March 2016: Balance Disorders



Content courtesy of the National Swimming Pool Foundation

The pool is not just a good place to practice balance reactions, it’s a great place. Frankly, it should rank near the top of anyone’s list. So how does immersed exercise offer so much therapeutic bang for so little effort? 

First, individuals who are too weak to move safely under gravity’s full effect are able to move with significant freedom in water. More movement creates more opportunities to fail… or to prevent failure. This is the nuts-and-bolts of balance training: repeated, progressive attempts with a learning curve. Second, individuals who are in too much pain or too fatigued to move regularly on land may be willing to make the effort in a reduced effort environment like the pool. Third, individuals who choose to forgo regular movement on land, due to fear of falling, may be willing to do so in the water. Forth, while weight bearing is reduced in water, muscle pull is increased (especially with rapid movements) and thus it becomes possible to stimulate bone growth and reduce bone loss, both which reduce the risk of falls. 

There is no doubt that health problems related to falls represent a persistent problem among the elderly and disabled. And while falls typically result in minor clinical consequences, they can occasionally have drastic results, and consistently lead to inpatient treatment and increasingly long stays in health care facilities. In contrast, fall reactions can be repeated practiced in the safe environment of the pool. 

A significant number of recent studies are demonstrating that water-based exercise is effective for patients with stroke (Mehrholz, 2013), spinal cord injury (Dolbow, 2016), multiple sclerosis (Izanloo, 2016), Parkinson’s disease (Pompeu, 2013), and even elderly populations (Alikhajeh, 2012) and athletes (Torres-Ronda, 2014). There is even a growing body of evidence that the pool is an ideal place for dual task processing and cognitive retraining (Myers, 2013). Each study has a unique exercise program (Alikhajeh, 2012), although they all generally involved a water adaptation and/or warm-up phase, a stretching phase, a strength and/or endurance phase, and a cool down phase. Some studies even examined the benefits of using unique aquatic equipment, such as underwater treadmills (Dolbow, 2016) or obstacle courses (Jung, 2014). Compared to controls, every aquatic exercise program showed significant improvement in at least one or more risk factors. 

All told, there is a general acknowledgement of the evidence supporting the effectiveness of aquatic exercise as an intervention for fall risk among neurologic, musculoskeletal and post-operative disorders (Barker, 2014; Marinho-Buzelli, 2014). 


Alikhajeh 2012
ELDERLY. This study examined what would happen when elderly, but otherwise healthy, sedentary men underwent 8 weeks of 3x/week balance training in water. The protocol used was comprised of three phases: aquatic adaptation, stretching, and balance exercises (both static and dynamic). The results showed that even these apparently healthy individuals made significant gains in balance after just 2 months of work. Therapists looking for treatment ideas may benefit from a quick look at this study protocol.

MUSCULO. This systematic review examined the combined results from 20 aquatic studies rated with high methodologic quality. All 20 studies examined the effects of aquatic exercise on various musculoskeletal conditions. Compared with no exercise, aquatic exercise produced moderate improvements in pain, physical function and quality of life. And while the results do not currently show one environment to be better than the other, the fact that both environments produced similar benefits has huge ramifications for individuals who are unable to exercise on land.

Dolbow 2016
CVA & SCI. Individuals interested in a quick look at the effects of underwater treadmill training on gait and balance for patients with stroke or spinal cord injury need look no further. This online journal article examined the effects of this up-and-coming method of training. 

Izanloo 2016
MS. Multiple sclerosis and balance disorders go hand-in-hand. A team of researchers asked themselves what would be the consequences of 12 weeks of aquatic aerobic and balance exercises on women with multiple sclerosis. After 24 sessions, the study participants showed a significant increase in static and dynamic balance as well as other quality of life indicators. The researchers made a strong case for the use of aquatic exercise for balance training with this population. 

Jung 2014
CVA. Why didn’t we think about this before? Researchers built an obstacle course for the sole purpose of challenging balance… but they put one obstacle course on land and one in the pool. Subjects with long-term effects of stroke were assigned to one group or the other randomly. After 12 weeks (36 visits), both groups improved significantly, but the aquatic group improved far more than their land-based counterparts. In short, the aquatic course was safer and more effective in challenging balance reactions.  

KING 2016
ELDERLY. In this systematic review, the authors compiled the net results of 13 studies which examined the benefit of aquatic therapy for the elderly. They found that almost all the studies found benefit with aquatic exercise, but that few studies showed that aquatic-based exercise was better than its land-based counterpart. This is an important distinction for payers who wish to know if aquatic exercise is most cost-effective than land-based exercise or just equally so.

Macías-Hernández 2013
MUSCULO. This article examined what happens when you marry the best of both words (martial arts and pool therapy) to work on balance. This paper attempts to make a case for providing Tai Chi in the pool as a combined intervention instead of providing Tai Chi or hydrotherapy alone. 

Marinho-Buzelli 2014
NEURO. This systematic review examined a total of 20 high quality studies to determine if aquatic exercise produces a positive effect on balance and gait speed in adults with neurological disorders (primarily MS and CVA). Their review demonstrated that the existing evidence does support the benefits of aquatics with a “fair” rating of evidence. 

Mehrholz 2013
CVA. This important systematic review by the Cochrane Library looked at the findings of 4 studies related to water-based exercise post-stroke. Their findings, while positive, were not strong enough to confirm or refute the benefit of aquatics for balance and other dysfunctions post-stroke. 

Myers 2013
DEMENTIA. One of the most compelling new areas of research in the field today is the search for exercises which benefit cognition as well as physical realms like balance deficits. This case study examines the compelling story behind why aquatic therapy worked for a man with significant dementia due to Alzheimer’s disease.  

Pompeu 2013
PARKINSON’S. This study attempted to determine the treatment effect of aquatic physical therapy on balance and gait for patients with Parkinson’s. After 36 weeks of aquatic therapy over a 3 month period, the patients demonstrated improvement in almost every parameter studied, including the Timed Up and Go, the Berg Balance Scale and the Dynamic Gait Index. 

Torres-Ronda 2014
ATHLETES. The authors of this article do an excellent job discussing the role of aquatic exercise in the recovery of balance and proprioception skills after injury in athletes. Individuals looking to make a case for use of the pool for higher-level clients can find support for their arguments here. 


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. doi:10.1016/j.sbspro.2012.05.458. Retrieved from

Barker, A., Talevski, J., & Morello, R. (2014). Effectiveness of aquatic exercise for musculoskeletal conditions: a meta-analysis. Archives of Physical Medicine and Rehabilitation, 95(9), 1776–86. Retrieved from 

Dolbow BS, BA, J. D., Gassler  PT, DPT, MS, GCS, J., Dolbow  PhD, DPT, RKT, D. R., & Stevens  PhD, S. L. (2016). Underwater Treadmill Training After Neural-Paralytic Injury. Clinical Kinesiology (Online), 70(1), 1–8. Retrieved from

Izanloo, 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 IJBPAS 2016 JAN SPCL 1120.pdf

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), 437–40. doi:10.1589/jpts.26.437. Retrieved from

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), 9-21. Retrieved from

Macías-Hernández, S. I. S., Vázquez-Torres, L., Morones-Alba, J. D., Coronado-Zarco, R., de Los Angeles Soria-Bastida, M., Cruz-Medina, E., & Nava-Bringas, T. I. (2015). Water-based Tai Chi: theoretical benefits in musculoskeletal diseases. Current evidence. Journal of Exercise Rehabilitation, 11(3), 120–4. doi:10.12965/jer.150207. Retrieved from

Marinho-Buzelli, A. R., Bonnyman, A. M., & Verrier, M. C. (2014). The effects of aquatic therapy on mobility of individuals with neurological diseases: A systematic review. Clinical Rehabilitation, 0269215514556297–. doi:10.1177/0269215514556297. Retrieved from

Mehrholz, J., Kugler, J., & Pohl, M. (2011). Water-based exercises for improving activities of daily living after stroke. Cochrane Database of Systematic Reviews (Online), (1)(1), CD008186. doi:10.1002/14651858.CD008186.pub2. Retrieved from

Myers, K. W., Capek, D., Shill, H., & Sabbagh, M. (2013). Aquatic Therapy and Alzheimer’s Disease. Annals of Long-Term Care, 21(5), 36-41. Retrieved from

Pompeu, J. E., Gimenes, R. O., Pereira, R. P., Rocha, S. L., & Santos, M. A. (2013). Effects of aquatic physical therapy on balance and gait of patients with Parkinson’s disease, J Health Sci Inst, 31 (2), 201–204. 

Torres-Ronda, L., & Del Alcázar, X. S. I. (2014). The Properties of Water and their Applications for Training. Journal of Human Kinetics, 44, 237–248. doi:10.2478/hukin-2014-0129. Retrieved from