Aquatic Therapy After Stroke

Balance impairment is one of the most common challenges following stroke and is closely associated with reduced mobility, slower walking speed and an increased risk of falls. A 2025 systematic review and meta-analysis evaluated the effectiveness of aquatic therapy after stroke, analysing 27 clinical studies involving more than 1,100 stroke survivors. The results demonstrate that aquatic therapy can significantly improve balance, walking performance and fall risk when incorporated into stroke rehabilitation.

Why aquatic therapy is beneficial after stroke

Many stroke survivors experience muscle weakness, impaired coordination, spasticity and reduced postural control. These impairments often make land-based rehabilitation physically demanding and may increase the fear of falling.

Water provides a unique rehabilitation environment where buoyancy reduces body weight, hydrostatic pressure enhances proprioceptive feedback and viscosity creates natural resistance during movement. Together, these properties allow patients to practise balance and gait exercises with greater confidence and reduced joint loading. Warm therapeutic water may also decrease pain and muscle stiffness while improving movement quality.

Study design

The review included 27 interventional studies involving 1,134 stroke survivors, of which 19 studies were included in the meta-analysis.

Participants ranged in age from approximately 50 to 69 years, with time since stroke varying from one month to more than five years. Aquatic therapy was compared with conventional rehabilitation, land-based physiotherapy or no aquatic intervention.

Significant improvements in balance

The primary outcome of the review was balance, measured using the Berg Balance Scale (BBS).

The meta-analysis demonstrated that aquatic therapy produced significantly greater improvements in balance than comparison interventions.

Improved balance is clinically important because it supports safer walking, greater independence and increased participation in daily activities after stroke.

Faster walking speed

Walking speed also improved significantly following aquatic therapy.

Many of the included studies reported improvements in gait performance using the 10-Metre Walk Test, 2-Minute Walk Test, aquatic treadmill training and functional walking assessments.

Improved walking speed is strongly associated with greater community mobility and functional independence after stroke.

Reduced risk of falls

The review found that aquatic therapy significantly reduced fall risk compared with conventional rehabilitation.

Improved postural control, better dynamic balance and increased confidence while walking are likely to contribute to this reduction in fall risk, an important outcome for long-term recovery.

Effective aquatic therapy methods

The review included a wide variety of evidence-based aquatic rehabilitation approaches.

Ai Chi

Several studies demonstrated that Ai Chi, which combines slow controlled movements with breathing exercises, improved balance and postural control. Combining Ai Chi with conventional land-based therapy often produced greater improvements than land-based therapy alone.

Halliwick Concept

The Halliwick Concept was shown to improve balance, trunk control and functional mobility through rotational control and water adaptation exercises.

Patients receiving Halliwick training frequently achieved greater balance improvements than those receiving conventional therapy alone.

Underwater treadmill training

Several studies incorporated underwater treadmills, demonstrating improvements in gait speed, balance and walking performance.

Underwater treadmill training combines repetitive gait practice with reduced weight-bearing, allowing stroke survivors to practise walking earlier and more safely than on land.

Proprioceptive Neuromuscular Facilitation (PNF)

Aquatic PNF techniques improved functional mobility, walking speed and balance more effectively than similar exercises performed on land in several studies included in the review.

Water temperatures used in rehabilitation

Most therapeutic pools operated between 30°C and 35°C, although reported temperatures ranged from 30°C to 38°C.

These temperatures provide a comfortable environment for neurological rehabilitation while facilitating relaxation and movement.

Clinical implications

The authors conclude that aquatic therapy represents an effective rehabilitation option for people recovering from stroke.

Potential clinical benefits include:

• Improved balance
• Faster walking speed
• Reduced fall risk
• Better gait quality
• Increased confidence during movement
• Greater functional independence

The review also found that treatment programmes consisting of 10–20 sessions and those exceeding 20 sessions produced comparable overall benefits, suggesting that meaningful improvements can be achieved with a range of treatment durations.

Limitations

Although the overall findings were positive, the authors advise interpreting the results with some caution.

The included studies demonstrated considerable variation in treatment protocols, aquatic therapy methods, patient characteristics and outcome measures. In addition, many studies had methodological limitations, including a high risk of bias due to limited blinding of therapists and participants.

Conclusion

This systematic review and meta-analysis provides strong evidence that aquatic therapy after stroke improves balance, walking speed and reduces fall risk in stroke survivors.

By combining the unique physical properties of water with structured neurological rehabilitation techniques such as Ai Chi, the Halliwick Concept, aquatic PNF and underwater treadmill training, aquatic therapy offers an effective and safe addition to modern stroke rehabilitation programmes. While further high-quality research is recommended, the current evidence strongly supports integrating aquatic therapy into comprehensive post-stroke rehabilitation.