November 2016: Safety & Precautions



Content courtesy of the National Swimming Pool Foundation

Aquatic therapy is wonderful but it is not for everyone. So, how should healthcare providers make the choice whether to take patients into the pool or not? Many therapeutic pools across the country have established their own unique (and contradictory) lists. Many such lists are based on blanket statements of outdated evidence. Instead, facilities must determine which conditions should be precautions (up to the discretion of the therapist). Therapists need to have a better understanding of how to make case-by-case judgements on patients with precautionary conditions. If something is listed as a frank contraindication, then there is no room for a discussion about mitigating circumstances. For example, not everyone who is incontinent of bowel is a high risk for immersion. If someone is on a morning bowel program and wearing retainer pants, it may be appropriate to allow immersion. If, however, something is listed as a frank contraindication, it prevents clinicians from using their clinical wisdom and decision-making skills to choose the best treatment. Worse, it will be very hard to defend – in retrospect  – a decision to allow someone into the water, especially if the decision turns out badly if something is listed as a contraindication.

Below is an incomplete list of some of the most recent publications which address the safety and feasibility of working with specific conditions (e.g., DVT) and/or diagnoses (e.g. Huntington’s disease) in the pool.



Becker, B. E. (2009). Aquatic therapy: scientific foundations and clinical rehabilitation applications. PM&R, 1(9), 859-872. Aquatic Therapy: Scientific Foundations and Clinical Rehabilitation Applications

Pendergast, D. D. R., Moon, R. R. E., Krasney, J. J., Held, H. E., & Zamparo, P. (2015). Human physiology in an aquatic environment. Comprehensive Physiology, 5(4), 1705–50. 

Severin, A. C., Burkett, B. J., McKean, M. R., & Sayers, M. G. (2016). Biomechanical Aspects of Aquatic Therapy: A Literature Review on Application and Methodological Challenges. Journal of Fitness Research.


Arca, E. A., Martinelli, B., Martin, L. C., Waisberg, C. B., & Franco, R. J. D. S. (2014). Aquatic exercise is as effective as dry land training to blood pressure reduction in postmenopausal hypertensive women. Physiotherapy Research International, 19(2), 93-98.

Adsett, J. A., Mudge, A. M., Morris, N., Kuys, S., & Paratz, J. D. (2015). Aquatic exercise training and stable heart failure: A systematic review and meta-analysis. International Journal of Cardiology, 186, 22–28.

Beltrame, L. G. N. L. L. G. N., Abreu, L., Almeida, J., & Boullosa, D. A. (2015). The acute effect of moderate intensity aquatic exercise on coagulation factors in haemophiliacs. Clinical Physiology and Functional Imaging, 35(3), 191–196.

Bougault, V., & Boulet, L. P. (2013). Airways disorders and the swimming pool. Immunology and allergy clinics of North America, 33(3), 395-408.Respiratory Risk with Poorly Ventilated Pools

Castro, R. E., Guimarães, G. V., Rodrigues da Silva, J. M., Bocchi, E. A., & Ciolac, E. G. (2015). Postexercise Hypotension after Heart Transplant: Water- versus Land-Based Exercise. Medicine and Science in Sports and Exercise.

Guimaraes, G. V., de Barros Cruz, L. G., Fernandes-Silva, M. M., Dorea, E. L., & Bocchi, E. A. (2014). Heated water-based exercise training reduces 24-hour ambulatory blood pressure levels in resistant hypertensive patients: a randomized controlled trial (HEx trial). International journal of cardiology, 172(2), 434-441.

Guimaraes, G. V., Cruz, L. G., Tavares, A. C., Dorea, E. L., Fernandes-Silva, M. M., & Bocchi, E. A. (2013). Effects of short-term heated water-based exercise training on systemic blood pressure in patients with resistant hypertension: a pilot study. Blood pressure monitoring, 18(6), 342-345.

Korzeniowska-Kubacka, I., Bilińska, M., Dobraszkiewicz-Wasilewska, B., Baranowski, R., Piotrowicz, E., & Piotrowicz, R. (2016). The influence of water-based training on arrhythmia in patients with stable coronary artery disease and preserved left ventricular function. Cardiology Journal, 23(1), 93–9.

Sosner, P., Gayda, M., Dupuy, O., Garzon, M., Lemasson, C., Gremeaux, V., ... & Nigam, A. (2016). Ambulatory blood pressure reduction following high-intensity interval exercise performed in water or dryland condition. Journal of the American Society of Hypertension, 10(5), 420-428.

Open trach/ Stoma/ Ventilated

Felten-Barentsz, K. M., Haans, A. J., Slutsky, A. S., Heunks, L. M., & van der Hoeven, J. G. (2015).  Feasibility and Safety of Hydrotherapy in Critically Ill Ventilated Patients. American journal of respiratory and critical care medicine, 191(4), 476-477.Ventilatory Patients in Pool Research

Karamzadeh, A. M., & Armstrong, W. B. (2001). Aquatic activities after total laryngectomy. Otolaryngology--Head and Neck Surgery, 125(5), 528-532.

Total Joint Replacement

Liebs, T. R., Herzberg, W., Rüther, W., Haasters, J., Russlies, M., Hassenpflug, J., & Project, M. A. A. (2012). Multicenter randomized controlled trial comparing early versus late aquatic therapy after total hip or knee arthroplasty. Archives of physical medicine and rehabilitation, 93(2), 192-199. 

Open Wounds

Villalta, E. M., & Peiris, C. L. (2013). Early aquatic physical therapy improves function and does not increase risk of wound-related adverse events for adults after orthopedic surgery: a systematic review and meta-analysis. Archives of physical medicine and rehabilitation, 94(1), 138-148. 

Metabolic and Systemic

Pechter, Ü., Raag, M., & Ots-Rosenberg, M. (2014). Regular aquatic exercise for chronic kidney disease patients: a 10-year follow-up study. International Journal of Rehabilitation Research, 37(3), 251-255.

Vomit/Blood/Fecal contamination of pool

Centers for Disease Control and Prevention (CDC) website (2016). Vomit and Blood Contamination of Pool Water. (2015) Vomit and blood contamination policy from CDC. Retrieved from

Centers for Disease Control and Prevention (CDC) website (2016). Fecal / Vomit / Blood Contamination Response Annex – Model (2016). Retrieved from:

Centers for Disease Control and Prevention (CDC) website (2016). Guidelines to Fecal and Body Fluid Accidents in Pools – CDC. Retrieved from

Centers for Disease Control and Prevention (CDC) website (2016). CDC - Swim Diapers & Swim Pants - Swimmer Protection. (2016). Retrieved from

Amburgey, J. E., & Anderson, J. B. (2011). Disposable swim diaper retention of Cryptosporidiumsized particles on human subjects in a recreational water setting. Journal of water and health, 9(4), 653-658. 

Health Related Behaviors

Gallè, F., Dallolio, L., Marotta, M., Raggi, A., Di Onofrio, V., Liguori, G., … Leoni, E. (2016). Health-Related Behaviors in Swimming Pool Users: Influence of Knowledge of Regulations and Awareness of Health Risks. International Journal of Environmental Research and Public Health, 13(5), 513.


Centers for Disease Control and Prevention (CDC) website (2016). Prevention & Control - Immunocompromised Persons. Retrieved from:

Ear infection 

Moualed, D., Masterson, L., Kumar, S., & Donnelly, N. (2013). Water precautions for prevention of infection following tympanostomy tube (grommet) insertion in children. The Cochrane Library. Ventilatory Tubes and Ear Infection research

Allergic Reaction

The Association of Pool and Spa Professionals.  Chemically-induced Rashes. Recreational Water Quality. (A Publication of the APSP Recreational Water Quality Committee). Jan 2008. Available at:


Noack, F., Schmidt, B., Amoury, M., Stoevesandt, D., Gielen, S., Pflaumbaum, B., ... & Schlitt, A. (2015). Feasibility and safety of rehabilitation after venous thromboembolism. Vascular health and risk management, 11, 397.

Maternal/Fetal Safety

Thisted, D. L. A., Nørgaard, L. N., Meyer, H. M., Aabakke, A. J. M., & Secher, N. J. (2015). Water immersion and changes in the foetoplacental and uteroplacental circulation: an observational study with the case as its own control. The Journal of Maternal-Fetal & Neonatal Medicine, 28(6), 661-665.

Neuro Compromised

Allison Coleman, A. P. (2015). Feasibility and Safety of an Aquatherapy Program in Mid- to Late-Stage Huntington Disease. International Journal of Neurorehabilitation, 2(4).