October 2016: Cardiac Compromise



Content courtesy of the National Swimming Pool Foundation

Not only is cardiac compromise no longer considered a contraindication for aquatic therapy, therapists are routinely putting their stable cardiac patients in the pool. Why? Because immersion in graded pressurized environment (i.e., the pool) can provide a safer environment in which to work with cardiac patients. It's amazing to think of how the human body deals with pressure - even out of water. At sea level, there are 14.7 pounds of air (1 Atmosphere) pressing against every square inch of the human body. This means that before a person immerses even one toe, each inch on his body is pounded by 14.7 pounds of molecules. As divers put it, we should be crushed to death!

However, inside our bodies are molecules that push back with an equal - or even greater - force. For instance, every time your heart pumps, it creates a pressure on your arterial vessels of approximately 120 mm. Even when the heart rests, there remains an intrinsic outward pressure of approximately 80 mm. You may know this more commonly as blood pressure (the normative 120/80 used as the example).

So, what happens when we enter the pool? The hydrostatic pressure of the water increases as depth increases. This hydrostatic pressure drives fluid to the large vessels of the lungs (creating a 60-percent increase in the work of breathing) and creates a large return of blood to the heart. This all happens before the first exercise is performed. Even better, with the proper instruction, the pool can be used to create an amazing therapeutic training effect while allowing the heart the functional assistance that comes with immersion. 


Adsett et al, 2015
This study reviewed research to determine what effect aquatic exercise had for patients with heart failure compared to traditional land-based therapy. The researchers reviewed 8 studies with a total of 156 participants. These studies compared aquatic exercise, land-based therapy, or a combination of both. The primary outcome was exercise performance. The researchers found these studies to show similar improvement in patients with heart failure when participating in an aquatic exercise program as compared with land-based therapy. They recommend that aquatic therapy provides a similar benefit for patients who may struggle to participate in traditional exercise programs.

Battistella et al, 2015
In this study, the researchers analyzed the responses of patients with chronic heart failure to exercise testing on land, followed by an underwater treadmill test. They found that patients were able to do more exercise in the pool than on land, suggesting that pool-based therapy may be a good option as an alternative to land-based therapy.

Beltrame et al, 2015
The researchers in this study analyzed the effects of aquatic exercise in people with hemophilia. The participants of the study performed a 20-minute exercise session in the pool. Upon completion of the exercise, blood samples were collected. The researchers found that short, moderate intensity aquatic exercise sessions can improve the time it takes for blood to clot in hemophilic patients. They suggest that this may be helpful for treatment of hemophilia in a clinical setting.

Castro et al, 2015
Hypertension is a common issue for those who have undergone a heart transplant. Exercise training has been shown to reduce blood pressure in those with hypertension. In order to find what effect, if any, aquatic exercise would have on hypertension in heart transplant recipients, the researchers analyzed the effects of water walking compared to land-based treadmill exercise in patients who had received a heart transplants. Their findings showed similar effects in both treatments, which suggests that aquatic exercise can be a useful tool for counteracting hypertension in this specific population.

Choi et al, 2015
This study looked at populations with coronary artery disease to compare the effects of aquatic and land-based treadmill exercise programs. 21 patients with stable coronary artery disease participated in an aquatic treadmill exercise and a land-based treadmill exercise. The researchers measured the peak cardiorespiratory responses in each exercise. Their findings showed similar benefits in each exercise. The researchers concluded that aquatic treadmill exercise may be beneficial for coronary artery disease patients in cardiac rehabilitation.

Gomes et al, 2016
Oftentimes, elderly patients have limitations that cause land-based therapy to be difficult or painful for them. The aquatic environment can offer some relief and added mobility for patients who struggle with these issues. The researchers of this study sought to learn if aquatic exercise would also offer similar effectiveness in treating hypertension, in addition to the benefit of added mobility. In order to do this, they compared the results of aquatic exercise with land-based therapy for a group of elderly hypertensive patients. They found that treatment in the water had a better effect on factors such as blood pressure response, and recommended researchers continue to learn how this type of treatment can assist hypertensive subjects.

Korzeniowska-Kubacka et al, 2016
This study looked at the effects that water-based training has on patients post-heart attack. Although the researchers found an increase in arrhythmias in patients who participated in a water-based training program compared to normal daily activity, they also found an improvement in physical capacity. The patients also maintained this increased physical capacity at a 1-year follow-up appointment.

Moore et al, 2015
Arterial stiffening is a partial cause of increased mortality rates in those suffering from metabolic syndrome. This study was designed to find the effects that deep-water exercise may have on arterial stiffening. They found that patients who participated in deep-water exercise had a decrease in arterial stiffening, in addition to an increase of positive cardiovascular benefits. This suggests that aquatic exercise is an effective method to improve cardiovascular health.

Noack et al, 2015
Rehabilitation for patients who suffered from a venous thromboembolism can help restore their quality of life. The researchers of this study compared several different physical exercises, including aquatic therapy and swimming. Along with other types of exercise, the researchers found aquatic therapy to be a safe option for pulmonary embolism patients.

Pendergast et al, 2015
This study lists the various cardiorespiratory benefits that can be achieved by aquatic therapy. The researchers specifically looked at head-out water immersion. They found benefits such as increased blood flow to respiratory muscles in addition to several other benefits. This research shows how aquatic therapy offers many opportunities for increasing quality of life in cardiovascular patients.


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. http://doi.org/10.1016/j.ijcard.2015.03.095

Battistella, L., Junior, P., & Garcia, M. (2015). Comparative study of a cardiopulmonary exercise test on land and underwater in patients with chronic heart failure. Physiotherapy, 101 (Suppl 1), e783–e784. Retrieved from http://www.physiotherapyjournal.com/article/S0031-9406(15)03694-9/abstract

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. http://doi.org/10.1111/cpf.12145

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. http://doi.org/10.1249/MSS.0000000000000846

Choi, J. H., Kim, B. R., Joo, S. J., Han, E. Y., Kim, S. Y., Kim, S. M., … Yoon, H. M. (2015). Comparison of cardiorespiratory responses during aquatic and land treadmill exercise in patients with coronary artery disease. Journal of Cardiopulmonary Rehabilitation and Prevention, 35(2), 140–6. http://doi.org/10.1097/HCR.0000000000000094

Gomes, S. G. ., Silva, L. G. ., Santos, T. M. ., Totou, N. L. ., Souza, P. M. ., Pinto, K. M. C. ., … Becker, L. K. (2016). Elderly Hypertensive Subjects Have a Better Profile of Cardiovascular and Renal Responses during Water-Based Exercise. Journal of Exercise Physiology Online, 19(4), 21. https://www.asep.org/asep/asep/JEPonlineAUGUST2016_Gomes_Becker.pdf

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. http://doi.org/10.5603/CJ.a2015.0065

Moore, C., Fournier, S., DeVallance, E., & Lee, K. (2015). Deep Water Exercise Training is Associated with Decreased Arterial Stiffening in Women. The Federation of American Societies for Experimental Biology Journal (FASEB), 29(1). http://doi.org/10.1096/fj.1530-6860

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, 397–401. http://doi.org/10.2147/VHRM.S81411

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. http://doi.org/10.1002/cphy.c140018