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BIOMECHANICAL ASPECTS OF AQUATIC THERAPY: A LITERATURE REVIEW ON

APPLICATION AND METHODOLOGICAL CHALLENGES

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 LITERATURE REVIEW

BIOMECHANICAL ASPECTS OF AQUATIC

THERAPY: A LITERATURE REVIEW ON
APPLICATION AND METHODOLOGICAL
CHALLENGES
Anna C. Severin1, Brendan J. Burkett1, Mark R. McKean1, Mark G.L. Sayers1
1
School of Health and Sports Sciences, University of the Sunshine Coast, Queensland, Australia
Corresponding author: Anna (Cicci) Severin
School of Health and Sports Sciences, University of the Sunshine Coast, Locked Bag 4, Maroochydore
DC, QLD, Australia, 4558; Email: cicci.severin@research.usc.edu.au

ABSTRACT
The application of aquatic therapy for health and rehabilitation purposes has been promoted for centuries.
Although used predominantly in clinical settings for the treatment, rehabilitation and management of chronic
conditions, the practice is also gaining popularity in athletic settings in such areas as recovery training and
for the rehabilitation of acute musculoskeletal injuries.

To date, most studies on the impact of aquatic-based rehabilitation on the human body have focused on
physiological aspects. There is a relative paucity of published research on the biomechanical implications
associated with aquatic-based activity. The published findings have been limited to the influence of the
aquatic environment on running and walking gait.

A clear challenge in this field is absence of standardised protocols for assessing the impact of aquatic
therapy and its possible role in rehabilitation. For example, methodologies often differ considerably between
studies, and there are no standardised reporting procedures for important variables such as water depth
and temperature. The research knowledge in this area has been questioned, with current medical guidelines
highlighting that high quality research into the roles of aquatic therapy in rehabilitation is warranted.

This review will summarise the current literature on water-based activity and how this can impact human
movement and subsequent rehabilitation.

Keywords: water; human movement; underwater kinematics; rehabilitation; fitness; isoinertial sensors

Volume 5, Issue 1, April 2015 | JOURNAL OF FITNESS RESEARCH 48

ISSN 2201-5655 © 2016, Australian Institute of Fitness
INTRODUCTION
The health related benefits of aquatic therapy
have been promoted for centuries.1 Common uses
for aquatic therapy in clinical settings is managing2,
3, 4, 5
and rehabilitating6, 7, 8 chronic conditions such
as osteoarthritis (OA) and fibromyalgia.3, 9, 10 Aquatic
therapy is also used for weight management, athlete
rehabilitation,11, 12, 13, 14 and recovery.15, 16, 17, 18
Despite decades of research examining the roles
of aquatic therapy in rehabilitation, many of the
results from scientific investigations are conflicting,
likely due to differences in applied methodologies
(Table 1). Because of the limited quality of current
research, reviews published by the Cochrane
Collaboration concludes that aquatic-based
rehabilitation programmes are assumed equally
effective to programmes performed on land, but
highlights that further high-quality research is
warranted.2, 19, 20, 21, 22 The lack of consensus among
previous research regarding the efficacy of aquatic-
based rehabilitation is resultant from several
methodological challenges and a lack of consensus
on the most appropriate outcome measures.
This review will briefly evaluate published
literature on water-based activity; its impact on
biomechanics and current role in rehabilitation
protocols. Existing limitations and challenges in
research methodology will also be reviewed along
with gaps and limitations in the current knowledge
and directions for future research will be
recommended.
AQUATIC THERAPY EXPLAINED
The appeal of aquatic therapy as a tool in
exercise, recovery and rehabilitation has increased
over recent years.23, 24, 25 Previous research has
identified several biomechanical and physiological
effects associated with exercising in water that must
be thoroughly understood by practitioners to
prescribe accurate and effective programmes.1, 26, 27,
28
These effects occur because of fundamental
principles of hydrodynamics and physical
properties of water, such as density, buoyancy,
hydrostatic pressure, viscosity and
thermodynamics.1, 26, 29
Volume 5, Issue 1, April 2016 | JOURNAL OF FITNESS RESEARCH
THE PHYSICAL PROPERTIES OF
WATER
Density
Density quantifies a substance’s mass by volume
unit (Kg·m-3).30 The density of 4°C freshwater is
approximately 1,000 Kg·m-3 at sea level (999.97
Kg·m-3). Although the temperature of the water
affects its density, the change is considered small
enough to dismiss (997.05 Kg·m-3 at 25°C).31 An
average human body consists of approximately
60% water,32 and its density is thus slightly lower
than that of water (approximately 974 Kg·m-3).1
The specific density of a human body depends on
body composition.33 Fat free mass, including bone,
muscle, organs and connective tissue, has a density
higher than water (close to 1,100 Kg·m-3) whilst fat
mass has a density lower than water (close to 900
Kg·m-3).33 Thus, an individual with a higher
percentage of fat free mass has a higher density
compared to an individual with a higher fat mass
percentage.
Buoyancy
A human body with a density lower than water
displaces a volume of water that weighs slightly
more than the body itself.1 By Archimedes
principle, an upwardly directed force is exerted on
the body equal to the volume of the water it
displaced. This buoyant force, opposes gravity and
pushes the submerged body towards the surface of
the water.1, 34 Accordingly, a human body with a
specific gravity of 0.974 (a density of 974 Kg·m-3)
will achieve floating equilibrium when 97.4% of the
body is submerged due to buoyancy.1 As the mass
of the submerged body increases, the buoyancy
force increases proportionally.35 Therefore, an
individual immersed to chest level experiences a
larger buoyancy force compared to someone
immersed to the waist.
Hydrostatic pressure
In addition to buoyancy, the volume of water
surrounding the submerged body also exerts a
compressive force on the body - hydrostatic
pressure.36 At sea level the pressure exerted on the
49

body by the air surrounding it is approximately
1013.0 Pa (7.6 mmHg),36 a value that is so small that
it is basically imperceptible. However, the
proportionally greater mass of water means that
immersion in water exposes the body to
considerably higher pressure,37 that like buoyancy,
increases with the depth of immersion at a rate of
approximately 981.0 Pa (73.5 mmHg) per meter.1, 35,
36
Accordingly, standing in water at neck depth will
result in approximately twice the hydrostatic
pressure on the calf muscles than on the chest.
Viscosity
Viscosity is the magnitude of internal friction a
fluid has during motion and is specific to each
fluid.1 An immersed body moving through water,
experiences resistive drag forces opposite to the
direction of travel because of viscosity.1, 34 The
viscous resistance is directly proportional to the
force exerted against the fluid.1 Therefore, the
resistance will increase with increased velocity and
surface area of the moving body.38 For example, a
fully outstretched arm produces a greater resistance
when moving through water than a hand only. 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.1
Thermodynamics
Water has a superior ability to retain heat and
transfer heat energy than air and has a heat capacity
of approximately 1.0 J·K-1 (1,000 times greater than
air).1 Water also has a higher heat capacity
compared to human body tissues (0.83 J·K-1),
resulting in body equilibrating faster than the
surrounding water.1 Thus, a body immersed in
water colder than core temperature will adapt to the
temperature of the water and lose heat. Water
warmer than core temperature therefore warms the
body and raises its core temperature.
Volume 5, Issue 1, April 2016 | JOURNAL OF FITNESS RESEARCH
EFFECTS OF WATER-BASED
EXERCISE ON THE HUMAN
BODY
The physical properties of water have large
biomechanical, neurological, physiological and
hormonal effects on the human body.1, 26, 27, 29, 34, 35
Previous research has identified many of these
effects; however, to explore them individually is
outside the scope of this literature review, thus only
those variables implicating on human movement
will be addressed. For additional insight on the
effects not included here, see reviews by Becker
(2009)1, Denning et al. (2012)26 and Mooventhan
and Nivethitha (2014)27.
Biomechanical effects of immersion
Studies into biomechanical aspects forms a
minority of previous research into the effects of
immersion on the human body.34 Of these, most
reported on differences in gait parameters between
the water- and land-based settings, (Table 1) thus,
insights into biomechanical implications of aquatic
therapy remains unreported. The published
research on water-based gait reports several
significant adjustments enforced by the aquatic
environment, believed to be mainly associated with
buoyancy and drag forces.39 However, some reports
on these adjustments are contradictive, most likely
due to the considerable differences in utilised
methodologies between studies (Table 1).
The inconsistencies in water depth and
temperature alone are likely resulting in differences
in reported findings as both properties are known
to impact on biomechanical variables.1, 36 However,
as the current understanding of biomechanical
adaptations to the aquatic environment is limited to
these reports, their findings should still be taken
into consideration. Most studies reported similar
joint angles during both aquatic and land-based
walking.40, 51, 52, 53, 54, 56, 57 A 2012 review on differences
in gait mechanics in water and on land concluded
similar joint motions at the knee and ankle during
water-walking, but highlighted that the activity at
the hip joint and pelvis increased.39 Several studies
have reported on increased reliance on the hip joint
50
Table 1: Articles investigating the effects of aquatic therapy on gait kinematics.
Study Activity Population Depth Temp Protocol Main Findings

No significant difference in SL, but

Barela and Sagittal view video recording at 60 Hz. significantly lower SF in water
10 elderly Not Self-selected speed on land and in water on
Duarte SR Xiphoid process and force platform recording at 1000 Slower walking speed in water
adults reported a walkway
(2008)40 Hz. Reduced GRFZ, and reduced knee ROM
in water
Frangolias 13 DWR had an initial water resistance of 0.5kg Significantly lower SF in water
Neck (with buoyancy Sagittal view video (recording rate not
and Rhodes DWR vs L endurance 28 °C (female) or 0.75kg (male) with increases each Reliance on lower trunk musculature
belt) reported)
(1995)41 runners minute during DWR with no eccentric contraction
Hall et al. Three bouts of five minutes at 2.5, 3.5 and Significantly lower SF at all speeds in
UT vs L 15 females Xiphoid process 34.5 °C Manually counting SF
(2004)42 4.5 km·h-1 water
Hall et al. 28 °C and Three bouts of five minutes at increasing
UT vs L 8 females Xiphoid process Manually counting SF Significantly slower SF in water
(1998)43 36 °C speeds (3.5, 4.5 and 5.5 km·h-1)
Lower SF for all speeds in water
Kato et al. Sagittal view video recording with a Initially 2.0 km·h-1, gradually increased up to Increased nonsupport phase in water
UT vs L 6 males Waist 29 °C
(2001)44 shutter speed of 1/250 seconds 12.0 km·h-1 Walking to running transition occurs at
lower speeds in water
Killgore et al. 20 distance Sagittal view video recording at 30 60% of maximal VO2 at 0% incline for 5-6
DWR vs L 3.96 m 27.2 °C Lower SF in water
(2006)45 runners frames per second minutes
Increased SF with increased RPE in water
Three exercise intensities (RPE 11, 13 and
Masumoto et EMG recording at 1500 Hz. but almost 50% slower compared to land
DWR vs L 7 adults Neck 28 °C 15) per element, with 4 min per intensity and
al. (2009)46 SF recording methodology not reported Different muscle patterns between DWR
1 min rest
and L
EMG recording at 1000 Hz. of thigh Three bouts of four minutes at: Greater SL at matched speeds but lower
Masumoto et 9 older
UT vs L Xiphoid process 31 ˚C and shank muscles UT – 1.2, 1.8 and 2.4 km·h-1 SF in water
al. (2008)47 females
SF recording methodology not reported L – 2.4, 3.6 and 4.8 km·h-1 Lower muscle activity in water

Umbilicus, Thigh-
Pohl and Running and walking in waist-deep and
6 university deep (midway Lower SF in water during running but
McNaughton UT vs L 33 °C SF manually counted thigh-deep water and on land
students between ASIS and lowest SF in the thigh-deep water
(2003)35 Walking five minutes at 4.0 km·h-1
center of patella)

Three bouts of four minutes at:

Shono et al. 6 older
UT vs L Xiphoid process 30.7 ˚C SF manually counted UT – 1.2, 1.8 and 2.4 km·h-1 Lower SF in water
(2001)48 females
L – 2.4, 3.6 and 4.8 km·h-1
 Three bouts of four minutes at:
Shono et al. 8 older
UT vs L Xiphoid process 30.7 ˚C Sagittal view video (Hz. not reported) UT – 1.2, 1.8 and 2.4 km·h-1 Greater SL and lower SF in water
(2007)49 females
L – 2.4, 3.6 and 4.8 km·h-1

DWR and SR – four minute of running.

Town and L – three minute incline increments starting at
DWR vs 9 college DWR – 2.5-4 m Not Greater step turnover in SR compared to
Bradley SF recording methodology not reported 5% incline at a predetermined running speed
SR vs L students SR – 1.3 m reported DWR
(1991)50 (males 14.48-16.90 km·h-1, females 12.87-
14.16 km·h-1).

Shorter SL in water
Orselli and
10 young Reduced joint loading
Duarte WW vs L Xiphoid process 30 °C Sagittal view video at 60 Hz. Walking at a self-selected speed
adults No changes in joint angle
(2011)51
Decreased hip joint forces

Reduced joint loading

Miyoshi et al. 16 healthy 2 cameras, sagittal view, recording at
WW vs L Axillae 34 °C Walking at a self-selected speed Increased hip joint involvement at higher
(2005)52 adults 30 Hz. and force platform at 1000 Hz.
speeds

Miyoshi et al. 15 healthy 2 cameras. Sagittal view, recording at Walking at a self-selected speed, with Reduced knee ROM in water
WW vs L Axillae 34 °C
(2004)53 adults 30 Hz. and force platform at 1000 Hz. increases and decreases in speed Reduced GRFz in water

No change in lower body ROM during

stance phase
Miyoshi et al. 8 healthy 2 cameras, sagittal view, recording at Decreased lower body joint moments in
WW vs L Axillae 34 °C Walking at a self-selected speed
(2003)54 adults 30 Hz. and force platform at 1000 Hz. water
Hip extension moment constant during
WW
Subject-dependent changes in the ankle
Kaneda et al. Walking at a self-selected speed for 10
WW vs L 6 adults 1.35 meters 27 °C Sagittal video capture at 25 Hz. joint between elements
(2012)55 meters
Differences in hip joint actions
Forward and backwards walking at a self-
Farber et al. 8 young 4 video cameras (placement not Increased asymmetries in SL at higher SF
WW vs L Xiphoid process 30±1 °C selected speed for 10 meters with high and
(2008)56 adults reported) recording at 60 Hz. Increased SL at low SF
low step frequency
Lower average walking speed in water
Sagittal view video recording at 60 Hz.
Barela et al. Not Self-selected speed on land and in water on No differences in lower body joint ROM
WW vs L 10 adults Xiphoid process and force platform recording at 1000
(2006)57 reported a walkway however, segmental angles ROM were
Hz.
smaller in water for knee and ankle

Abbreviations are SR – Stationary water Running, L – Land-based treadmill/walking, WA – Water Aerobics, UT – underwater treadmill, DWR – Deep Water Running, WW – water walking along pathway, SL – step length,
SF-Stride frequency.
during water-based walking.25, 40, 44, 51, 53, 54, 57, 58
Kaneda et al. (2008)58 reported an increased hip
joint range of motion (ROM) during water walking
and suggested that it was a consequence of
buoyancy allowing an increased hip flexion motion
during swing phase. It is possible that these
adaptations in hip joint kinematics may influence
other movements performed in water, such as
squats and lunges. Miyoshi et al. (2003)54 further
noted a hip extension moment throughout the
entire stance phase during walking in water that was
not present during land-based walking. A similar
study reported decreased joint torques about the
knee and ankle during water-walking compared to
overland, but highlighted that no decreases were
noted at the hip joint.51 Perhaps this is because of
the increased resistance supplied by the water as the
hip joint attempts to translate the leg forward
through the viscous fluid. These studies on gait has
concluded that kinematical adaptations occur in
aquatic settings, and highlights the need for future
kinematic research conducted on exercises used for
aquatic-based rehabilitation. One study highlighted
that although drag forces of water might be
advantageous for rehabilitation, they may be a
contra indicator against water-based exercise if not
properly understood.34 The added, and abnormal
resistance supplied by the water element may result
in compensations or prove too much for an injured
tissue and should be considered when programming
for rehabilitation.
Biomechanical research has also been conducted
into vertical ground reaction forces (GRFZ) during
aquatic activities compared to land-based
equivalents, and shown significant differences
between the two environments.53, 59, 60 These
differences have been attributed to the decreased
loading associated with buoyancy and drag forces.39
Further, research comparing jumping actions in
water and on land, reported increased force
production, rate of force development, and power
output during water based jumping actions.61 It was
also noted the aquatic environment produced lower
impact forces.59, 60, 62 These studies inferred that the
aquatic environment is ideal for plyometric training
as it reduces potentially harmful impact forces.
Volume 5, Issue 1, April 2016 | JOURNAL OF FITNESS RESEARCH
Similarly, Martel et al. (2005)63 suggested that
aquatic-based plyometric training improves land-
based plyometric performance and potentially
reduces muscle soreness. Although these studies
were not performed in a rehabilitation context, they
have provided further evidence of biomechanical
implications in the aquatic environment, which
should be considered in the application of aquatic
therapy.
Further, authors have suggested that the aquatic
environment might be beneficial for static and
dynamic balance training.64, 65, 66, 67 However,
although studies have reported significant
improvements in balance following aquatic-based
exercise, the improvements were not significantly
different from those achieved with land-based
programmes.68, 69 The aquatic environment is often
considered a safer environment than land, as it
provides increased stability and reduces the risk of
injury in case of a fall.39, 54, 70 Consequently,
performing some exercises in the aquatic
environment offers clear advantages over the
land-based equivalent for populations with a high
risk of falls such as older adults and post-surgery
patients.
Although previous kinematic research is limited
to gait, it seems the aquatic environment has the
potential to affect several parameters of human
movement. Future research should include other
activities common in everyday life, exercise and
rehabilitation.
AQUATIC THERAPY IN
REHABILITATION OF HUMAN
MOVEMENT
Buoyancy and viscosity are the two physical
properties of water believed to have considerable
effect on the biomechanical aspects of
rehabilitation.39, 51 Buoyancy opposes gravity and
thus decreases the loading on joints and muscles.1, 51
Becker (2009)1, reported that immersion to the
pubic symphysis offloads approximately 40% of the
body weight, immersion to the umbilicus offloads
50%, and immersion to the xiphoid process
53
offloads 60%. Reduced joint and muscle loading
during immersion to these depths may allow a
patient to perform exercises and activities earlier
than may be possible during full gravitational
loading.1 Decreased loading of joints and early
rehabilitation could be beneficial across several
acute and chronic injuries, and for several different
populations including athletes, elderly and patients
with various chronic conditions as it facilitates
movement.13, 71, 72, 73, 74
The viscosity of water provides resistance to
movements and may therefore be helpful for
building muscle strength and endurance following
musculoskeletal injuries or surgery.1, 49, 51, 53, 60
However, research has shown the improvements in
strength achieved with water-based training are
significantly less than improvements achieved with
similar exercises performed on land.75, 76 The ability
of the aquatic environment to build strength with
decreased joint loading constitutes the rationale for
the use of aquatic therapy in improving the quality
of life for an elderly or obese population, or as a
part of a general weight-management programme.66,
70, 77
Current rehabilitation protocols for ligamentous
injuries recommend early functional treatment.2
These protocols aim to control inflammation during
the acute phase and limit subsequent loading
stress.13 The hydrostatic pressure and decreased
joint loading supplied by the water caters to both
these aims and constitutes the use of aquatic
therapy in rehabilitation of musculoskeletal
injuries.13, 78 Kim et al. (2010)13 reported that
aquatic-based rehabilitation produce superior
rehabilitation outcomes at two and four weeks
post-injury compared to a land-based programme
for ligamentous injuries in the knee. Previously,
Bartels et al. (2007)2 highlighted the low quality of
past studies in their meta-analysis on the use of
aquatic-therapy as a rehabilitation regime for OA. It
was suggested that aquatic-based rehabilitation
exercise protocols offer some short-term benefits in
rehabilitation of knee OA, but that further research
is needed before any definitive conclusions can be
drawn. Clearly, current knowledge on the roles of
aquatic therapy in rehabilitation is lacking, and
Volume 5, Issue 1, April 2016 | JOURNAL OF FITNESS RESEARCH
future research should aim to settle protocols and
guidelines to ensure best outcomes.
CURRENT METHODOLOGICAL
CHALLENGES IN AQUATIC
THERAPY RESEARCH
The growing attractiveness of aquatic-based
rehabilitation among medical professionals is likely
based on suggestions that the aquatic environment
allows for an earlier commencement of
rehabilitation and reduces joint and muscle
loading.1, 26, 27 However, despite being a common
part of many rehabilitation programmes, there is a
paucity of high-quality scientific literature on the
efficacy of aquatic-based rehabilitation training
regimens. The different context offered by the
aquatic environment provides several challenges to
researchers rending it difficult to conduct high-
quality research projects.
MOTION TRACKING IN THE
AQUATIC ENVIRONMENT
Most previous research into kinematical effects
of water-based motion have relied on video analysis
capturing the sagittal view only and operating at 30
or 60 Hz. (Table 1)40, 52, 53, 54, 57 Researchers used
video cameras placed along an underwater walkway
and recorded participants as they walked past.40, 51, 52,
53, 54, 57, 79
Caution is advised when performing
kinematic analysis using video footage because of
the risk of parallax error (Figure 1). Parallax error
denotes a distortion of the image because of an
angle of inclination between the subject and
camera.80, 81 Further, by limiting the analysis to
sagittal view due to camera positions, data on
frontal and transverse plane movements are not
recorded. Collecting video footage from a sagittal
and frontal view allows for a more comprehensive
analysis, however, the capacity of video analysis to
accurately assess data on frontal and transverse
plane movements have been questioned.81
54

Figure 1: Diagram depicturing the parallax error in
biomechanical research conducted with video analysis. A
subject positioned at A would portray different gait
parameters than a subject positioned at B.
Further, the reliance on video analysis for
kinematic parameters in gait research has been
questioned as the surrounding water induces
differences in basic kinematic descriptors such as
stride frequency and length.34 The author thus
recommended that electromyography (EMG) would
provide valuable additional information during
kinematic gait studies. A literature review on surface
EMG during aquatic-based exercise concluded that
muscle activity generally is lower in during activity
performed in water compared to land.82 However,
the review highlighted that the included studies
were low in number and that more high-quality
research is needed to fully understand the
implications of this. Further, authors have reported
that the use of EMG underwater requires caution
as it constitutes further challenges including water
interfering with the signals and safety
considerations when using electrical components in
water.34 82
Current practice considers motion capture
technologies the gold standard for analysing human
movement. Motion capture using infrared cameras
to track reflective markers on participants are
capable of capturing at frequencies of up to 50
KHz.83, 84 However, motion capture systems are
expensive, complicated, and limited to laboratory
settings.85 Therefore, their availability and
application in clinical and practical settings are
Volume 5, Issue 1, April 2016 | JOURNAL OF FITNESS RESEARCH
restricted. In addition, as the refractory index
differs between air and water, light travels
differently in the two mediums. Thus using systems
relying on infrared cameras in water remains
challenging.
The use of isoinertial sensors, such as
accelerometers and gyroscopes, is gaining
popularity amongst researchers in attempts to track
human motion in non-laboratory settings.85, 86, 87, 88
These sensors are small, inexpensive and portable,
thus allowing for testing in various settings.85
Studies have confirmed the accuracy of these
sensors during walking, the timed-up-and-go test,
and the sit-to-stand test.85, 86, 87, 88, 89 However, only
sagittal plane data, peak velocities and power were
reported. Thus, future research should aim to
examine the use of isoinertial sensors in non-
sagittal plane human motion, as this could further
establish their role in biomechanical research. In
addition, isoinertial sensors rely on measurements
from within the sensor itself and so can therefore
be used to track human movement in water.
Research into the effectiveness of isoinertial
sensors for tracking human movement in aquatic
environments would provide valuable and exciting
additions to current knowledge and research
methodologies.
LACKING PROTOCOLS
To date, the consensus on the biomechanical and
physiological effects of aquatic based activity are
lacking. A likely reason for reported contradictions
is differences in methodological protocols,
including differences in water depth, temperature,
activity and intensity (Table 1).29, 43, 47, 50, 57, 90, 91, 92, 93
These factors are all known to impact
biomechanical and physiological responses to
exercise.1, 26, 27 Caution is therefore warranted when
comparing studies reporting on effects of aquatic-
based exercise, and target population and exercise
specifications should be considered. Establishment
of guidelines for water temperature and depth
would also be beneficial for aquatic-based exercise
and research.
55
COMPARATIVE STUDIES – LAND
VERSUS WATER
There are numerous systematic reviews and
meta-analyses published assessing the differences in
water- and land-based rehabilitation for patients
with lower limb OA, fibromyalgia, chronic
obstructive pulmonary disorder, asthma and
stroke.2, 3, 9, 10, 19, 20, 21, 72, 94, 95, 96 However, these reviews
agree that previous research is of poor quality and
fails to show significantly different outcomes
between the two environments. These reviews
highlight the need for high quality comparative
studies in this domain.
Much of the research in this domain relies on
outcome measures, typically including subjective
pain scales,6, 97, 98 functional tests with hand-held
stopwatches,99, 100 isolated muscle strength testing
using non-specific hand-held dynamometers101, 102
and isolated ROM tests.98, 102 Although scientifically
validated in clinical settings,124,136-138 research has
questioned the application of these measurements
in comparative research. Hatfield et al. (2011)103
highlighted that subjective reports are insensitive
and likely produce skewed results. Further research
has reported that pain is not necessarily reflective
of functional outcomes104, 105, 106, 107 and so the use
of pain scales as an assessment tool may not be a
valid measure of performance. The reliability of
ROM tests have also been questioned following
total knee replacement (TKR) surgeries, as ROM
may be affected by several factors including the
prosthetic design, preoperative motion and surgical
technique.108
An objective alternative to the outcome measures
in question is the use of motion capture systems to
determine pre- and post-intervention changes in
kinematics. Although motion capture testing
comprises several known limitations, it provides
objective information on human movement that
subjective data cannot provide.84 A recent literature
review by Komnik et al. (2015)83 showed that
motion capture is a common method to identify
differences in kinematics following TKR. The
review highlighted several lingering alterations in
kinematics following surgery, including asymmetries
Volume 5, Issue 1, April 2016 | JOURNAL OF FITNESS RESEARCH
between the limbs, and have provided useful
information on the use of rehabilitation
programmes following TKR surgery. However, this
review was limited to include studies assessing
kinematics following only land-based rehabilitation
protocols.
Surprisingly, despite providing no empirical
evidence to support these claims, highly regarded
medical research foundations such as the Cochrane
Collaboration and BioMed Central have indicated
that aquatic-based rehabilitation is comparable to
conventional land-based protocols.2, 9, 95 However, at
the time of this review no published studies have
investigated biomechanical differences between the
two media using empirical methods such as motion
capture. Research comparing pre- and post-
rehabilitation kinematics of individuals following
land- or water-based rehabilitation programmes
would provide new information on the roles of
aquatic therapy in rehabilitation and its effect on
human movements.
SUMMARY
Aquatic therapy can aid in the rehabilitation of
musculoskeletal, cardiovascular and neurological
conditions as it offers a safe and social alternative
to common land-based protocols. The physical
properties of the water including buoyancy,
viscosity and hydrostatic pressure has beneficial
effects on joint loading, pain perception and blood
flow. Studies have assessed the effectiveness of
water based rehabilitation programmes for
management of various medical conditions.
However, these studies relied on subjective or
clinical outcome measures. Although the subjective
experience is an important aspect of rehabilitation,
its scientific validity has been questioned.
Further, previous research into the biomechanical
and physiological effects of water-based
rehabilitation present contradicting results and a
consent on practices such as water depth and
temperature have not been established.Additionally,
the current limitations in motion tracking
methodologies adds further complexities to this
research area, as it is possible that exercises
56
performed in the aquatic environment has
biomechanical implications that remain unknown.
This literature review identify several gaps in the
current knowledge and highlights possible pathways
for future research. By bridging the gaps and
gaining new knowledge in the roles of aquatic
therapy in rehabilitation, we can establish protocols
and procedures to ensure optimal recovery for
individuals with injuries and pathologies.
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