April 2017: Fall Prevention



Why do balance training and fall prevention activities with patients in water? In the water, patients may be challenged beyond limits of stability without the fear of consequences of falling which are often present with land-based balance training. The environment leads to improvement in balance reactions which are translatable to land.
#1. Sensory and Motor Input. Movement through water is affected by turbulence and viscosity. Water is more viscous than air, and resistance to flow through water is greater than resistance to flow through air. Thus, it takes more force to push through water molecules than to push through air molecules. The faster an object is pushed through the water, the more turbulence is created and this creates additional resistance to movement. Additionally, the viscosity of water creates drag and this drag stimulates the sensory systems of the body.

#2. Reaction Time. A body immersed is surrounded by a viscous fluid which retards the speed of movement. This viscosity prevents rapid falling and elongates the period of time in which a patient can respond to a shift of his center of mass outside his base of support.

#3. Safety. In water, the natural end result of any loss of balance which is not corrected is a fall into a compliant fluid (water) and not a fall to a noncompliant solid (the ground). Thus, the patient may be challenged to move outside his base of support without fear of traumatic consequences. Which brings us to...

#4. Fear of Failure. This reduction in patient anxiety may encourage the patient to attempt tasks which he would not attempt on land. It becomes possible to elicit balance challenges which the patient has both time and mental confidence to combat. On land, without the assistance of such aquatic properties, the resultant balance responses may be incomplete.

#5. Alertness and Arousal. Recent studies show that patients with cognitive disorders like dementia make major gains in alertness and arousal after treatment with aquatic therapy.

The pool has truly become a treatment environment of choice for patients with balance disorders. Read more about its amazing potential below; the amount of research available is staggering.

Recent Publications: Studies, systematic reviews, and meta-analysis

Alberton, C. L. C., Finatto, P., Pinto, S. S., Antunes, A. H., Cadore, E. L., Tartaruga, M. P., & Kruel, L. F. M. (2015). Vertical ground reaction force responses to different head-out aquatic exercises performed in water and on dry land. Journal of Sports Sciences, 33(8), 795–805. https://www.tandfonline.com/doi/abs/10.1080/02640414.2014.964748

Alikhajeh, Y., Hosseini, S. R. A., & Moghaddam, A. (2012). Effects of Hydrotherapy in Static and Dynamic Balance Among Elderly Men. Procedia - Social and Behavioral Sciences, 46, 2220–2224. https://www.sciencedirect.com/science/article/pii/S187704281201587X?via%3Dihub

Ambrosini, A. B., Brentano, M. A., Coertjens, M., Kruel, L. F. M., Batterham, S. I., Heywood, S. E., … Bliddal, H. (2012). A Randomized Controlled Trial to Investigate the Effects of Water-Based Exercise to Improve Falls Risk and Physical Function in Older Adults With Lower-Extremity Osteoarthritis. Archives of Physical Medicine and Rehabilitation, 93(1), 27–34. http://www.archives-pmr.org/article/S0003-9993(11)00686-1/fulltext

Anderson, R. L., & Fishback, E. (2010). Balance Specific Training in Water and on Land in Older Adults: A Pilot Study. International Journal of Aquatic Research & Education, 4(3), 300–311. https://scholarworks.bgsu.edu/ijare/vol4/iss3/8/

Andrade, T. de, & Rufino, T. (2016). Impact of pool training on balance of elderly individuals. Manual Therapy, Posturology & Rehabilitation Journal, 14, 355. Retrieved from https://www.researchgate.net/profile/Heleodorio_Santos/publication/306273005_Impact_of_pool_training_on_balance_of_elderly_individuals/links/57ca1fc308ae89cd1e81effd.pdf

Arnold, C. M., Faulkner, R. A., & Gyurcsik, N. C. (2011). The relationship between falls efficacy and improvement in fall risk factors following an exercise plus educational intervention for older adults with hip osteoarthritis. Physiotherapy Canada, 63(4), 410–420. https://utpjournals.press/doi/10.3138/ptc.2010-29

Arnold, C. M. (2010). Fall risk in older adults with hip osteoarthritis: Decreasing risk through education and aquatic exercise. Dissertation Abstracts International: Section B: The Sciences and Engineering, 71(3–B), 1647. Retrieved from https://core.ac.uk/download/pdf/55299048.pdf

Arnold, C. M., Faulkner, R. A., CM, A., & RA, F. (2010). The effect of aquatic exercise and education on lowering fall risk in older adults with hip osteoarthritis. Journal of Aging & Physical Activity, 18(3), 245–260 16p. Retrieved from https://journals.humankinetics.com/doi/abs/10.1123/japa.18.3.245

Badawy, W. W. M., Ibrahem, M. M. B., Ph, D., Ibrahem, M. M. B., & Ph, D. (2016). Comparing the Effects of Aquatic and Land-Based Exercises on Balance and Walking in Spastic Diplegic Cerebral Palsy Children. Medical Journal of Cairo, 84(1), 1–8. Retrieved from http://medicaljournalofcairouniversity.net/home2/images/pdf/2016/march/57.pdf

Barbar, A., Bahadoran, R., & Ghasemzadeh, Y. (2014). The effect of aquatic exercise on balance of adults with multiple sclerosis. European Journal of Experimental Biology, 4(1), 38–43. Retrieved from http://www.imedpub.com/articles/the-effect-of-aquatic-exercise-on-balance-of-adults-with-multiple-sclerosis-ali-barbar-reza-bahadoran-and-yaser-ghasemzadeh.pdf

Bayraktar, D., Guclu-Gunduz, A., Yazici, G., Lambeck, J., Batur-Caglayan, H. Z., Irkec, C., … Nazliel, B. (2013). Effects of Ai-Chi on balance, functional mobility, strength and fatigue in patients with multiple sclerosis: A pilot study. NeuroRehabilitation, 33(3), 431–437. https://content.iospress.com/articles/neurorehabilitation/nre974

Benson, A. (2014). Aquatic Physiotherapy Group Aquatic Physiotherapy Level 3 Course Literature Review Program design for effective aquatic physiotherapy to improve balance in the elderly. http://www.physiotherapy.asn.au/DocumentsFolder/APAWCM/LearningandDevelopment/LiteratureReview-A.Benson_UnitD.pdf

Bento, P. P. C. B., Lopes, M. de F. M., Cebolla, E. C. E., Wolf, R., & Rodacki, A. (2015). The Effects of a Water-based Training on Static and Dynamic Balance of Older Women. Rejuvenation Research. http://doi.org/10.1089/rej.2014.1650

Bergamin M, Ermolao A, Tolomio S, Berton L, Sergi G, Zaccaria M, Bergamin, M., Ermolao, A., Tolomio, S., Berton, L., Sergi, G., & Zaccaria, M. (2013). Water- versus land-based exercise in elderly subjects: Effects on physical performance and body composition. Clinical Interventions in Aging, 8, 1109–1017. https://www.dovepress.com/water--versus-land-based-exercise-in-elderly-subjects-effects-on-physi-peer-reviewed-article-CIA

Bland, D. C., Zampieri-Gallagher, C., & Damiano, D. L. (2011). Effectiveness of physical therapy for improving gait and balance in ambulatory individuals with traumatic brain injury: a systematic review of the literature. Brain Injury : [BI], 25((7-8)), 664–679. https://www.tandfonline.com/doi/full/10.3109/02699052.2011.576306.

Bocalini, D. S., Serra, A. J., Rica, R. L., & Santos, L. Dos. (2010). Repercussions of training and detraining by water-based exercise on functional fitness and quality of life: a short-term follow-up in healthy older women. Clinics (Sao Paulo, Brazil), 65(12), 1305–1309. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1807-59322010001200013&lng=en&nrm=iso&tlng=en

Bressel, E., Wing, J. E., Miller, A. I., & Dolny, D. G. (2014). High-intensity interval training on an aquatic treadmill in adults with osteoarthritis: effect on pain, balance, function, and mobility. Journal of Strength and Conditioning Research / National Strength & Conditioning Association, 28(8), 2088–96. https://insights.ovid.com/crossref?an=00124278-201408000-00002

Buszek, B. (2015). Does aquatic therapy improve balance better than conventional land based therapy for patients post stroke? University of New Mexico. Retrieved from http://digitalrepository.unm.edu/dpt/105/

Byoungook, K., & Hyojeong, L. (2015). Effects of Aquatic Rehabilitation Program on Gross Motor Function and Balance in Children with Cerebral Palsy. Journal of The Korean Society of Integrative Medicine, 3(3), 35–42. http://koreascience.or.kr/article/ArticleFullRecord.jsp?cn=DHTHB4_2015_v3n3_35

Cancela, J. J. M., Ayan, C., Crispim, C., Seijo-Martínez, M., Nascimento, C. M. C., & Seijo-Martínez, M. (2015). Effects of Water-Based and Callisthenic Exercise on Freezing of Gait, Postural Control, and Functional Independence in Patients With Mild to Moderate Parkinson. Topics in Geriatric Rehabilitation, 31(2), 152–158 7p. https://journals.lww.com/topicsingeriatricrehabilitation/Abstract/2015/04000/Effects_of_Water_Based_and_Callisthenic_Exercise.11.aspx

Cappadocia, C. E., Gras, L. Z., Egbert, K. L., & Leathem, K. C. (2016). Improved Balance with Aquatic Therapy and Body Weight Supported Treadmill Training for a Patient with Chronic Strokes. Journal of Aquatic Physical Therapy, Epub ahead of print. https://www.researchgate.net/publication/298352245_Improved_Balance_with_Aquatic_Therapy_and_Body_Weight_Supported_Treadmill_Training_for_a_Patient_with_Chronic_Strokes

Cha, H.-G., Shin, Y.-J., & Kim, M.-K. (2017). Effects of the Bad Ragaz Ring Method on muscle activation of the lower limbs and balance ability in chronic stroke: A randomised controlled trial. Hong Kong Physiotherapy Journal, 37, 39–45. https://www.sciencedirect.com/science/article/pii/S1013702516300033?via%3Dihub

Chan, K., Phadke, C. P. C., Stremler, D., Suter, L., Pauley, T., Ismail, F., … Boulias, C. (2016). The effect of water-based exercises on balance in persons post-stroke: a randomized controlled trial. Topics in Stroke Rehabilitation, Epub ahead of print. https://www.tandfonline.com/doi/abs/10.1080/10749357.2016.1251742

Chow, G. C. C., Yam, T. T. T., Chung, J. W. Y., & Fong, S. S. M. (2017). Effects of postexercise ice-water and room-temperature water immersion on the sensory organization of balance control and lower limb proprioception in amateur rugby players. Medicine, 96(7), e6146. https://insights.ovid.com/crossref?an=00005792-201702170-00050

Covill, L. G. L., Utley, C., & Hochstein, C. (2016). Comparison of Ai Chi and Impairment-Based Aquatic Therapy for Older Adults With Balance Problems: A Clinical Study. Journal Of Geriatric Physical Therapy, Epub ahead of print. https://insights.ovid.com/crossref?an=00139143-201710000-00005

Fisken, A. L., Waters, D. L., Hing, W. A., Steele, M., & Keogh, J. W. (2015). Comparative effects of 2 aqua exercise programs on physical function, balance, and perceived quality of life in older adults with osteoarthritis. Journal of Geriatric Physical Therapy (2001), 38(1), 17–27. https://insights.ovid.com/crossref?an=00139143-201501000-00003

Foster, S. S. (2015). A Systematic Review of Aquatic Exercise Programs on Balance Measures in Older Adults. All Graduate Plan B and other Reports. Logan, Utah. Retrieved from https://digitalcommons.usu.edu/gradreports/478/ https://digitalcommons.usu.edu/gradreports/478/

Gervasoni, E., Cattaneo, D., Montesano, A., & Jonsdottir, J. (2012). Effects of Fatigue on Balance and Mobility in Subjects with Multiple Sclerosis: A Brief Report. ISRN Neurology, 2012, 1–4. https://www.hindawi.com/journals/isrn/2012/316097/

Hamed, S., Osama, S., & Azab, A. (2016). Effect of Aquatic Program Therapy on Dynamic Balance in Down’s Syndrome Children. Journal of Medical Science and Clinical Research, 4(3), 9938–9942. Retrieved from http://jmscr.igmpublication.org/v4-i3/59%20jmscr.pdf

Han, S. K., Kim, M. C., & An, C. S. (2013). Comparison of effects of a proprioceptive exercise program in water and on land the balance of chronic stroke patients. Journal of Physical Therapy Science, 25(10), 1219–22. article. https://www.jstage.jst.go.jp/article/jpts/25/10/25_jpts-2013-131/_article

Jung, J. J., Lee, J. J., Chung, E. E., & Kim, K. (2014). The effect of obstacle training in water on static balance of chronic stroke patients. Journal of Physical Therapy Science, 26(3), 437–40. https://www.jstage.jst.go.jp/article/jpts/26/3/26_jpts-2013-398/_article

Kalron, A., Nitzani, D., & Magalashvili, D. (2015). A personalized, intense physical rehabilitation program improves walking in people with multiple sclerosis presenting with different levels of disability: a a retrospective cohort. BMC Neurology…. Retrieved from https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-015-0281-9

Khodaveisi, H., & Ahanjan, S. (2016). The effect of 12 weeks aquatic exercise with emphasis on central stability training on balance in women with chronic low back pain. International Journal of Sport Studies, 6(12), 2251–7502. Retrieved from http://ijssjournal.com/fulltext/paper-13032017044414.pdf


Kim, E.-K. E., Lee, D. D.-K., & Kim, Y.-M. Y. Y.-M. (2015). Effects of aquatic PNF lower extremity patterns on balance and ADL of stroke patients. Journal of Physical Therapy Science, 27(1), 213–5. https://www.jstage.jst.go.jp/article/jpts/27/1/27_jpts-2014-404/_article

Kim, K., Lee, D. D.-K., & Jung, S.-I. S. (2015). Effect of coordination movement using the PNF pattern underwater on the balance and gait of stroke patients. Journal of Physical Therapy Science, 27(12), 3699–701. https://www.jstage.jst.go.jp/article/jpts/27/12/27_jpts-2015-613/_article

Kim, K., Lee, D.-K., & Kim, E.-K. (2016). Effect of aquatic dual-task training on balance and gait in stroke patients. J. Phys. Ther. Sci., 28. https://www.jstage.jst.go.jp/article/jpts/28/7/28_jpts-2016-130/_article

King, A., & Eitivipart, C. (2016). Systematic Review of Published Research on Aquatic Exercise for Balance in the Elderly. Journal of Aquatic Physical Therapy, 24(1). https://www.researchgate.net/publication/295547453_Systematic_Review_of_Published_Research_on_Aquatic_Exercise_for_Balance_in_the_Elderly

Kotzamanidou, M. C., Panoutsakopoulos, V., Aggeloudis, K., Avramidou, E., Zafeiriou, I., Manavis, K., … Kollias, I. A. (2015). Gait and Balance Parameters Improvements in Adolescents With Developmental Disorders After An 8-Week Aquatic Therapy. In 2nd European Conference on Evidence Based Aquatic Therapy [AQUA LEUVEN 2015]. KU Leuven, Belgium: Belgium: Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven. Retrieved from http://www.researchgate.net/profile/Vassilios_Panoutsakopoulos/publication/275213767_Gait_and_balance_parameters_improvements_in_adolescents_with_developmental_disorders_after_an_8-week_aquatic_therapy_program/links/55426a330cf24107d3946ef4.pdf

Kurt, E. E. E., Büyükturan, B., Büyükturan, Ö., Erdem, H. R., & Tuncay, F. (2017). Effects of Ai Chi on balance, quality of life, functional mobility, and motor impairment in patients with Parkinson’s disease. Disability and Rehabilitation, Epub ahead of print. https://www.tandfonline.com/doi/full/10.1080/09638288.2016.1276972

Kwon, S., Kim, J., & Yoo, K. (2012). The effect of 8-week aquatic exercise on strength, balance and gait speed in hemophilia. Haemophilia, 18, 155. https://insights.ovid.com/haemophilia/hemop/2012/07/003/effect-week-aquatic-exercise-strength-balance-gait/727/00043737

Lim, H. S., Roh, S. Y., & Yoon, S. (2013). An 8-week Aquatic Exercise Program is Effective at Improving Gait Stability of the Elderly. Journal of Physical Therapy Science, 25(11), 1467–70. https://www.jstage.jst.go.jp/article/jpts/25/11/25_jpts-2013-212/_article

Louder, T., Bressel, E., Baldwin, M., Dolny, D. G., Gordin, R., & Miller, A. (2014). Effect of Aquatic Immersion on Static Balance. International Journal of Aquatic Research and Education, 8(1), 53–65. https://scholarworks.bgsu.edu/ijare/vol8/iss1/6/

Majdinasab, N., Nakhostin-Mortazavi, A., Bahadoram, M., Pouretezad, M., & Afraz, P. Effect of Aquatic Therapy on Functional Balance in Patients with Multiple Sclerosis: A Randomized Controlled Trial, 3Persian Journal of Medical Sciences (PJMS) (2016). Retrieved from http://www.persianjms.com/index.php/PJMS/article/view/42

Mann, L., & Kleinpaul, J. (2014). Influence of aquatic exercise training on balance in young adults. Fisioterapia em Movimento, 27(4). Retrieved from http://www.scielo.br/scielo.php?pid=S0103-51502014000400573&script=sci_arttext

Marandi, S. M., Nejad, V. S., Shanazari, Z., & Zolaktaf, V. (2013). A comparison of 12 weeks of pilates and aquatic training on the dynamic balance of women with mulitple sclerosis. International Journal of Preventive Medicine, 4(Suppl 1), S110--7. article. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665016/

Methajarunon, P., Eitivipart, C., Diver, C. C. J., & Foongchomcheay, A. (2016). Systematic review of published studies on aquatic exercise for balance in patients with multiple sclerosis, Parkinson’s disease, and hemiplegia. Hong Kong Physiotherapy Journal, 35, 12–20. https://www.sciencedirect.com/science/article/pii/S1013702515300178?via%3Dihub

Montagna, J. C. J. J. C. J. C., Santos, B. C. B. B. C. B. C., Battistuzzo, C. R., & Loureiro, A. P. C. (2014). Effects of aquatic physiotherapy on the improvement of balance and corporal symmetry in stroke. International Journal of Clinical and Experimental Medicine, 7(4), 1182–1187. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4057885/

Montgomery, R. E., Hartley, G. L., Tyler, C. J., & Cheung, S. S. (2015). Effect of segmental, localized lower limb cooling on dynamic balance. Medicine and Science in Sports and Exercise, 47(1), 66–73. https://insights.ovid.com/crossref?an=00005768-201501000-00010

Morris, D. M. (2010). Aquatic Therapy to Improve Balance Dysfunction in Older Adults. Topics in Geriatric Rehabilitation, 26(2), 104–119. https://journals.lww.com/topicsingeriatricrehabilitation/Abstract/2010/04000/Aquatic_Therapy_to_Improve_Balance_Dysfunction_in.4.aspx

Motta, M. (2012). The Effects of Aquatic and Land-based Exercise on Balance and Gait in People Post Stroke, (December), 1–70. http://www.journalcra.com/article/effects-aquatic-and-land-based-exercise-balance-and-gait-post-stroke-patient

Oh, S., Lim, J.-M., Kim, Y., Kim, M., Song, W., & Yoon, B. (2015). Comparison of the effects of water- and land-based exercises on the physical function and quality of life in community-dwelling elderly people with history of falling: A single-blind, randomized controlled trial. Archives of Gerontology and Geriatrics, 60(2), 288–293. https://www.sciencedirect.com/science/article/pii/S0167494314002027?via%3Dihub

Orselli, M. I. V., & Duarte, M. (2011). Joint forces and torques when walking in shallow water. Journal of Biomechanics, 44(6), 1170–1175. article. https://linkinghub.elsevier.com/retrieve/pii/S0021929011000479

Park, J., & Roh, H. (2011). Postural Balance of Stroke Survivors in Aquatic and Land Environments. Journal of Physical Therapy Science, 23(6), 905–908. article. https://www.jstage.jst.go.jp/article/jpts/23/6/23_6_905/_article

Park, S. W., Lee, K. J., Shin, D. C., Shin, S. H., Lee, M. M., & Song, C. H. (2014). The effect of underwater gait training on balance ability of stroke patients. Journal of Physical Therapy Science, 26(6), 899–903. article. https://www.jstage.jst.go.jp/article/jpts/26/6/26_jpts-2013-556/_article

Piva, S. R., Gil, A. B., Almeida, G. J. M., DiGioia  III, A. M., Levison, T. J., & Fitzgerald, G. K. (2010). A balance exercise program appears to improve function for patients with total knee arthroplasty: a randomized clinical trial. Phys Ther, 90(6), 880–894 15p. http://doi.org/10.2522/ptj.200901S0

Pompeu, J. E., Gimenes, R. O., Pereira, R. P., Rocha, S. L., & Santos, M. A. (2011). Effects of aquatic physical therapy on balance and gait of patients with Parkinson ’ s disease, 201–204. Retrieved from

Pro, S., Bains, R., & Li, K. (2015). For healthy older adults, does participation in a water-based balance training exercise program, when compared to a land-based balance training exercise program. Retrieved from https://scholar.dominican.edu/ot-caps/9/?utm_source=scholar.dominican.edu%2Fot-caps%2F9&utm_medium=PDF&utm_campaign=PDFCoverPages

Rezazadeh, N., & Baluchi, R. (2016). The Effect of 12 Weeks Exercise in the Water and Land on the Static and Dynamic Balance and the Risk of Falling the Old People. Iranian Journal of Ageing, 10(4), 140–151. Retrieved from http://salmandj.uswr.ac.ir/article-1-788-en.html

Rivas Neira, S., Pasqual Marques, A., Pegito Pérez, I., Fernández Cervantes, R., & Vivas Costa, J. (2017). Effectiveness of Aquatic Therapy vs Land-based Therapy for Balance and Pain in Women with Fibromyalgia: a study protocol for a randomised controlled trial. BMC Musculoskeletal Disorders, 18(1), 22. https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-016-1364-5​

Roghani, T., Torkaman, G., Movasseghe, S., Hedayati, M., Goosheh, B., & Bayat, N. (2013). Effects of short-term aerobic exercise with and without external loading on bone metabolism and balance in postmenopausal women with osteoporosis. Rheumatology International, 33(2), 291–298. https://link.springer.com/article/10.1007%2Fs00296-012-2388-2​

Schaefer, S. Y. ., Louder, T. J. ., Foster, S., Bressel, E., & Bressel, Eadric2, 3, 4. (2015). Effect of Water Immersion on Dual-task Performance: Implications for Aquatic Therapy. Physiotherapy Research International : The Journal for Researchers and Clinicians in Physical Therapy, 21(3), 147. http://onlinelibrary.wiley.com/doi/10.1002/pri.1628/abstract;jsessionid=12863AB7959B9FC26CE05D0A55CA3759.f02t03​

Skinner, E. E. H., Dinh, T., Hewitt, M., Piper, R., & Thwaites, C. (2016). An Ai Chi-based aquatic group improves balance and reduces falls in community-dwelling adults: A pilot observational cohort study. Physiotherapy Theory and Practice, 32(8), 581–590. https://www.tandfonline.com/doi/full/10.1080/09593985.2016.1227411​

Smith, K. (2016). The Effects of Aquatic Exercise on Balance Outcomes in Individuals With Multiple Sclerosis. California State University. Retrieved from http://scholarworks.csun.edu/handle/10211.3/172665​

Stevens, S. S. L., Caputo, J. L. J., Fuller, D. K., & Morgan, D. W. (2015). Effects of underwater treadmill training on leg strength, balance, and walking performance in adults with incomplete spinal cord injury. The Journal of Spinal Cord Medicine, 38(1), 91–101. https://www.tandfonline.com/doi/full/10.1179/2045772314Y.0000000217​

Teixeira, R., Perez, L., Lambeck, J., & Neto, F. (2011). The influence of ai chi on balance and fear of falling in older adults: A randomized clinical trial. Physiotherapy (United Kingdom), 97, eS654. http://www.physiotherapyjournal.com/article/S0031-9406(11)00069-1/pdf​

Vasile, L., & Stănescu, M. (2013). The Aquatic Therapy in Balance Coordination Disorders. Procedia - Social and Behavioral Sciences, 92, 997–1002. https://www.sciencedirect.com/science/article/pii/S1877042813029212?via%3Dihub​

Volpe, D., & Giantin, M. (2014). Comparing the effects of hydrotherapy and land-based therapy on balance in patients with Parkinson’s disease: a randomized controlled pilot study. Clinical Rehabilitation, 28(12), 1210–1217. Retrieved from http://journals.sagepub.com/doi/abs/10.1177/0269215514536060​

Volpe, D., Giantin, M. G., Maestri, R., & Frazzitta, G. (2014). Comparing the effects of hydrotherapy and land-based therapy on balance in patients with Parkinson’s disease: a randomized controlled pilot study. Clinical Rehabilitation, 28(12). http://journals.sagepub.com/doi/10.1177/0269215514536060​

Walker, C., Oblock, A., Dunn, M., Vroom, K., & Hiatt, J. (2016). The Effects of an Aquatic Exercise Program on Dynamic and Static Balance of Sedentary Elders. Linfield College Student Symposium: A Celebration of Scholarship and Creative Achievement. Event. Linfield College. Retrieved from http://digitalcommons.linfield.edu/symposium/2016/all/34/​

Yang, H. (2015). Effects of Underwater Treadmill Gait Training on Gait, Balance, and Pulmonary Function in Stroke Patients. Daejeon University. Retrieved from​

YOUSEFSHAHI, M., & PARSAEI, N. (2016). The Impact of an Aquatic Physical Balance Training Course On the Static Balance of Novice Damaged Athletes. International Journal of Biology, Pharmacy and Allied Sciences, 5(1), 398–408. Retrieved from http://ijbpas.com/pdf/2016/January/1452607152MS%20IJBPAS%202016%20JAN%20SPCL%201119.pdf​

Zanloo, Z., & Zareei, N. (2016). Effect of Selected Water Exercises on Balance and Life Quality of Women with Multiple Sclerosis. International Journal of Biology, Pharmacy and Allied Sciences, 5(1), 409–423. Retrieved from http://ijbpas.com/pdf/2016/January/1452607225MS%20IJBPAS%202016%20JAN%20SPCL%201120.pdf​

Zhu, Z., Cui, L., Yin, M., Yu, Y., Zhou, X., Wang, H., & Yan, H. (2015). Hydrotherapy vs. conventional land-based exercise for improving walking and balance after stroke: A randomized controlled trial. Clinical Rehabilitation, 30(6), 587–593. http://journals.sagepub.com/doi/10.1177/0269215515593392​

Zverev, Y., & Kurnikova, M. (2016). Adapted Community-Based Group Aquatic Program for Developing Balance: A Pilot Intervention Study Involving Children and Adolescents with Cerebral Palsy. Journal of Physical Education and Sport, 16(4), 1258. https://www.questia.com/library/journal/1P3-4309705191/adapted-community-based-group-aquatic-program-for​