June 28, 2023 10 min read

When submerged in water, our aching bodies find both relief and strength—a testament to the transformative power of the aquatic environment for those grappling with pain. Aquatic exercise is an excellent form of rehabilitation and also provides numerous benefits for those experiencing both acute and chronic pain.

Water cycling and other forms of exercise done in the water are particularly beneficial. Often, people recovering from an orthopaedic challenges encounter pain during land-based rehabilitation or exercise. This can lead individuals to dread therapy or avoid movement altogether. Aquatic settings fill this gap by providing a place where those hurting or healing can move more freely, build strength and flexibility, and even improve mental health outcomes.


Orthopaedics is the branch of medicine that manages and treats the musculoskeletal system (muscles and skeleton) and its structures (i.e., tendons and ligaments). There are many ways to treat musculoskeletal system, modern methods include surgery, acupuncture, osteopathy, chiropractic adjustment, occupational therapy, prescription pain relievers, physical therapy, remedial massage and water therapy. These treatments are run by different specialists and are often used in conjunction to help the musculoskeletal system to heal and remove the symptoms and or pain.

Aquatics can be used as a therapeutic practice in the form of prevention, exercise, maintenance, pain management, or in a formal rehabilitation setting. There is an synergistic benefit of using both land and water therapy known as the Burdenko Method. However, land based specialists are often not widely trained in water and the same movement on land is often not the most effective form of treatment when considering the waters unique properties and specialised aquatic equipment available.  There is increased interest in using aquatics as a part of or at particular stages and in certain situations, the sole modality in orthopaedic rehabilitation. 

We know that exercise is important for the prevention of various ailments and resistance training and cardio are both great for rehabilitation. In this article, we’ll discuss the evidence base for aquatic therapy for orthopaedic conditions and what sets aquatic therapies apart from land-based exercise.


According to the Australian Institute of Health and Welfare, roughly three in ten Australians have chronic musculoskeletal conditions. This is oftentimes quantified by a subjective measurement like quality of life and pain. Musculoskeletal pain can be acute or chronic pain. Acute pain may be caused by an accident or injury. Chronic pain is sometimes genetic or attributed to lifestyle factors and age.

The anatomy and biomechanics of the human musculoskeletal system are intricate, leading to the multifaceted nature of musculoskeletal pain. Muscles are connected to bones by tendons, while ligaments connect bones to other bones. An issue in one component can affect adjacent structures. For instance, a tightened muscle may cause misalignment of bones, or an inflamed joint can exert pressure on nearby muscles.

Because of these complexities, management involves a comprehensive approach. Aquatic therapy works with the body instead of against it, which can be vital for those with musculoskeletal pain on land.



In Australia, one in seven people has arthritis, according to Arthritis Australia. There are over a hundred different types of arthritis, but a common one and type that often requires treatment is osteoarthritis (OA). This type of arthritis breaks down the cartilage in a joint and starts to reshape the underlying bone. At a certain point, the joint may have to be replaced entirely, otherwise known as a knee or hip replacement. Non-invasive management is often the first line treatment for those suffering from OA.

There is solid evidence that points to exercise for knee osteoarthritis. This trial in particular saw improvement after 8-12 weeks of therapy 3-5 times per week for an hour. In a review study with older adults with knee or hip osteoarthritis, researchers measured the effects of aquatic therapy on pain, disability and quality of life. Nine trials were reviewed that resulted in clinically relevant improvements in all outcome measures after 12-week programs, on average. This aligns with another meta-analysis that included 13 studies totalling 883 participants, which concluded that aquatic physical therapy improved pain, physical function, knee extension muscle strength, and walking ability in patients with knee osteoarthritis. Furthermore, a controlled trial observed greater improvements in symptoms of knee OA after a 12-week aquatic cycling program compared to usual care.

Another less common type of arthritis, rheumatoid arthritis (RA), is an autoimmune disease that causes painful swelling in the joints. In addition to the general benefits of water-based therapy for arthritis, this study indicates strong evidence for aquatic therapy in those who suffer from RA specifically due to its anti inflammation properties.


Another prime use for aquatic therapy is for competitive athletes where joint injuries are commonplace. Especially for professionals, it’s imperative to expedite recovery as much as possible to get them back into competition safely.

An innovative trial studied the effects of aquatic proprioceptive training with male athletes after an ACL reconstruction surgery. Thirty-eight participants were divided into a hydrotherapy or conventional training group, and there were better proprioception metrics in the test group than in the control. Proprioception is largely related to balance and control and the awareness we have about how and how our body moves in space. Sometimes, this awareness suffers after an injury or surgery.

Again, the primary advantage of aquatic rehabilitation over land-based is that those injured are able to start rehab much faster after surgery or after an injury. Also, aqua therapy helps manage joint effusion (joint swelling) associated with ACL injuries. This is backed by evidence from this study. A very small study with three soccer players after ACL reconstruction also discussed the efficacy of an accelerated hydrotherapy program versus traditional therapy.


Chronic low back pain (CLBP) affects millions of people worldwide. Chronic pain may or may not have a cause, making it difficult to treat. Oftentimes, those living with CLBP have tried multiple modalities and treatments. Due to the therapeutic and supportive properties of water, it makes for an excellent medium for those with chronic low back pain to exercise and help manage their symptoms.

In a 2022 trial with 113 participants, therapeutic aquatic exercise proved to be more beneficial for chronic low back pain compared to traditional physical therapy modalities. This supports a previous study that indicated that patients with CLBP could benefit from hydrotherapy, but also that there has been very low-quality evidence thus far. 

In this study that analysed results from sixteen studies, the authors concluded that proprioception training improved pain and reduced disability. Proprioceptive training helps improve balance, allowing your body to stay upright and move while maintaining control in various environments, which is what aquatic therapy is, however, the study didn’t explicitly mention aquatic therapy.


Osteoporosis is a condition that weakens the bones and can cause people to be more susceptible to fractures and breaks. It’s a condition associated with ageing and is also most common in postmenopausal women. Bone mineral density (BMD) tends to decrease after menopause due to lower estrogen levels

This aquatic-based trial randomly divided 25 postmenopausal women into a trained and untrained group. BMD significantly improved in the training group compared to the control group. Another randomized controlled trial found similar results. Fifty postmenopausal women were split into a treatment and control group. Balance and quality of life were significantly improved in the treatment group compared to control.


Aquatic therapy, sometimes referred to as hydrotherapy or pool therapy, encompasses a diverse range of therapeutic exercises and techniques conducted in water to take advantage of its unique properties. Aquatic therapy is considered by some an underused or overlooked modality, but there is the potential for a wide range of uses in the aquatic environment.

Because of water’s physical properties, it provides multiple benefits for rehabilitation and pain management. It’s considered less painful for many with musculoskeletal conditions and pain due to the water’s buoyancy, hydrostatic pressure, viscosity, and temperature if the water is heated.

Additionally, exercise therapy in the water helps improve flexibility, strength and balance for anyone, not just those with prior ailments. This is key for preventing common orthopaedic disorders.

There are a few key differences between land-based and aquatic-based rehabilitation. Land-based exercise can be more challenging for those who are overweight, arthritic or don’t have good balance and coordination. In this respect, aquatic therapy is safer for some.

An RCT that compared traditional land movement to specific aquatic movement and observed that hip abductor strength significantly improved after two weeks of aquatic in patients after a recent hip replacement surgery. This agrees with another trial that tested an aquatic therapy regimen against just a land-based one in individuals after knee replacement surgery. After six weeks of therapy, participants in the combination group achieved greater range of motion and had fewer symptoms associated with post-operative knee replacement. Research is evolving, but there are definitely advantages to integrating aquatic therapy into orthopaedic rehabilitation plans.

There are a few different types of aqua therapy and aquatic equipment that can be employed for orthopaedics. 

A few types of water-based therapies include:

Water Cycling: Indoor and outdoor cycling are great for cardiovascular fitness and strength. Aqua cycling has these same benefits but to a greater extent due to the water’s resistance and more cushion for the joints. Water cycling is especially beneficial for strengthening the knee joint, which is a common injury site in people of all ages.

Underwater Running on a Treadmill: Running in water rather than on land is much kinder on the joints. Underwater running can prevent injury in the first place, quicken recovery, and improve strength.

Resistance Bands: Bands are a great addition to any water fitness or rehabilitation regimen, and they can be used in combination with other aquatic equipment. Resistance bands provide a unique form of strength training that improves flexibility, stability, and coordination.

Again, the professionals involved will use the method of their choice or a combination of a few to help exercises heal and achieve their intended results.



The water’s buoyancy removes much of gravity’s impact on already achy joints. This is why it is such a common treatment method for those with arthritis. This is also the case for those who are obese or overweight; water helps take pressure off the joints


The water provides a natural resistance that is an excellent medium for strength training. Muscular endurance is typically built with lighter weight and more repetition, so water is also a great way to train muscle endurance. 


After a musculoskeletal injury or surgery, the area is bound to be stiff and have a pretty small range of motion, for example, knee replacement. While this is normal, it requires rehabilitation to gain that range of motion back.


Hydrotherapy or aquatic exercises activate stabiliser muscles (smaller/accessory muscles) that land-based training may miss. Oftentimes these smaller muscles are vital for balance and coordination. Furthermore, should someone have poor balance, falls are unlikely with the water’s support.


This may be especially important for athletes, but anyone is going to be better off recovering faster. You don’t need to be running a marathon after a knee replacement, but you do need to be able to do activities of daily life like going up and down stairs, feel stable and balanced, and bend down to pick things up off the ground. Those who can’t stand or get around easily on land may be able to begin rehab sooner in the water.


Various forms of water-based therapy and exercise have been found to help with stress relief, mood improvement, and even managing mental health conditions. The mind and body are undoubtedly intertwined; a healthy mind helps a healthy body and vice versa.


If you are new to aquatics, feel free to ask questions about how aquatic therapy works.

1. Wear the right attire. Non-skid water shoes can help with traction. Also, wear a comfortable swimsuit that doesn’t restrict movement. If you aren’t comfortable in swimwear or struggle to wear swimwear, come to therapy how you are most comfortable and can be ready to work.

2. Come warm. If it’s winter, the pools may be heated, but removing outer layers and entering the water is even less enticing if you’re already chilly. Your therapist will provide a warm-up, but it’s always good to come with warm muscles ready to start the session.

3. Pay Attention to Breathing: Just as with land-based exercises, it's important to maintain a steady and deep breathing pattern to optimize oxygen delivery to the muscles.

4. Consistency is key. Like all therapies, consistency matters. Regular sessions, combined with home exercises as advised by the therapist, can offer better outcomes. Work with your therapist to create a schedule that works well for you and is effective. The frequency and length of training will depend on your particular injury or condition.

5. Integrate it into daily life. After therapy, consider continuing with aquatic group fitness classes to maintain strength, flexibility, balance, and coordination.


The pool can be a very safe place if proper precautions are taken and the right conditions are ensured. Most exercises are done in shallow water (where you can touch) or on specialised machines and with qualified lifeguards present.

Some skin conditions or post-operative wounds need to heal before being exposed to pool water, but that’s up to a medical provider to decipher when this is the case.

Aquatic therapy is not only for seniors or severe orthopaedic cases. The image we usually associate with aquatic exercise and rehab is that of an older person in the pool. This type of therapy is definitely not just for seniors, but also for those with musculoskeletal pain, and injuries, and those that struggle with land-based exercise at any age. Also, it’s important to note that young people also have arthritis. Physical movement is crucial for all of us, and younger age groups shouldn’t miss out on power of aquatic exercise and its relief and preventative benefits.


There are exciting and techniques currently technological advancements in aquatic therapy made possible with aquatic equipment specialists like Hydrorider. With growing customer results and popularity, there is the potential for integrating aquatic therapy into mainstream orthopaedic practices. Soon aquatic therapy may be considered a primary modality to manage and treat common orthopaedic conditions. Until then, more controlled trials are needed to support customer experience and results seen by companies like Water Resist which help to outline the efficacy of aquatic therapy for prevention, management, rehabilitation, and management of orthopaedic issues. With more research comes updated guidelines, and practitioners have a even more available data when prescribing treatment plans for their patients.


Aquatic therapy plays a significant role in orthopaedics, whether it be for prevention, management, or rehabilitation of musculoskeletal conditions and injuries. There are a few modalities available for aquatic exercise and rehab such as aqua cycling, underwater running, regimens using aquatic resistance bands, and more. It’s encouraged for both practitioners and patients to stay informed and explore the benefits.

Orthopaedics focuses on treating the musculoskeletal system, including muscles, bones, tendons, and ligaments. When injuries or conditions arise, the aim is to resolve the problem regardless of the modality. Often a combination of modalities are used to heal and reduce pain. Aquatic therapy, also known as hydrotherapy, has garnered increased interest for its role in orthopaedic rehabilitation. The water's properties, including buoyancy, hydrostatic pressure, and viscosity, offer advantages like reduced joint impact, improved muscle strength, enhanced flexibility, quicker recovery times, and psychological benefits.  Studies indicate its efficacy in treating conditions like osteoarthritis, sports-related injuries, and osteoporosis. Moreover, its application is not limited to seniors; people of all ages can benefit, including those who find land-based exercises challenging. Technological advancements are further enriching the aquatic therapy field, potentially positioning it as an important treatment modality in orthopaedics. As research progresses, more evidence will back customer experiences and guide practitioners in integrating aquatic therapy into their treatment plans.

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