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

Abbasi, A., & Rahmanpourmoghaddam, J. (2012). The Effect of Ten Weeks Aquatic Balance Training and Functional Training on Dynamic Balance in Inactive Elder Males Bachelor in Physical Education and Sport Sciences. Middle-East J. Science, 11(3), 296–303.

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. http://doi.org/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. http://doi.org/10.1016/j.sbspro.2012.05.458

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://doi.org/10.1016/j.apmr.2011.08.004

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. http://search.ebscohost.com/login.aspx?direct=true{&}db=s3h{&}AN=52800601{&}site=ehost-live

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. http://doi.org/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 http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2010-99180-119&site=ehost-live

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 http://search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=105038504&site=ehost-live

Avelar, N. C. P. N. C. P., Bastone, A. C., Alcântara, M. a, Gomes, W. F., Alcantara, M. a, Gomes, W. F., … Gomes, W. F. (2010). Effectiveness of aquatic and non-aquatic lower limb muscle endurance training in the static and dynamic balance of elderly people. Revista Brasileira de Fisioterapia São Carlos São Paulo Brazil, 14(3), 229–236. http://doi.org/S1413-35552010000300007 [pii]

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://pelagiaresearchlibrary.com/european-journal-of-experimental-biology/vol4-iss1/EJEB-2014-4-1-38-43.pdf

Bashiri, J., & Hadi, H. (2011). The Effect of Aquatic, Whole Body Vibration and concurrent ( aquatic and Whole Body Vibration ) Training on Dynamic Balance in Elderly females, 2(5), 269–274. article.

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. http://doi.org/10.3233/NRE-130974

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. http://doi.org/10.2147/CIA.S44198

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. http://doi.org/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://doi.org/10.1590/S1807-59322010001200013

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. http://doi.org/10.1519/JSC.0000000000000258

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://repository.unm.edu/handle/1928/27545

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://doi.org/10.15268/ksim.2015.3.3.035

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. http://doi.org/10.1097/TGR.0000000000000062

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

Catarina, S., & Paulo, S. (2011). Comparison of Ground Reaction Forces Between In-Place and Forward Water Running at Two Levels of Immersion. Aquatic Biomechanics Rese, 11, 495–498.

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. http://doi.org/10.1016/j.hkpj.2017.02.001

Chan, K., Suter, L., Heth, D., Pauley, T., Boulias, C., & Ismail, F. (2010). A study examining the effect of hydrotherapy on balance in post stroke out-patients. Stroke, 41(7), e492--e492.

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. http://doi.org/doi.org/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. http://doi.org/10.1097/MD.0000000000006146

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. http://doi.org/10.1519/JPT.0000000000000100

Daneshjoo, A., & Yusof, A. (2016). Effects of Water and Land-based Sensorimotor Training Programs on Static Balance among University Students. International Journal of Applied Exercise Physiology, 5(2), 2322–3537.

Denise Fernandes Moreira, L., Fronza, F. C. A. O., Dos Santos, R. N., Teixeira, L. R., Kruel, L. F. M., Lazaretti-Castro, M., … Lazaretti-Castro, M. (2013). High-intensity aquatic exercises (HydrOS) improve physical function and reduce falls among postmenopausal women. Menopause (New York, N.Y.), 20(10), 1012–9. article. http://doi.org/10.1097/GME.0b013e3182850138

Dolbow, J. J., Jones, T., Dolbow, D. D., Dolbow, James D, MS; Jones, Timothy, EdD; Dolbow, David R, DPT, PhD, RKT; Stevens, Sandra L, P., Dolbow, J. J., Jones, T., … Stevens, S. (2016). Efficacy of Underwater Treadmill Training as a Complimentary Gait Restorative Therapy for Spinal Cord Injured Individual: a Case Report. Clinical Kinesiology, 9(2), Epub ahead of print.

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. http://doi.org/10.1519/JPT.0000000000000019

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 http://digitalcommons.usu.edu/gradreports/478/

Furnari, A., & Calabrò, R. (2014). Is hydrokinesitherapy effective on gait and balance in patients with stroke? A clinical and baropodometric investigation. Brain Injury, 28(8), 1109–11. Retrieved from http://informahealthcare.com/doi/abs/10.3109/02699052.2014.910700

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. http://doi.org/10.5402/2012/316097

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 jmscr.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. http://doi.org/10.1589/jpts.25.1219

Im, S. Y., Eo, S. J., Kim, S. J., Hur, S. H., An, K. J., Lee, J. K., & Lee, J. S. (2016). The Effect of 12-weeks Aquatic Exercise on Dynamic Balance and Pain Factors in Elderly Osteoarthritis Patients. Journal of the Korea Academia-Industrial Cooperation Society, 17(2), 601–609.

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. http://doi.org/10.1589/jpts.26.437

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 http://www.biomedcentral.com/1471-2377/15/21/

Kang, S. S., Kim, J. J., & So, J. M. (2016). Effect of Aquatic Exercise on Foot Pressure Balance and Posture Stability in Elderly Women. In ISBS-Conference Proceedings Archive (Vol. 1).

Kargarfard, M., Chitsaz, A., Azizi, S., M., K., A., C., S., A., … Azizi, S. (2012). Effects of an 8-week aquatic exercise training on balance in patients with Parkinson’s disease. Journal of Isfahan Medical School, 30(178).

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 www.ijssjournal.com

Kieffer, H. S., Lehman, M. A., Veacock, D., & Korkuch, L. (2012). The Effects of a Short-Term Novel Aquatic Exercise Program on Functional Strength and Performance of Older Adults. Int J Exerc Sci, 5(4), 321–333.

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. http://doi.org/10.1589/jpts.27.213

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. http://doi.org/10.1589/jpts.27.3699

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. http://doi.org/10.1589/jpts.28.2044

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. http://doi.org/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. http://doi.org/http://dx.doi.org/10.1111/j.1365-2516.2012.02820.x

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. http://doi.org/10.1589/jpts.25.1467

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. http://doi.org/10.1123/ijare.2013-0014

Kargarfard, M et al (2013). Changes in speed, endurance and balance in women with multiple sclerosis after 4 and 8 weeks of aquatic exercise training. Journal of Isfahan Medical School, 31(256). Retrieved from http://www.embase.com/search/results?subaction=viewrecord&from=export&id=L373856345

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

Maniu, D. A., & Maniu, E. A. (2015). Does the Acquisition of Water Orientation Skills Influence the Abilities of Moving on Land and Improve Balance on Land? In 4th International Congress of Physical Education, Sport and Kinesiotherapy (ICPESK 2014) (pp. 33–38).

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 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3665016{&}tool=pmcentrez{&}rendertype=abstract

Methajarunon, P. (2015). The effectiveness of aquatic exercises on balance control in people with hemiplegia: A systematic review of randomized controlled trials. Physiotherapy (United Kingdom). http://doi.org/10.1016/j.physio.2015.03.1862

Methajarunon, P., & Eitivipart, C. (2015). The effectiveness of aquatic exercises on balance control in people with hemiplegia: a systematic review of randomized controlled trials. Physiotherapy, 101(Suppl 1), e999. Retrieved from https://scholar.google.com/scholar?as_ylo=2015&q=%22aquatic+therapy%22+OR+%22aquatic+exercises%22&hl=en&as_sdt=0,43#9

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. http://doi.org/10.1016/j.hkpj.2016.03.002

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 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4057885{&}tool=pmcentrez{&}rendertype=abstract

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. http://doi.org/10.1249/MSS.0000000000000379

Morris, D. M. (2010). Aquatic Therapy to Improve Balance Dysfunction in Older Adults. Topics in Geriatric Rehabilitation, 26(2), 104–119. http://doi.org/10.1097/TGR.0b013e3181dfda0a

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. http://doi.org/10.1016/j.archger.2014.11.001

Orselli, M. I. V., & Duarte, M. (2011). Joint forces and torques when walking in shallow water. Journal of Biomechanics, 44(6), 1170–1175. article. http://doi.org/10.1016/j.jbiomech.2011.01.017

Palamara, G., Gotti, F., Maestri, R., Bera, R., Gargantini, R., Bossio, F., … Frazzitta, G. (2017). Land Plus Aquatic Therapy Versus Land-Based Rehabilitation Alone for the Treatment of Balance Dysfunction in Parkinson Disease: A Randomized Controlled Study With 6-Month Follow-Up. Archives of Physical Medicine and Rehabilitation, Epub ahead. http://doi.org/10.1016/j.apmr.2017.01.025

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. http://doi.org/10.1589/jpts.23.905

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. http://doi.org/10.1589/jpts.26.899

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 http://scholar.dominican.edu/ot-caps/9/?utm_source=scholar.dominican.edu%2Fot-caps%2F9&utm_medium=PDF&utm_campaign=PDFCoverPages

Rammage, E. R. (2010). Aquatic physical therapy for balance after stroke. Journal of Aquatic Physical Therapy, 18(1), 10–21. article. Retrieved from http://search.ebscohost.com/login.aspx?direct=true{&}db=c8h{&}AN=2010864405{&}site=ehost-live

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. http://doi.org/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. http://doi.org/10.1007/s00296-012-2388-2

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://doi.org/10.1002/pri.1628

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. http://doi.org/10.1080/09593985.2016.1227411

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