Is aquatic therapy an appropriate option in fall risk management?

By Lynda Keane PGc, MSc, BSc (Hons), ATRIC, AEA, mSMA

This article is not a systematic review for accredited purposes nor is it a like for like comparison study it is simply because there is a need for a study on aquatic therapy and falls. Following is a brief analysis of the current available literature.

This past year has been very challenging for everyone’s health, be it mental or physical, with only a small minority coming out fitter and healthier. Nonetheless for the elderly and those with whose fitness was not the best before this past year it has cost them a great deal physically. Falls are a constant concern and often an associated hazard of aging, but does this need to be the case? There is much research around the subject of falling or lack of balance, why we fall and how to best prevent doing so. Balance is the ability to control one’s body during stillness and movement and is the result of the co-ordinated unison of many systems within the body including the musculoskeletal, neurological and sensory systems (Morris 2010). However there are many reasons why these systems cease to work harmoniously resulting in a loss of balance and subsequent falling, this can be in part due to medical conditions, muscle weakness, including age related Sarcopenia, and other degenerative age related conditions.

The fear of falling is very real especially as we age and this can lead to further complications including hospitalisation. According to the UK government the cost of falls to the NHS was over £4.4billion per annum during 2018/2019 (www.gov.uk accessed 20/05/2021) and these falls do not include injuries obtained through intrinsic events such as a stroke.

Fall prevention or balance is a subject that has been researched extensively and the rationale for using aquatic therapy as a viable option is not new. It is evident that the properties of water play an important role in retraining and resynchronising some of the systems. Buoyancy supports the body and reduces the fear of falling and as it gives support to the body there is less impact through joints that could be painful and thus allowing the participant to exercise for longer with less fatigue. The viscosity of the water reduces the speed of movement and helps stimulate the proprioception allowing for neuromuscular reprogramming and training as well as muscular strength. Hydrostatic pressure and the resistance of water through the principle of action and reaction helps with muscular strength all of which assist in fall reduction and decreased fear of movement. In addition to the properties there is the benefit of the biopsychosocial aspect of being part of a class or programme that is both physically and mentally stimulating and supportive all of which can result in reported improvements to quality of life.

For this article I am summarising a small number of journals/articles that I accessed through google scholar, using 2017 onwards as a search criteria with keywords aquatic therapy and fall. I then selected just the first page to read and briefly discuss. 10 studies were selected and of these one did not open and one was purely reviewing the effect of specific questionnaires post aquatic therapy. Within these articles all subjects were in the older age bracket (65 years plus). However whilst reading I did not find many articles which discussed ease of access to a pool, ease of entry and exit and pool temperature. All but 1 article were of short duration not exceeding 12 weeks and as previous research states that when the duration is over 12 weeks aquatic therapy exceeds land therapy in pain reduction which can be a cause of falls, plus longer duration will increase neuromuscular conditioning both on land and in water.

As with many aquatic therapy studies group exercise is a very popular modality, with fall risk and prevention being no exception, as it is cost effective, can be accessed by the majority and a variety of instructors can deliver the programme. The ratio for gender was not specified within most of the studies. 

Two of the studies accessed were systematic reviews looking at randomised control trials which is reported to reduce bias towards a result, both studies reviewed 14 papers dated from 2005-2018 and 2019-2020 respectively one asked the question “does aquatic exercise improve commonly reported predisposing risk factors to falls within the elderly?”(Guillamon et al 2019), the other “Is aquatic therapy optimally prescribed for Parkinson’s disease?” (Carroll et al 2020), they cover two different topics but both cover the risk of fall and balance.

The first of these reviews found that a majority of studies did not specify what exercises were undertaken for aquatic stretching and only 5 studies specified what strength training exercises where undertaken. This would make a lower quality study for replication and research as without the exercises being listed and described the study cannot be repeated. However the review did state that despite the low quality research there was evidence to support the use of aquatic exercise in fall prevention and that it may improve the negative physiological effects of ageing which are predisposing, modifiable risks of a fall (Guillamon, et. al. 2019).

The second review, which looked at aquatic therapy as an option for Parkinson’s disease, covered eight studies of modest quality. Again exercises were very varied and were not described adequately for research replication. However within this study it was found statistics for aquatic exercise showed higher positive outcomes than land exercises in the early stages of Parkinson’s disease despite the intervention being under-dosed and the duration of the trials being low ranging from 3-11 weeks (Carroll, et. al. 2020).

Another study written by Carroll et al (2021) looked at the opinions of people living with Parkinson’s and their views on accessing and participating in aquatic therapy. This study gives us a prospective on how the individual feels about attending classes within the aquatic environment. The study was an international collaboration between Ireland and Australia and found that participants were optimistic about choosing aquatic therapy as a benefit to their health and quality of life. Their reasons were identified as having programmes specifically tailored to their needs, ability to attend at least once per week, working at a moderate to high intensity and being taught by a qualified instructor. Some participants reported water competence, past experiences and fear of falling associated with the aquatic environment as barriers to participation (Carroll et al 2021). This does not state aquatic exercise as a fall prevention modality but does state that participants enjoy the exercise and are therefore more likely to adhere to it long term.

Of the remaining studies three included Ai-Chi as an appropriate technique for decreasing the potential of falls in the elderly. A pilot study by Nissim et al (2020) used Ai-Chi aquatic therapy technique as an intervention on fall risk, working memory and hazard-perception in older people. The study included 42 healthy older participants divided into three groups and compared Ai-Chi with Tai-Chi and imagery over a period of 12 weeks. The two intervention groups each took part in 30 minutes of exercise twice a week, both being delivered by qualified instructors and using the same guided movements. The study found that the Ai-Chi was of benefit for decreasing falls and that it also improved balance, verbal and visuospacial working memory. From the test results undertaken within this study Ai-Chi showed significant improvements faster than the Tai-Chi and imagery interventions on a majority of the specified tests performed. However it does need to be considered that this was only on a limited number of healthy individuals and consideration needs to be taken when delivering exercise to any elderly populations who could potentially have additional medical needs.

Covill et.als. (2017) clinical study compared two aquatic interventions Ai-Chi and an impairment-based aquatic therapy programme in an elderly community dwelling. This study found no significant differences between the two groups in participant reported outcomes to balance measures, balance confidence, or pain, but there was a significant improvement in physical outcome measures for the Ai-Chi group compared to the normal impairment-based aquatic therapy. This was a small group study indicating that future studies in this field should look to determine the most effective treatment frequency and duration within this population.

The final Ai-Chi article was a commentary by Ku et al (2020) in which they discuss the virtues of the technique and the populations it can benefit. The paper is not one about fall prevention but does discuss its merit for Stroke alongside a suggestion for its use in conditions such as Multiple Sclerosis, Parkinson’s, the elderly and individuals with non-specific lower back pain to name but a few. In Ku et al’s commentary he reviews the technique and provides a list of the Ai-Chi Kata’s for the reader to review and provides some images to assist in the execution. Though this is not a clinical or research study it does offer an insight into how the technique can be performed as well as explanations on its benefits to the musculoskeletal and fascial system and using the properties of water to enhance the effects of the AI-Chi movements.

An abstract on Silva et al’s (2020) randomised clinical trial. Looked at Halliwick and Bad Ragaz as their aquatic interventions when comparing with land based physiotherapy. This was a very small group study with only 19 participants. The study duration was 20 sessions, twice a week for 50 minutes per session. Results from this trial found that both interventions proved to be efficient but the aquatic therapy demonstrated certain advantages such as gait speed, balance, motor abilities and a reduction in risk of fall over standard physiotherapy.

The final study by Morris D (2010) the oldest study but worth a mention looked at “aquatic therapy to improve balance dysfunction in older adults”. In this paper Morris initially takes a look at the aging process and discusses the benefits provided by the properties of water. Within this paper Morris discusses Watsu, AI-Chi, Bad Ragaz and Halliwick as techniques that can contribute to balance control. The paper then discusses some of the literature written about the use of aquatic therapy for the various populations including age and age related medical conditions. The evidence in all the papers that have been discussed in this article point to the fact that aquatic therapy is a beneficial addition to the rehabilitation field when providing a programme to reduce the risk of falls.

To conclude from these studies it appears that there is a place for aquatic therapy in fall prevention though studies of longer duration should be considered along with larger group participation. This can be hard to accommodate when inclusion criteria is taken into account and can exclude participants who are unable to enter a pool independently.

In addition Ai-Chi appears to be an appropriate technique for risk of fall reduction which can be taught by aquatic instructors as well as physiotherapists. The technique has been well researched and is of significant importance within the aquatic industry. A disadvantage could be a cooler pool as the technique is generally one of slower movements which are an advantage for neuromuscular reprogramming making a warmer pool more ideal. The Halliwick programme with rotational patterns and Bad Ragaz with its passive and active re-education patterns are all of significance when retraining the weaker older adult. 

References:

Carroll, L, M., Morris, M, E., O’Connor, W, T., Clifford, A, M.. (2020). Is Aquatic Therapy Optimally Prescribed for Parkinson’s Disease? A Systematic Review and Meta-Analysis. Journal of Parkinson’s Disease. 10 (1), 59-76.

Carroll, L, M., Morris, M, E., O’Connor, W, T., Clifford, A, M.. (2021). Community aquatic therapy for Parkinson’s disease: an international qualitative study. Disabilities and Rehabilitation. 0 (0), 1-7.

Covill, L.G., Utley, C., Hochstein, C.. (2017). Comparison of Ai Chi and Impairment-Based Aquatic Therapy for Older Adults With Balance Problems: A clinical study. Journal of Geriatric Physical Therapy. 40 (4), 204-213.

da Silva, R., Magalhaes, r., Farias, L., Chaves, G., Manaia, F., Vieira, N do., Cardaretti, E., Adames, R., Paula, A., Brauns, D., da Silva, I. . (2020). effects of aquatic physiotherapy versus conventional physical therapy on the risk of fall in the elderly: a randomized clinical trial. Fisioterapia Brasil. 21 (3), 253-264.

Guillamon, E, M-C., Burgess, L., Immins, T.. (2019). Does aquatic exercise improve commonly reported preisposing risk factors to falls within the elderly? A systematic review. BMC Geriatrics . 0 (0), 1-16.

Ku,Pei-Hsin., Lambeck, J., Yeh, Nai-Chen., Wang, Ray-Yau. . (2020). Commentary to the New Rising Aquatic Exercise: Ai-Chi. Journal of Experimental Neurology. 1 (3), 73-79.

Morris, D. M.. (2010). Aquatic Therapy to improve Balance Dysfunction in OLder Adults. Geriatric Rehabilitation. 26 (2), 104-119.

Nissim, M., Livny, A., Barmatz, C., Tsarfaty, G., Berner, Y., Sacher, Y., Giron, J., Ratzon, N, Z.. (2020). Effects of aquatic physical intervention on fall risk, working memory and hazard-perception as pedestrians in older people: a pilot study. BMC Geriatrics . 20 (0), 1-12.