This chapter is a narrative review of the health benefits derived from therapeutic
Interventions in water and includes both active (therapeutic aquatic exercise; TAE) and
passive immersion treatments. Literature in which immersion and TAE have been
combined mostly refer to balneotherapy or (inpatient) rehabilitation. TAE more
typically is presented in literature as a stand-alone treatment for outpatients.
Especially in musculoskeletal diseases, a dichotomy can be found in literature: TAE
versus balneotherapy. Therefore we followed this dichotomy in the musculoskeletal
section. Other sections are about TAE, realizing that these exercises can take place in
water of various chemical compositions.
Balneotherapy is defined as using thermal mineral water and other natural factors (mud,
gas) for treatment and rehabilitation. It is commonly used as bathing (water immersion),
but interventions with active movement can also be included.
TAE can be defined as an intervention utilizing the mechanical and thermal
characteristics of water during immersion , in combination with the effects of movement,
aimed at a systematic approach to treat a health problem. Both balneotherapy and TAE
evoke short-term and long-term adaptation mechanisms of a person with a deranged
biological system (World Confederation of Physical Therapy – Aquatic Physical Therapy
International network; WCPT-APTI).
Comparisons with dry land interventions have not been made due to the limited space
available. A comprehensive systematic review is planned to be conducted at a later stage
We have primarily focused on persons with a medical diagnosis as described in the ICD-
10 and their resultants effects (as described in the ICF)., but have restricted ourselves to
diseases, which have been presented in aquatic research literature sufficiently.
The description is based on searches in health care databases (Pedro, Pubmed, Embase,
Cochrane central, Cinahl) in the period May 2012 – October 2012.
We have also added a subchapter on aquatic activities for individuals without a health
problems as described in the ICD-10. In this text we have focused on possibilities to
maintain health in individuals whose health is endangered by lifestyle or age.
The description of the levels of evidence is based on the table of the Oxford Centre of
Evidence Based Medicine (OCEBM, 2011), categorize studies to reflect the degree to
which the evidence is flawed. This chapter mostly has been able to present results with
evidence levels of 1 to 3. The annotation will be mostly as ,  or .
OCEBM describes the levels, related to treatment benefits, as:
Draft January 2013
– level 1: systematic review of randomized trials or n-of-1 trials
– level 2: randomized trial or observational study with dramatic effect
– level 3: non-randomized controlled cohort/follow-up study
– level 4: case-series, case-control studies, or historically controlled studies
– level 5: mechanism-based reasoning
TAE and balneotherapy are interventions that in general do not give unwanted side
effects or harms. Some pathologies however can be negatively influenced by the effects
of immersion and TAE. In those cases, this has been stated clearly in the respective subchapters.