September 2016: Strokes



Content courtesy of the National Swimming Pool Foundation

Cerebrovascular disease is the third most common cause of death and the leading cause of serious disability in the United States. Stroke rehabilitation is complex because of the many complications and impairments of function that can follow a cerebrovascular accident, not all of them due to the neurological deficit induced. Weakness or paralysis is, of course, the chief problem in stroke recovery, but the awkward ways that the body compensates for spasticity are often a greater challenge in the longer term. 

Impaired sensation and balance, together with loss of sensation, results in falls and injury and is often an impediment to therapeutic exercise. The mental and emotional alterations that follow strokes can also impair rehabilitation, but may be worsened by the effects of immobility or reduced mobility, as are the many medical complications that follow stroke. There is growing evidence from studies in the last decade that physical therapy in an aquatic environment may be easier, safer and as effective, if not more so, than standard rehabilitative measures.


Dolbow et al, 2016
This study looked at studies concerning patients with spinal cord injury or stroke who suffered from gait issues as a result of some level of paralysis. The study presents research on patients who participated in underwater treadmill training as a method of restoring their gate. The limited amount of literature on this subject shows an increase in quality of life, gait performance, leg strength, and balance in patients who have suffered a stroke. 

Lee et al, 2016
Researchers investigated the cardiorespiratory responses of patients with subacute stroke to exercise stress tests in both an aquatic and land-based treadmill test. They found that the aquatic treadmill exercise had a better peak cardiorespiratory response than when a similar exercise was conducted on land. They concluded that aquatic treadmill exercise is just as effective as land-based treadmill exercise for treating patients with subacute stroke.

Matsumoto et al, 2016
This study’s aim was to evaluate the efficacy of underwater exercise in enhancing conventional therapy for post-stroke patients. A group of post-stroke patients receiving conventional therapy was contrasted with an experimental group that received both conventional land-based therapy and participated in underwater exercise. The exercise consisted of 30-minute training sessions in the pool twice a week in addition to the patients’ typical therapeutic treatments. The researchers found significant improvements in the experimental group, leading them to conclude that adding aquatic therapy to the treatment plan for post-stroke patients can improve their quality of life.

Park et al, 2016
The researchers in this study compared the effects of aquatic and land-based exercise programs on stroke patients to see what effect, if any, aquatic therapy had on gait. The subjects participated in the exercise program for 4 weeks, during which time they performed an exercise program incorporating both conventional land based exercises with aquatic exercises. The researchers found significant improvement in the patients’ gait performance ability, suggesting that adding aquatic therapy programs to conventional therapeutic measures for stroke patients may be beneficial.

Zhang et al, 2016
This study aimed to evaluate the effects of aquatic exercise on muscular strength in subacute stroke patients with partial paralysis of the lower limbs. The participants were randomly assigned to either conventional or aquatic therapy. The researchers measured the contraction and extension strength of the limbs in each group. They found the aquatic group to have significantly higher knee extension and a higher rate of ambulation. The researchers concluded that the aquatic exercise enhanced the muscle strength of the patients compared to the conventional land-based therapy group.


Buszek, B. (2015). Does aquatic therapy improve balance better than conventional land based therapy for patients post stroke? Thesis paper. University of New Mexico. Retrieved from

Calderón García, A. (2015). Effectiveness of the Halliwick Method in the treatment of subacute stroke. fisioGlía: Revista de Divulgación En Fisioterapia. FisioEducación. Retrieved from

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. Retrieved from

Chetlin, R., & Pritt, N. (2014). The Combined Effects of Aquatic Therapy and Occupational Therapy in Stroke Patients: Phase II. Medicine and Science in Sports and Exercise, 46(5), 530. Retrieved from

Dolbow, J. (2016). Underwater Treadmill Training After Neural-Paralytic Injury. Clinical Kinesiology (Online), 70(1), 1–8. Retrieved from
Duffy, K. (2014). Aquatic therapy for a patient post-stroke: A case report. Florida Gulf Coast University. Retrieved from

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

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).

Jeng, B., Todd, T., Narasaki-Jara, M., Konstantinos, V., Lim, H., Fujii, T., & Jung, T. (2016). Energy Expenditure Of Aquatic Walking In Individuals Post-stroke. Medicine and Science in Sports and Exercise, 48(5 Suppl 1), 210.

Jung, J., Lee, J., Chung, 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), 437–440. Retrieved from

Jung, T., & Ozaki, Y. (2014). Comparison of Energy Expenditure Between Aquatic and Overground Treadmill Walking in People Post‐Stroke. Physiotherapy Research International, 19(1), 55–64. Retrieved from

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.

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.

Lai, B., Jeng, B., Vrongistinos, K., & Jung, T. (2015). Post-exercise hypotensive responses following an acute bout of aquatic and overground treadmill walking in people post-stroke: a pilot study. Topics in Stroke Rehabilitation, 22(3), 231–238.

Lee, Y. K., Kim, B. R., & Han, E. Y. (2016). Peak Cardiorespiratory Responses of Patients with Subacute Stroke During Land and Aquatic Treadmill Exercise. American Journal of Physical Medicine & Rehabilitation, 1.

Marinho-Buzelli, A. R., Bonnyman, A. M., & Verrier, M. C. (2015). The effects of aquatic therapy on mobility of individuals with neurological diseases: a systematic review. Clinical Rehabilitation, 29(8), 741–51.

Matsumoto, S., Uema, T., Ikeda, K., Miyara, K., Nishi, T., Noma, T., & Shimodozono, M. (2016). Effect of Underwater Exercise on Lower-Extremity Function and Quality of Life in Post-Stroke Patients: A Pilot Controlled Clinical Trial. The Journal of Alternative and Complementary Medicine, 22(8), 635–641.

Montagna, J., & Santos, B. (2014). Effects of aquatic physiotherapy on the improvement of balance and corporal symmetry in stroke survivors. Int J Clin Exp Med., 7(4), 1182–1187. Retrieved from

Nishiyori, R., & Lai, B. (2014). The Use of Cuff Weights for Aquatic Gait Training in People Post‐Stroke with Hemiparesis. Physiotherapy Research International : The Journal for Researchers and Clinicians in Physical Therapy, 21(1). Retrieved from

Park, B.-S. B., Noh, J.-W. J., Kim, M.-Y. M., Lee, L.-K., Yang, S.-M., Lee, W.-D., … Kim, J.-H. J. J.-Y. (2015). The effects of aquatic trunk exercise on gait and muscle activity in stroke patients: a randomized controlled pilot study. Journal of Physical Therapy Science, 27(11), 3549–53.

Park, B.-S., Noh, J.-W., Kim, M.-Y., Lee, L.-K., Yang, S.-M., Lee, W.-D., … Kim, J.-H. J. (2016). A comparative study of the effects of trunk exercise program in aquatic and land-based therapy on gait in hemiplegic stroke patients. Journal of Physical Therapy Science, 28(6), 1904–1908.

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.

Pugh, C. J. A., Sprung, V. S., Ono, K., Spence, A. L., Thijssen, D. H. J., Carter, H. H., & Green, D. J. (2015). The effect of water immersion during exercise on cerebral blood flow. Medicine and Science in Sports and Exercise, 47(2), 299–306.

Tripp, F., & Krakow, K. (2014). Effects of an aquatic therapy approach (Halliwick-Therapy) on functional mobility in subacute stroke patients: a randomized controlled trial. Clinical Rehabilitation, 28(5), 432–439.

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

Yoo, J., Lim, K. K.-B., Lee, H.-J., & Kwon, Y.-G. (2014). Cardiovascular response during submaximal underwater treadmill exercise in stroke patients. Annals of Rehabilitation Medicine, 38(5), 628–36.

Zhang, Y., Wang, Y. Y.-Z., Huang, L. L.-P., Bai, B., Zhou, S., Yin, M.-M., … Wang, H.-T. (2016). Aquatic Therapy Improves Outcomes for Subacute Stroke Patients by Enhancing Muscular Strength of Paretic Lower Limbs Without Increasing Spasticity: A. American Journal of Physical Medicine & Rehabilitation / Association of Academic Physiatrists, Epub Ahead of Print.

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.