatments can help you explore whether aquatic therapy might complement your current care plan.
Fibromyalgia
Fibromyalgia patients demonstrate particularly strong responses to warm water therapy. Multiple systematic reviews from 2023-2024 confirm significant benefits over no intervention for pain, fatigue, fibromyalgia impact, depression, and both physical and mental function. Research found that programmes exceeding 20 weeks produced 43.5-metre improvements in six-minute walk tests alongside meaningful reductions in stiffness.
The Cochrane review concluded that aquatic training improves wellness, symptoms, and fitness in this population—offering hope for those who have found land-based exercise too painful.
Balance Disorders in Older Adults
Elderly adults represent perhaps the ideal population for aquatic therapy. A 2023 systematic review found aquatic approaches more effective than land-based alternatives for balance, gait, quality of life, and crucially, reducing fear of falling.
The water environment provides inherent safety during balance training—a critical consideration when falls represent a leading cause of injury in this demographic. For those concerned about stability, this safety net can make the difference between avoiding exercise entirely and engaging in effective rehabilitation.
Neurological Conditions
For neurological conditions, the evidence reaches moderate strength with promising results. Stroke patients demonstrate improvements in balance, walking speed, muscular strength, proprioception, and quality of life when aquatic therapy is compared to land-based alternatives. Parkinson's disease patients show 1.5-second improvements in Timed Up and Go tests—a clinically meaningful gain for mobility.
Multiple sclerosis patients benefit from improved postural balance and reduced fatigue without adverse effects, though cooler water temperatures below 29°C are recommended to prevent heat-related symptom exacerbation.
Post-Surgical Rehabilitation
Post-surgical rehabilitation shows limited but promising evidence. Moderate-quality research indicates that combining aquatic and land-based therapy after hip or knee replacement improves functional outcomes and knee range of motion while reducing oedema compared to land-based therapy alone. ACL reconstruction benefits from aquatic therapy's ability to introduce plyometric training earlier, maintain cardiovascular fitness, and provide superior proprioceptive training.
Understanding Different Approaches to Aquatic Therapy
The terminology surrounding water-based therapy can create confusion. Aquatic physiotherapy specifically denotes programmes designed by HCPC-registered, degree-trained physiotherapists utilising water's properties to maximise individual function. Hydrotherapy encompasses a broader category including both active and passive treatments. Balneotherapy refers to hydrotherapy without exercise—essentially spa therapy—and systematic reviews demonstrate aquatic exercise produces superior outcomes for musculoskeletal conditions.
Specialist Techniques
Ai Chi combines Tai Chi principles with warm water immersion through 19 choreographed movements performed at breathing rate. Evidence supports its use for knee osteoarthritis (with substantial WOMAC improvements after 10 sessions), chronic stroke, and Parkinson's disease. The Dutch Clinical Practice Guideline for Stroke recommends Ai Chi based on Level 1 evidence.
Watsu (Water Shiatsu) involves passive one-on-one therapy where patients are floated, cradled, stretched, and massaged. A 2020 meta-analysis established moderate evidence for beneficial effects on pain in fibromyalgia, low back pain, and neck pain, alongside improved quality of life and psychological wellbeing.
The Halliwick Concept, developed in London in the 1950s, employs a Ten-Point Programme progressing from water adaptation through rotational control to swimming movements. Research shows particular effectiveness for cerebral palsy and autism spectrum disorder.
The Mental Health Benefits of Aquatic Therapy
Beyond physical rehabilitation, aquatic therapy produces measurable mental health improvements that warrant clinical attention. A 2022 systematic review in Frontiers in Psychiatry found aquatic exercise significantly improved mood and anxiety symptoms. Notably, aquatic exercise demonstrated superior anxiety reduction compared to land-based aerobic exercise, traditional Chinese exercise, and meditation.
The mechanisms underlying these psychological benefits involve both physiological and experiential factors. Warm water immersion reduces cortisol levels, releases endorphins and dopamine, and reduces pro-inflammatory cytokines. The sensation of weightlessness reduces perceived physical burden, while hydrostatic pressure provides calming sensory input.
Interestingly, research indicates low-intensity aquatic exercise produces greater mental health benefits than high-intensity approaches—patients need not push themselves hard to gain psychological benefits.
Accessing Aquatic Therapy in the UK
NICE explicitly recommends hydrotherapy as adjunctive therapy for axial spondyloarthritis (Guideline NG65)—the only major NICE guideline containing a specific hydrotherapy recommendation. The guidance states clinicians should "consider hydrotherapy as an adjunctive therapy to manage pain and maintain or improve function."
The Chartered Society of Physiotherapy (CSP) recognises the Aquatic Therapy Association of Chartered Physiotherapists (ATACP) as the professional network establishing competency standards. Patients seeking qualified practitioners should verify ATACP accreditation or ensure their physiotherapist has completed Foundation Programme training.
Note on NHS Access: NHS hydrotherapy services vary considerably by location. A 2017 survey found 85% of physiotherapists had referral access to NHS hydrotherapy, though up to 25% of hydrotherapy pools remained closed following the pandemic. Funding pressures have created variable access across different areas. At CK Physio, we can advise you on the most appropriate treatment options for your specific circumstances.
What to Expect from Aquatic Physiotherapy
Initial aquatic physiotherapy appointments typically last 45-60 minutes and occur on land, allowing thorough assessment, medical history review, and treatment planning. Subsequent pool sessions usually run 45-60 minutes at frequencies of 1-3 times weekly. Pools are maintained at therapeutic temperatures between 28-34°C with depths allowing standing at various levels.
You don't need to know how to swim. Flotation devices support those uncomfortable in water, and head submersion is rarely required. Trained therapists and lifeguards maintain safety throughout sessions. Contraindications requiring screening include open wounds, active infections, uncontrolled epilepsy, severe cardiac conditions, and extreme water fear.
What to Bring to Your Session
- Swimwear allowing free movement
- Towel
- Water bottle
- Pool shoes or flip-flops
Optimal Treatment Protocols
Research suggests optimal protocols include water temperatures of 30-34°C, session durations of 45-60 minutes, frequencies of 2-3 times weekly, and minimum programme lengths of 8-12 weeks. Combined aquatic and land-based approaches often outperform either alone, allowing water-based gains to transfer to functional daily activities.
When pool access proves limited, land-based alternatives can partially replicate aquatic benefits. Resistance bands simulate water resistance, balance training on unstable surfaces addresses proprioceptive goals, and supported exercises reduce joint loading. However, certain aquatic-specific benefits—uniform hydrostatic pressure, precise temperature control, the unique sensory environment—cannot be fully replicated on land.
Frequently Asked Questions
What conditions can aquatic therapy help treat?
Aquatic therapy has the strongest evidence base for osteoarthritis of the knee and hip, fibromyalgia, and balance disorders in older adults. It also shows promising results for neurological conditions such as stroke recovery, Parkinson's disease, and multiple sclerosis, as well as post-surgical rehabilitation following hip or knee replacement.
Do I need to know how to swim for aquatic physiotherapy?
No, you do not need to know how to swim. Flotation devices support those who are uncomfortable in water, and head submersion is rarely required during aquatic physiotherapy sessions. Trained therapists and lifeguards maintain safety throughout all sessions.
How does aquatic therapy compare to land-based exercise?
For chronic low back pain, aquatic therapy has shown superior results at 3, 6, and 12-month follow-ups compared to land-based alternatives. Water provides unique benefits including up to 90% body weight reduction through buoyancy, 15 times greater resistance than air, and uniform hydrostatic pressure that improves circulation. However, combined aquatic and land-based approaches often deliver the best overall outcomes.
What should I expect during an aquatic physiotherapy session?
Initial appointments typically last 45-60 minutes and occur on land for thorough assessment and treatment planning. Subsequent pool sessions run 45-60 minutes at frequencies of 1-3 times weekly. Pools are maintained at therapeutic temperatures between 28-34°C. You should bring swimwear allowing free movement, a towel, water bottle, and pool shoes.
Is hydrotherapy recommended by NICE guidelines?
Yes, NICE explicitly recommends hydrotherapy as an adjunctive therapy for axial spondyloarthritis in Guideline NG65. The guidance states clinicians should consider hydrotherapy to manage pain and maintain or improve function. This is currently the only major NICE guideline containing a specific hydrotherapy recommendation.
The Evidence Supports Broader Clinical Adoption
The research landscape for aquatic therapy has matured substantially, with multiple high-quality systematic reviews now supporting its effectiveness across conditions. Osteoarthritis, fibromyalgia, and balance disorders in older adults demonstrate the strongest evidence, while neurological conditions and post-surgical rehabilitation show moderate support warranting clinical consideration.
The evidence limitations merit acknowledgment—most studies feature small samples, variable protocols, and limited long-term follow-up. GRADE assessments frequently rate evidence quality as low to moderate. Yet the consistent direction of findings across conditions, populations, and research groups strengthens confidence in aquatic therapy's legitimate role within evidence-based rehabilitation.
When aquatic therapy is accessible, the science suggests it deserves serious consideration as a rehabilitation option—particularly for patients who struggle with land-based exercise due to pain, fear of falling, or joint loading intolerance. The water, it appears, offers therapeutic properties that land simply cannot match.
Explore Your Treatment Options
If you're living with chronic pain or recovering from injury, our Chartered Physiotherapists can help you understand which treatment approaches might work best for your specific circumstances.
Book Your AssessmentReferences & Further Reading
- Wang T, Wang J, Chen Y, et al. (2023). Efficacy of aquatic exercise in chronic musculoskeletal disorders: a systematic review and meta-analysis of randomized controlled trials. Journal of Orthopaedic Surgery and Research, 18:942. View study
- Bartels EM, Juhl CB, Christensen R, et al. (2016). Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database of Systematic Reviews. View Cochrane review
- National Institute for Health and Care Excellence (2017). Spondyloarthritis in over 16s: diagnosis and management (NG65). View NICE guideline
- Chartered Society of Physiotherapy - Aquatic Therapy Association of Chartered Physiotherapists. Learn more about ATACP
- NHS - Hydrotherapy overview. NHS physiotherapy information
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