Water-based therapeutic exercise in stroke: a scoping review

PURPOSE

To (1) describe the state of the literature on water-based therapeutic exercise (WBTE) for people living with stroke, (2) describe the content and structure of interventions, (3) summarize the effects of interventions described in the literature, and (4) identify gaps in the literature limiting application and implementation.

MATERIALS AND METHODS

Scoping review methodology described by Arksey and O'Malley (2005) and Levac et al. (2010). Electronic databases were searched for articles with eligibility criteria including: (1) adult stroke survivors (18 years or older) of any type (ischemic/hemorrhagic) or stage (acute/chronic) in any setting, and (2) the study intervention involved WBTE to address a post-stroke deficit.

RESULTS

40 articles were included in this review. Five trials had a treatment control, 20 had an active comparison. Calculated intervention effect sizes demonstrated a strong effect of WBTE on balance and gait related outcomes in 80% of controlled and comparison trials.

CONCLUSIONS

This scoping review highlights common parameters of WBTE interventions and provides an inventory of the differences in the treatment approaches utilized in this population. Opportunities for future work include the development of a standardized treatment protocol, qualitative or mixed methodology research, and greater inclusion of more individuals with more severe stroke-related impairments. IMPLICATIONS FOR REHABILITATIONWater-based therapeutic exercise is an approach that may allow stroke survivors to carry out challenging activities in a safe and accessible environment.Water-based interventions for stroke survivors appear to have a beneficial impact on walking and balance.Given that an aquatic environment offers an opportunity for individuals with more significant physical impairments to carry out early practice of walking and balance related tasks, clinicians should explore the feasibility and effectiveness for this subset of stroke survivors.

Effects of aquatic exercise on mood and anxiety symptoms: A systematic review and meta-analysis

OBJECTIVE

Exercise has beneficial effects on mood and anxiety symptoms. However, the impact of aquatic exercise on mood and anxiety symptoms has not been clearly confirmed. Therefore, this study aimed to synthesize and systematically analyze evidence available on boosting mental health through aquatic exercise.

METHOD

A systematic review and meta-analysis were conducted under the PRISMA 2020 guidelines. PubMed, BIOSIS Previews, PsycINFO, Medline, SPORTDiscus, Education Source, and Web of Science Core Collection (WoSCC) were searched in May 2022. The research included the influence of aquatic exercises on mood and anxiety symptoms. After assessing trial quality and completing data extraction, a meta-analysis was carried out through R software. The results were presented as a standardized mean difference (SMD) and the corresponding 95% confidence interval.

RESULTS

A total of 18 original trials were included. People who received aquatic exercise intervention had a statistically significant reduction in mental disorder symptoms compared with before. The results were aquatic exercise [SMD = -0.77, 95% CI (-1.08, -0.47), I² = 77%, P < 0.01], swimming [SMD = -0.51, 95% CI (-1.14, 0.12), I² = 78%, P < 0.01], aquatic aerobics [SMD = -0.92, 95% CI (-1.32, -0.53), I² = 78%, P < 0.01], moderate intensity [SMD = -0.75, 95% CI (-1.07, -0.43), I² = 67%, P < 0.01], and low intensity [SMD = -1.07, 95% CI (-1.08, -0.47), I² = 85%, P < 0.01].

CONCLUSION

Aquatic exercise could statistically significantly improve mental health. Light aquatic aerobics probably has a better effect on mood and anxiety symptoms. However, given the number and quality of included research, verifying the aforementioned conclusions requires a larger sample of high-quality studies.

The efficacy of aquatic therapy in stroke rehabilitation: A protocol for systematic review and meta-analysis

BACKGROUND

Few studies have reported the clinical effect of aquatic therapy in stroke rehabilitation. Therefore, we performed a protocol for systematic review and meta-analysis to assess the effectiveness of aquatic therapy for individuals affected by strokes.

METHODS

This protocol of systematic review and meta-analysis has been drafted under the guidance of the preferred reporting items for systematic reviews and meta-analyses protocols. This study will use the Cochrane Library, Web of Science, PubMed, Embase, Allied and Complementary Medicine Database (AMED), China Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), Wanfang Database, and Ongoing Clinical Trials Database. Quality assessment of the included studies was evaluated using the Cochrane risk of bias assessment tool. We performed the meta-analysis by RevMan 5.4 software.

RESULTS

The results of this systematic review and meta-analysis will be published in a peer-reviewed journal.

CONCLUSION

Aquatic therapy may be a valid means for the rehabilitation of people affected by stroke.Open Science Framework registration number: https://doi.org/10.17605/OSF.IO/ZKE3Y10.17605/OSF.IO/8UDV9.

The Effects of Sit-to-Stand Training Combined with Real-Time Visual Feedback on Strength, Balance, Gait Ability, and Quality of Life in Patients with Stroke: A Randomized Controlled Trial

This study aimed to investigate the effects of lower limbs muscles' strength, balance, walking, and quality of life through sit-to-stand training combined with real-time visual feedback (RVF-STS group) in patients with stroke and to compare the effects of classic sit-to-stand training (C-STS group). Thirty patients with stroke were randomly divided into two groups. The RVF-STS group received sit-to-stand training combined with real-time visual feedback using a Wii Balance Board (n = 15), and the C-STS group received classic sit-to-stand training (n = 15). All participants received training for 20 min once a day, 5 days a week for 6 weeks, and both groups underwent general physical therapy for 30 min before training. Before and after the training, the muscle strength of the hip flexor, abductor, and knee extensor were measured, and the Wii Balance Board was used to perform the center of pressure test and Berg Balance Scale to evaluate static and dynamic balance. Additionally, the 10 m walking test and the Timed Up and Go test were performed to evaluate gait function. The Stroke-Specific Quality of Life was used to measure the quality of life. The results showed that the lower extremity muscle strength, balance ability, walking ability, and quality of life of the RVF-STS group significantly improved in comparison of the pre- and post-differences (p < 0.05), and it also showed significant differences between groups (p < 0.05). This study showed that sit-to-stand training combined with real-time visual feedback was effective at improving the muscle strength of the lower extremities, balance, gait, and quality of life in patients with stroke. Therefore, repeating sit-to-stand training combined with real-time visual feedback could be used as an effective treatment method for patients with stroke.

Basic locomotor muscle synergies used in land walking are finely tuned during underwater walking

Underwater walking is one of the most common hydrotherapeutic exercises. Therefore, understanding muscular control during underwater walking is important for optimizing training regimens. The effects of the water environment on walking are mainly related to the hydrostatic and hydrodynamic theories of buoyancy and drag force. To date, muscular control during underwater walking has been investigated at the individual muscle level. However, it is recognized that the human nervous system modularly controls multiple muscles through muscle synergies, which are sets of muscles that work together. We found that the same set of muscle synergies was shared between the two walking tasks. However, some task-dependent modulation was found in the activation combination across muscles and temporal activation patterns of the muscle synergies. The results suggest that the human nervous system modulates activation of lower-limb muscles during water walking by finely tuning basic locomotor muscle synergies that are used during land walking to meet the biomechanical requirements for walking in the water environment.

Effects of Aquatic Exercise and Land-Based Exercise on Cardiorespiratory Fitness, Motor Function, Balance, and Functional Independence in Stroke Patients-A Meta-Analysis of Randomized Controlled Trials

The aim of this study was to evaluate the efficacy of aquatic exercise (AE) and land-based exercise (LE) on cardiorespiratory fitness, motor function, balance, and functional independence in stroke patients. Design: Through searching PubMed, Embase, Cochrane Library, Web of Science, CNKI, VIP and Wanfang Database, only randomized controlled trials (RCTs) were collected to study the effects of AE and LE on cardiorespiratory fitness, motor function, balance, and functional independence in patients with stroke. The included studies were evaluated for methodological quality by the Cochrane bias risk assessment tool, and statistical analysis was carried out by the Review Manage 5.3 and Stata 15.1 software. Results: The RCTs were collected between the earliest available date and April 2021. Eleven RCTs were included, including five studies with low risk and six studies with moderate risk. The total sample size used in the study was 369, which included 187 patients undertaking AE and 182 patients undertaking LE. The results of the meta-analysis showed that AE can significantly improve patients’ Berg Balance Scale (BBS) (MD = 5.19, 95% CI: 2.66 to 7.71, p < 0.0001), peak oxygen uptake (VO₂peak) (MD = 3.49, 95% CI: 0.17 to 6.8, p = 0.04), Fugl–Meyer Assessment (FMA) (MD = 3.84, 95% CI: 1.64 to 6.04, p = 0.0006), and Functional Independence Measure (FIM) (MD = 6.1, 95% CI: 4.05 to 8.15, p < 0.00001). However, there was no statistically significant difference between the two exercise modes in the Timed Up and Go Test (TUGT) (MD = −2.52, 95% CI: −5.95 to 0.91, p = 0.15) or the Functional Ambulation Category scale (FAC) (MD = 0.28, 95% CI: −0.21 to 0.76, p = 0.26). Conclusion: Based on the improvement in the Berg Balance Scale, peak oxygen uptake, Fugl–Meyer Assessment, and Functional Independence Measure, we can state that aquatic exercise offers better advantages than land-based exercise for patients’ balance, motor function, cardiorespiratory fitness, and functional independence.

The Effect of Water-Based Therapy Compared to Land-Based Therapy on Balance and Gait Parameters of Patients with Stroke: A Systematic Review

INTRODUCTION

Stroke is defined as the lack of blood supply to the brain, leading to rapid loss of brain function presenting with impairments such as muscle weakness, spasticity, lack of coordination, and proprioception loss. Both hydrotherapy and land-based therapy aim to target these aspects in the process of rehabilitation. The study aims to determine the effectiveness of water-based therapy on balance and gait of patients with stroke compared to land-based therapy.

METHODS

Data for this review were extracted from databases such as CINAHL, OTseeker, Ovid, PEDro, and PubMed (MEDLINE) and other sources such as Google Scholar. PRISMA guidelines were followed to exclude irrelevant studies. Only randomized controlled trials (RCTs) were included, and methodological quality was assessed using the PEDro scale. A meta-analysis of extracted data was conducted.

RESULTS

A total of 16 relevant RCTs were included for the review (n = 412 participants). All RCTs investigated the effect of water-based therapy compared to land-based therapy on balance and gait of patients with stroke. Meta-analysis of studies that used the Berg Balance Scale (BBS) as a primary outcome measure favored land-based therapy. Studies that used the Good Balance System (GBS) and the Biodex Balance System (BioBS) to measure the changes in anteroposterior sway and mediolateral sway favored water-based therapy. The overall pooled effect favored land-based therapy in improving gait parameters.

CONCLUSION

Findings from meta-analysis support the effectiveness of land-based therapy in the improvement of balance and gait parameters of patients with stroke. However, the evidence for water-based therapy continues to be limited, and higher quality studies are required to determine the effectiveness of water-based therapy on patients with stroke, particularly on balance and gait.

Evaluation of quality of life in individuals with chronic stroke who underwent aquatic exercises: A case series

BACKGROUND

Aquatic exercises are among the treatments available to improve the quality of life after stroke.

OBJECTIVES

To investigate changes in the quality of life after 8-week of aquatic exercises in post-stroke individuals.

METHODS

A case series study was designed, including four male participants. Exclusive aquatic exercise was performed for 8-week, 50 minutes per session, 2×/week. Their quality of life was evaluated before and after the intervention using the Stroke Impact Scale (SIS).

RESULTS

Participant 1 improved in the mobility domain, achieving a Clinically Important Difference (CID). Participant 2 improved in the strength and mobility domain, achieving CID; his stroke recovery was 6%, and it reached 50% post-intervention. Participant 3 improved in the mobility domain, achieving a CID and a Minimal Detectable Change (MDC); his stroke recovery increased from 45 to 60% post-intervention. Participant 4 improved the strength, mobility, and activities of daily living domains, achieving a CID and a MDC, but his stroke recovery remained unchanged at 80%.

CONCLUSIONS

All participants achieved a CID in the mobility domain; thus, the aquatic exercise intervention was considered meaningful. Moreover, the SIS is able to evaluate aspects of the recovery process regarding health-related quality of life after stroke, as demonstrated by the results of the overall recovery after aquatic exercises.

Aquatic Exercise and Land Exercise Treatments after Total Knee Replacement Arthroplasty in Elderly Women: A Comparative Study

Background and Objectives: Early intensive exercise after total knee replacement arthroplasty (TKRA) has become increasingly popular due to its ability to enhance knee physical function and reduce pain. When implemented exclusively, aquatic exercise (AE) appears to be more advantageous than land exercise (LE), particularly in the early phase after TKRA. Our study aimed to compare the clinical efficacy of AE and LE with respect to their effects on pain and physical function after TKRA. Materials and Methods: Between February 2008 and January 2020, 100 female patients who underwent TKRA were enrolled in this retrospective study. We measured the range of motion (ROM) of the knee, the isokinetic strength of the knee joint (function), and pain both initially and one month after TKRA. Two weeks after TKRA, the participants were enrolled in either the AE or the LE program for a total of two weeks. Two 30 min sessions of intensive ROM and knee strengthening exercises and balance training were provided to the AE and LE groups for 10 days. The home exercise group (HE) only received information on ROM and strengthening exercises. There were 33, 21, and 46 patients allocated to the AE, LE, and HE groups, respectively. Results: The ROM of the side on which surgery was performed improved significantly in all groups, as did the pain scores. In the AE group, the knee flexor strength showed a tendency toward improvement. Contrastingly, there was no significant improvement in the knee extensor strength in the AE group. Conclusions: Overall, the AE and LE groups showed superior outcomes compared with HE. In addition, the AE group demonstrated some improvement in knee muscle strength even with a short hospital stay. Further study with long-term follow-up should be performed to better define the outcomes.

Aquatic therapy in stroke rehabilitation: systematic review and meta-analysis

The main object of this systematic review and meta-analysis is to collect the available evidence of aquatic therapy in stroke rehabilitation and to investigate the effect of this intervention in supporting stroke recovery. The PubMed, the Cochrane Central Register of Controlled Trials and the PEDro databases were searched from their inception through to 31/05/2020 on randomized controlled trials evaluating the effect of aquatic therapy on stroke recovery. Subjects´ characteristics, methodological aspects, intervention description, and outcomes were extracted. Effect sizes were calculated for each study and outcome. Overall, 28 appropriate studies (N = 961) have been identified. A comparison with no intervention indicates that aquatic therapy is effective in supporting walking, balance, emotional status and health-related quality of life, spasticity, and physiological indicators. In comparison with land-based interventions, aquatic therapy shows superior effectiveness on balance, walking, muscular strength, proprioception, health-related quality of life, physiological indicators, and cardiorespiratory fitness. Only on independence in activities of daily living the land- and water-based exercise induce similar effects. Established concepts of water-based therapy (such as the Halliwick, Ai Chi, Watsu, or Bad Ragaz Ring methods) are the most effective, aquatic treadmill walking is the least effective. The current evidence is insufficient to support this therapy form within evidence-based rehabilitation. However, the available data indicate that this therapy can significantly improve a wide range of stroke-induced disabilities. Future research should devote more attention to this highly potent intervention.

Validation of the functional component of the Halliwick-ICF assessment scale

Introduction: Aquatic rehabilitation therapy can improve strength and functional ability. Previous studies measured outcomes on land but did not measure underwater functional ability.Purpose: This study aimed to validate the functional component of the Halliwick-ICF assessment scale, and to compare the scale between underwater and on-land activities.Methods: Rehabilitation and medical charts of individuals with brain lesions and/or spine injuries who underwent aquatic therapy were retrospectively reviewed. Twenty-one functional components of the Halliwick-ICF assessment scale items were categorized through exploratory factor analysis: center of gravity alteration, basic functional activity, and progressive basic functional activity. Confirmatory factor analysis was performed to evaluate the validity of the functional components of the Halliwick-ICF assessment scale. Spearman's correlation analyses were conducted using Medical Research Council sum and modified Barthel index scores.Results: Ninety-five participants (mean age: 53.4 years, range: 27-73 years) were included in the analysis. Convergence and discrimination validity for all three factors were established. Total scores of the scale showed correlations with the modified Barthel index (r = 0.636, p < .001) and Medical Research Council sum (r = 0.298, p = .01) scores.Conclusion: The functional components of the Halliwick-ICF assessment scale demonstrated validity with physical function on land, suggesting its usefulness in aquatic therapy.

Comparison between Three Therapeutic Options for the Treatment of Balance and Gait in Stroke: A Randomized Controlled Trial

Stroke patients are more likely to be at risk of falling, which leads to limitation in their abilities to perform daily living activities and participate in society. The aim was to compare the relative effectiveness of three different treatment groups for improvements in postural control and for improvements in balance. Forty-five participants diagnosed with acquired brain injury, with over one year's evolution, were divided into a dry land therapy group (control group), an experimental group (Ai Chi aquatic therapy), and a combined group (therapy on dry land and aquatic therapy with Ai Chi). The Berg balance scale, tandem stance, the timed up and go test, and the five times sit-to-stand test were used. After twelve weeks of treatment, the results improved significantly for the combined therapy group (p < 0.01), and were significantly higher compared to the dry land therapy group (p < 0.01). In addition, improvements were also found in the aquatic Ai Chi therapy group. In conclusion, aquatic Ai Chi and/or the combination of aquatic therapy with dry land therapy is effective for the improvement of static and dynamic balance and for enhancing functional capacity, therefore, increasing the quality of life of acquired brain injury patients.

Effect of an Aquatic Balance-Training Program in Patients with Chronic Stroke: A Single-Group Experimental Pilot Study

Background and Objectives: Stroke survivors face severe problems affecting their mobility, such as balance impairments and an increased risk of falls. The principal aim of this study was to quantify the effects of 12 sessions of Halliwick aquatic therapy for the treatment of balance in patients with chronic stroke. Materials and Methods: Twenty-nine people with stroke participated in this single-group experimental pilot study. Sessions were performed three times a week for a total of 12 sessions. A stabilometric assessment was conducted using a computerized platform. The evaluations were performed at baseline, at four weeks, and one month after completing the aquatic program. Results: The results obtained revealed significant differences for postural stability values (p < 0.001) and single-leg stabilometry. However, in the case of values within the limits of stability, such as forward (F = 0.339, p = 0.676), backward (F = 0.449, p = 0.644), forward right oscillations (F = 1.637, p = 0.21), and the anterior/posterior instability index (F = 0.614, p = 0.55), no significant differences were found. Conclusions: These findings suggest that Halliwick therapy may potentially improve stroke balance impairments. The main limitations of the study were the sample size, the lack of a control group, and the study not being blind.

Aquatic Therapy in Contemporary Neurorehabilitation: An Update

Aquatic therapy has been used extensively in a number of neurologic diseases and pathologies. This review describes disease-specific rehabilitative applications for this population. Recent research has offered scientific support for use in common neurological diseases that are part of rehabilitative practice, and very recent findings may create even firmer support for its use in these as well as other conditions. Stroke, Parkinsonism, and multiple sclerosis are areas that have recently received a significant number of published studies. Dementia is another area that has been more recently studied and received basic science support. Cerebral palsy has also had recent supportive evidence published. Available literature is reviewed to create a more evidence-based support for the use of aquatic therapy in neurorehabilitation.

Comparison of underwater gait training and overground gait training for improving the walking and balancing ability of patients with severe hemiplegic stroke: A randomized controlled pilot trial

BACKGROUND

Walking training is an essential intervention to improve the function in stroke patients. However, only a limited number of gait training strategies are available for stroke patients with relatively severe disabilities.

RESEARCH QUESTION

Is underwater gait training or overground gait training more effective in severe stroke patients?

METHODS

A total of 21 patients with severe hemiplegic stroke were randomly assigned to the experimental and control groups. All participants (n = 21) received 60-minute sessions of general physical therapy, 5 times a week for a period of 12 weeks. Additionally, the experimental and control groups underwent underwater and overground walking training, respectively, for 30 min twice times a week for 12 weeks. Postural assessment for stroke score, center of pressure path length and velocity, step time and step length difference, and walking velocity were measured before and after the 12-week training.

RESULTS

Both groups showed a significant decrease in the center of pressure path length and velocity after the intervention compared to the values before the intervention (p < .05). However, there was no significant difference in the center of pressure path length and velocity changes after training between the two groups (p > .05). In the walking variables, the step length difference changes after training between the two groups showed a significant difference (p < .05). In the experimental group, the step length difference increased after the intervention compared to that before the intervention (+4.55 cm), whereas that of the control group decreased (-1.25 cm).

SIGNIFICANCE

In severe stroke patients, underwater gait training can be effective for improving balancing ability, but it may be less effective on the improvement of gait function than overground walking.

CLINICAL TRIAL REGISTRATION NUMBER

KCT0002587 (https://cris.nih.go.kr).

Muscle Activation and Distribution during Four Test/Functional Tasks: A Comparison between Dry-Land and Aquatic Environments for Healthy Older and Young Adults

BACKGROUND

The use of rehabilitation protocols carried out in water has been progressively increasing due to the favorable physical properties of the water. Electromyography allows one to register muscle activity even under water.

AIM

To compare muscle activity between two groups (healthy young adults (HYA) and healthy older adults (HOA)) in two different environments (dry land and aquatic) using surface electromyography during the execution of four different test/functional movements.

METHODS

Analytical cross-sectional study. HYA and HOA carried out four functional tasks (Step Up and Down, Sit To Stand test, Gait Initiation and Turns During Gait) in two different environments (dry land and aquatic). Absolute and relative muscle activation was compared between each group and between each environment. In addition, the stability of the measured was calculated through a test-retest (ICC 2:1).

RESULTS

Within the same environment there were significant differences between young and older adults in three of the four functional tasks. In contrast, in the gait initiation, hardly any significant differences were found between the two groups analysed, except for the soleus and the anterior tibial. Measurement stability ranged from good to excellent.

CONCLUSIONS

Level of the musculature involvement presents an entirely different distribution when the test/functional task is performed on dry land or in water. There are differences both in the relative activation of the musculature and in the distribution of the partition of the muscles comparing older and young adults within the same environment.

A Water-Based Sequential Preparatory Approach vs. Conventional Aquatic Training in Stroke Patients: A Randomized Controlled Trial With a 1-Month Follow-Up

Background: Many studies hypothesize that people who have suffered stroke could benefit from water-based exercises to improve their strength and ability to perform the activities of daily living. Objective: The study aim was to compare the effects of a water-based sequential preparatory approach (SPA) and conventional aquatic therapy in improving motor functions and quality of life in patients with chronic stroke. Methods: Thirty-three chronic stroke outpatients diagnosed with hemiplegia were recruited and randomly assigned to the experimental or control group. Subjects in the experimental group underwent a trial water-based SPA balance training, and patients in the control group were given traditional water balance training. Both groups of participants underwent 45 min of therapy twice a week for 4 weeks. All patients were evaluated before treatment (T0), after 4 weeks of training (T1), and 4 weeks after the end of training (T2) using the Berg balance scale (BBS), the modified Barthel index (MBI), the Tinetti balance and gait scale (TBG), the Stroke Specific Quality Of Life Scale (SS-QOL), and the modified Ashworth scale (MAS). Results: After the training, statistically significant differences (p < 0.05) were found between the groups in their score averages on the BBS (p = 0.01) and the SS-QOL scale (p = 0.03). Furthermore, the SPAg showed a significantly greater percentage of improvement on the BBS (p = 0.02) and the SS-QOL (p = 0.03). Both groups obtained a significantly improved MAS score (p < 0.01). Conclusion: Results indicate that water training based on an SPA is more effective than traditional aquatic training for balance rehabilitation of chronic poststroke patients.

Effect of aquatic therapy on balance and gait in stroke survivors: A systematic review and meta-analysis

BACKGROUND

The evidence on aquatic therapy (AT) for improving balance and gait deficits post-stroke is unclear. Therefore, this study aimed to determine the effect of AT on balance and gait in stroke survivors.

METHODS

We searched CINAHL, PubMed, Web of Science, Aqua4balance, Ewac, Cochrane, and EMBASE databases from inception to 1^st November 2019.

RESULTS

Eleven studies with 455 participants were included for the review. Meta-analysis showed that AT was effective for improving balance (MD 3.23, 95% CI 1.06, 5.39; p = 0.004; I² = 61%) and gait speed (MD 0.77, 95% CI 0.25, 1.29; p = 0.004; I² = 0%) when delivered alone. AT was effective in improving cadence (MD 4.41, 95% CI 0.82, 8.00; p = 0.02; I² = 68%) when delivered as an adjunct to land-based therapy.

CONCLUSION

AT may be used to improve balance and gait after stroke; however, the evidence to support its use is still low.

The effect of aquatic physical therapy in patients with stroke: A systematic review and meta-analysis

Objective: The purpose of this study was to evaluate the literature reports of qualitative and quantitative results of physical therapy treatments in the alternative aquatic setting for individuals affected by strokes. Method: PRISMA guidelines were used to carry out the systematic review and meta-analysis. Three bibliographic databases were searched: MEDLINE, PEDro, and the Cochrane Library. Papers included in the study were required to: (a) have a randomized controlled trial (RCT) design of research; and (b) be published in English; (c) be published during the last 10 years (2008-2018). Only randomized controlled trials were employed in the study. The quality of the clinical trials to be included was evaluated according to the Jadad scale. The internal validity was assessed according to the PEDro scale. Results: Eleven RCTs were initially identified in the systematic review. Eight of these were involved in the meta-analysis comparing outcomes and follow-up. Eight studies received a Jadad score of three, indicating a high level of quality. The remaining three studies achieved a lower score which indicated lower qualitative level. Nearly all of the results of the quantitative analysis were statistically significant (P < 0,05) and most of them favored of the experimental group subject to aquatic treatment. Conclusion: Aquatic physical therapy may be a valid means for the rehabilitation of people affected by stroke. The integration of this methodological approach with conventional physical therapy should be considered. However, more studies; a larger number of participants; and varying lengths of follow-up times are necessary.

Effects of exercise timing and intensity on neuroplasticity in a rat model of cerebral infarction

Exercise therapy plays key roles in functional improvements during neurorehabilitation. However, it may be difficult for some people to properly perform exercise because mobility and endurance might be restricted by neurological deficits due to stroke. Additionally, there is little evidence detailing the biological mechanisms underlying the most effective swimming exercise protocols for neuroplasticity after stroke. Thus, the present study investigated the effects of swimming exercise on neuroplasticity in a cerebral infarction rat model according to the timing and intensity of exercise. A total of 45 male Sprague-Dawley rats (300 ± 50 g, 10 weeks old) were subjected to photothrombotic cerebral infarction and randomly divided into five groups: non-exercise (group A, n = 9); early submaximal (group B, n = 9); early maximal (group C, n = 9); late submaximal (group D, n = 9); and late maximal (group E, n = 9). Swimming exercise was performed five times a week for 4 weeks, and cognition was evaluated with the Morris water maze (MWM) test. Assessments of superoxide dismutase (SOD) activity and malondialdehyde (MDA) levels and immunohistochemical analyses of brain-derived neurotrophic factor (BDNF) were conducted in the ipsilesional hippocampus region. After 4 weeks of exercise, the escape latency was shorter and velocity was greater in group B than in groups A, C, D, and E (p = 0.046, p <  0.001, respectively). Furthermore, SOD activity was higher and MDA levels were lower in group B than in groups A, C, D, and E (p = 0.004, p = 0.019). The immunohistochemistry results revealed that the greatest BDNF immunoreactivity was in group B. Taken together, these results indicate that early submaximal swimming exercise may be the most effective protocol for the recovery of neurological deficits in a rat model of cerebral infarction.

The effects of Ai Chi for balance in individuals with chronic stroke: a randomized controlled trial

This study investigated the effectiveness of Ai Chi compared to conventional water-based exercise on balance performance in individuals with chronic stroke. A total of 20 individuals with chronic stroke were randomly allocated to receive either Ai Chi or conventional water-based exercise for 60 min/time, 3 times/week, and a total of 6 weeks. Balance performance assessed by limit of stability (LOS) test and Berg balance scale (BBS). Fugl-Meyer assessment (FMA) and gait performance were documented for lower extremity movement control and walking ability, respectively. Excursion and movement velocity in LOS test was significantly increased in anteroposterior axis after receiving Ai Chi (p = 0.005 for excursion, p = 0.013 for velocity) but not conventional water-based exercise. In particular, the improvement of endpoint excursion in the Ai Chi group has significant inter-group difference (p = 0.001). Both groups showed significant improvement in BBS and FMA yet the Ai Chi group demonstrated significantly better results than control group (p = 0.025). Ai Chi is feasible for balance training in stroke, and is able to improve weight shifting in anteroposterior axis, functional balance, and lower extremity control as compared to conventional water-based exercise.

Effects of hydrokinesitherapy on balance and walking ability in stroke survivors: a systematic review and meta-analysis of randomized controlled studies

BACKGROUND

Balance and walking impairment are common dysfunctions after stroke. Emerging data has demonstrated that hydrokinesitherapy may have a positive influence on improvement of balance and walking ability. However, there is no firm evidence to support these results. Therefore, the aim of this review is to evaluate the effects of hydrokinesitherapy in stroke survivors systematically.

METHODS

Medline, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, CINAHL and SPORTDiscus were systemic searched from their inception to Septemter 30, 2018. RevMan 5.3 software was used to perform data synthesis. The fixed-effect model or random-effect model was employed according to the results of heterogeneity test. The mean differences (MD) or standardized mean difference (SMD) was used to evaluate the pooled effect of hydrokinesitherapy on balance function, walking ability and activty of daily life (ADL).

RESULTS

A total of 13 studies were included involving 381 stroke survivors. Meta-analysis results indicated that hydrokinesitherapy could improve balance ability based on three test: Berg balance scale (BBS: MD = 3.84, 95% confidence interval (95% CI) 2.84 to 4.86, P < 0.001), Time Up To Go Test (TUGT: MD = - 1.22, 95% CI - 2.25 to - 0.18, P = 0.02, fixed-effect model), Functional Reach Test (FRT: MD = 2.41, 95% CI 1.49 to 3.33, P < 0.001). Additionally, we found a weakly positive effect on walking speed (SMD = 0.75, 95% CI 0.26 to 1.25, P = 0.003) and walking ability test (SMD = 0.36, 95% CI 0.04 to 0.68, P = 0.03). There was no significant difference between experimental group and control group in terms of ADL.

SHORT CONCLUSION

Hydrokinesitherapy can improve balance function and had a weakly positive effect on walking ability in stroke survivors. We did not find sufficient evidence to indicate that hydrokinesitherapy could improve the ADL of stroke survivors. However, due to the methodological shortcoming and small number of included studies, caution is needed when interpreting these results. Due to imprecision and publication bias, the quality of the evidence was downgraded to "low-quality" for the primary outcomes of balance and walking ability.

TRIAL REGISTRATION

CRD42018110787.

Evaluating the effectiveness of aquatic therapy on mobility, balance, and level of functional independence in stroke rehabilitation: a systematic review and meta-analysis

Objective:

To meta-analyze and systematically review the effectiveness of aquatic therapy in improving mobility, balance, and functional independence after stroke.

Data Sources:

Articles published in Medline, Embase, CINAHL, PsycINFO, and Scopus up to 20 August 2019.

Study Selection:

Studies met the following inclusion criteria: (1) English, (2) adult stroke population, (3) randomized or non-randomized prospectively controlled trial (RCT or PCT, respectively) study design, (4) the experimental group received >1 session of aquatic therapy, and (5) included a clinical outcome measure of mobility, balance, or functional independence.

Data Extraction:

Participant characteristics, treatment protocols, between-group outcomes, point measures, and measures of variability were extracted. Methodological quality was assessed using Physiotherapy Evidence Database (PEDro) tool, and pooled mean differences (MD) ± standard error and 95% confidence intervals (CI) were calculated for Functional Reach Test (FRT), Timed Up and Go Test (TUG), gait speed, and Berg Balance Scale (BBS).

Data Synthesis:

Nineteen studies (17 RCTs and 2 PCTs) with a mean sample size of 36 participants and mean PEDro score of 5.6 (range 4–8) were included. Aquatic therapy demonstrated statistically significant improvements over land therapy on FRT (MD = 3.511 ± 1.597; 95% CI: 0.381–6.642; P = 0.028), TUG (MD = 2.229 ± 0.513; 95% CI: 1.224–3.234; P < 0.001), gait speed (MD = 0.049 ± 0.023; 95% CI: 0.005–0.094; P = 0.030), and BBS (MD = 2.252 ± 0.552; 95% CI: 1.171–3.334; P < 0.001).

Conclusions:

While the effect of aquatic therapy on mobility and balance is statistically significant compared to land-based therapy, the clinical significance is less clear, highly variable, and outcome measure dependent.

Improving balance with wobble board exercises in stroke patients: single-blind, randomized clinical trial

Background: A primary objective in stroke rehabilitation is to restore functional balance, in order to reduce falls.Objectives: To identify the efficacy and safety of wobble board exercises when combined with conventional physiotherapy, in improving balance in hemiplegic patients following ischemic strokes.Methods: A block-randomized, controlled, observer blinded, superiority trial was conducted on ambulatory hemiplegic patients following ischemic strokes of middle cerebral artery territory. Subjects in the control group received a conventional physiotherapy regime. Subjects in the intervention group received training on a wobble board combined with conventional physiotherapy. Main Outcome measures were the improvement of Four-Square Step Test (FSST) and the Berg Balance Scale (BBS), both of which assess functional balance at the end of 6 weeks.Results: Thirty patients were randomly assigned for intervention (n = 15) and control (n = 15) groups. One patient dropped out from the study, leaving 29 eligible for the analysis. Intervention and control groups were comparable in sociodemographic characteristics and pre-test scores of balance. A repeated-measures MANOVA showed a significant difference in improvement of balance between the two study groups after 6 weeks [F(1,28) = 32.6,p = .000; Wilk's lambda = .46]. The improvement of mean score of balance in interventional group was greater than in the control group [BBS:9.5 (intervention group),5.5 (control group); FSST:3.9 (intervention group),1.7 (control group)]. There were no injuries in both groups.Conclusions: Wobble board exercises, when combined with the conventional physiotherapy, are safe and effective in restoring functional balance in patients with hemiplegia following ischemic strokes.

Aquatic Exercises in the Treatment of Low Back Pain: A Systematic Review of the Literature and Meta-Analysis of Eight Studies

OBJECTIVE

Low back pain is the most common musculoskeletal condition with a high prevalence. There was no sufficient evidence to recommend that aquatic exercise was potentially beneficial to patients with low back pain. The aim of this study was to systematically analyze all evidence available in the literature about effectiveness of the aquatic exercise.

DESIGN

A comprehensive search of PubMed, the Cochrane Library, Embase, and Cumulative Index to Nursing and Allied Health was conducted from their inceptions to November 2016 for randomized controlled trials, which concerned the therapeutic aquatic exercise for low back pain. The results were expressed in terms of standardized mean difference and the corresponding 95% confidence interval.

RESULTS

Eight trials involving 331 patients were included in the meta-analysis, and the results showed a relief of pain (standardized mean difference = -0.65, 95% confidence interval = -1.16 to -0.14) and physical function (standardized mean difference = 0.63, 95% confidence interval = 0.17 to 1.09) after aquatic exercise. However, there was no significant effectiveness with regard to general mental health in aquatic group (standardized mean difference = 0.46; 95% confidence interval = -0.22 to 1.15).

CONCLUSIONS

Aquatic exercise can statistically significantly reduce pain and increase physical function in patients with low back pain. Further high-quality investigations on a larger scale are required to confirm the results.

The effectiveness of group exercise for improving activity and participation in adult stroke survivors: a systematic review

BACKGROUND

Following post stroke rehabilitation, group exercise interventions can be used to continue improving cardiovascular fitness, activity levels, balance, gait, movement efficiency, and strengthening. However, little is known of the effectiveness of group exercise for improving activity and participation in stroke survivors.

OBJECTIVES

This review aims to assess the effectiveness of group exercise for improving activity and participation in adult stroke survivors.

DATA SOURCES

Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, and the Cochrane Library.

STUDY ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) of group exercise using validated outcome measures of activity and participation for post stroke rehabilitation. Two independent reviewers assessed all abstracts, extracted data, conducted a narrative synthesis and assessed the quality of all included articles. The Cochrane Risk of Bias Tool assessed methodological quality and included outcome measure quality was assessed.

RESULTS

14 RCTs were included (n=624 chronic stroke survivors collectively). Studies ranged between 12 and 243 stroke participants with an average of left:right hemisphere lesions of 32:39 and average age was 66.7 years. Although intervention and control groups improved, no significant difference between group differences were evident.

CONCLUSION

and implications of key findings: The review found improvements are short-term and less evident at long-term follow up with little improvements in participation after 6months. However, this review was limited to the standard of intervention reporting. Further research should consider consistency in measuring underpinning mechanisms of group exercise interventions, which may explain the lack of activity changes in long-term follow-up.

SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO

CRD42017078917.

Is the aquatic thermal environment a suitable place for providing rehabilitative treatment for person with Parkinson's disease? A retrospective study

Many authors showed that aquatic physiotherapy could improve quality of life and reduce postural instability and risk of falling in elderly subjects. The aim of this research was to explore if the thermal aquatic environment is a suitable place for rehabilitative training in person with Parkinson disease (PwP) with results comparable to the standard physiotherapy. A retrospective study was conducted on a database of 14 persons with Parkinson who were admitted to a thermal aquatic rehabilitation to undergo treatments made to improve gait and balance impairments. The rehabilitation training consisted of 45-min sessions conducted twice a week, on non-consecutive days, over 4 weeks of functional re-education and kinesitherapy in the thermal pool. Educational and prevention instructions were also given to the patients during each session. Additionally, nutrition (diet), health education, and cognitive behavioral advice were given to our patients by therapists. The clinical characteristics of the sample were age 66 ± 9, disease duration 7 ± 5, and Hoehn and Yahr 1.5 ± 0.5. The statistical analysis showed a statistically significant improvement for the UPDRS p = 0.0005, for The Berg Balance Scale p = 0.0078, for the PDQ8 p = 0.0039, Tinetti p = 0.0068, and for Mini BESTest p = 0.0002. Our data suggest that this intervention could become a useful strategy in the rehabilitation program of PwP. The simplicity of treatment and the lack of side effects endorse the use of thermal aquatic environment for the gait and balance recovery in PwP.

Effect of hydrokinesitherapy on balance and walking ability in post-stroke patients: A systematic review protocol

INTRODUCTION

Brain stroke is the second most common cause of death and major cause of disability in adults, representing a huge burden on patients and their families. Hydrokinesitherapy, a type of physical rehabilitation, may be beneficial to post-stroke recovery. We will systematically assess the clinical effectiveness and safety of hydrokinesitherapy for rehabilitation of stroke survivors in this review.

METHODS

We will perform a systematic search to identify all potentially relevant published studies on this topic. Online electronic databases including MEDLINE (via PubMed), EMBASE (via embase.com), Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, CINAHL (via EBSCOhost) and SPORTDiscus (via EBSCOhost) will be searched without language restrictions from their inception to September 30, 2018. All relevant randomized controlled trails (RCTs) will be screened according to predetermined inclusion criteria. Two independent reviewers will evaluate the methodological quality of each study included. One reviewer will extract data and another reviewer will check the accuracy. Any disagreements will be discussed with a third reviewer. The posture balance and walking ability will be defined as primary outcomes. Activities of daily living (ADL), drop-out and adverse events will also be assessed as secondary outcomes. The evaluation of methodological quality, data analysis will be completed using Cochrane Review Manager 5.3 according to Cochrane Handbook for Systematic Reviews of Interventions.

TRIAL REGISTRATION NUMBER

CRD42018110787.

Falls in Geriatric Populations and Hydrotherapy as an Intervention: A Brief Review

Falls and fall-related injuries are a serious health concern in geriatric populations, especially with age-related deficits in postural control and during postural control challenging dual-task situations. Balance training has been reported to be beneficial in reducing falls. However, some of these exercises have their inherent physical challenges that prevent the elderly population from performing them effectively. Other concomitant age-related illness in the elderly pose further challenges in performing these exercises. Hence, the topic of finding alternative types of balance training that are effective and are performed in a safer environment is constantly researched. One such alternative is hydrotherapy that focuses on balance and postural perturbation-based exercises in water-based environments such as aquatic swimming pools or in dedicated hydrotherapy pools. Hydrotherapy for geriatric populations has been reported to be beneficial in improving balance, motor and cognitive tasks with improved motivation and positive attitude towards exercises. Additionally, hydrotherapy also has properties of buoyancy, resistance and temperature, which benefit biomechanical and physiological wellness and offers a safe environment to perform balance training. Hydrotherapy balance training need to be scaled and prescribed according to individual needs and can serve as an effective training and rehabilitation protocol in reducing falls in geriatric population.

Effect of regular swimming exercise to duration-intensity on neurocognitive function in cerebral infarction rat model

Objective: This study investigated the effect of regular swimming exercise according to the duration-intensity on neurocognitive function in a cerebral infarction rat model. Methods: Forty male Sprague-Dawley 10-week-old rats, weighing 300 ± 50 g, were subjected to photothrombotic cerebral infarction. The remaining 36 rats were randomly divided into four groups (n = 9 per group: non-exercise (group A); swimming exercise of short duration-intensity (5 min/day, group B); swimming exercise of moderate duration-intensity (10 min/day, group C); and swimming exercise of long duration-intensity (20 min/day, group D). Exercise was performed five times a week for 4 weeks, beginning the day after cerebral infarction. Neurocognitive function was evaluated with the Morris water maze test. Immunohistochemistry and western blot analysis examined brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF) at 4 weeks postinfarction. Results: At 4 weeks postinfarction, escape latency was found to be shorter in group C than in any of groups A, B, or D. Immunohistochemistry revealed the most significant immunoreactivity for BDNF and VEGF in group C. Western blot analysis demonstrated that BDNF and VEGF proteins were markedly expressed in group C. Conclusions: Regular swimming exercise of moderate duration-intensity may be the most effective exercise protocol for the recovery of neurocognitive function in cerebral infarction rat model.

Effect of aquatic versus land based exercise programs on physical performance in severely burned patients: a randomized controlled trial

[Purpose] To compare the effect of an aquatic-based versus a land-based exercise regimen on the physical performance of severely burned patients. [Subjects and Methods] Forty patients suffering from severe burn (total body surface area more than 30%) were recruited from several outpatient clinics in Greater Cairo. Their ages ranged between 20 to 40 years and were randomly assigned into two equal groups: group (A), which received an aquatic based exercise program, and group (B), which received a land-based exercise program. The exercise program, which took place in 12 consecutive weeks, consisted of flexibility, endurance, and lower and upper body training. Physical performance was assessed using 30 seconds chair stand test, stair climb test, 30 meter fast paced walk test, time up and go test, 6-minute walk test and a VO2max evaluation. [Results] Significantly increase in the 30 second chair stand, 6-minute walk, 30 meter fast paced walk, stair climb, and VO2 max tests and significantly decrease in the time up and go test in group A (aquatic based exercise) compared with group B (a land-based exercise) at the post treatment. [Conclusion] Twelve-week program of an aquatic program yields improvement in both physical performance and VO2 max in patients with severe burns.

The effectiveness of hydrokinesiotherapy on postural balance of hemiplegic patients after stroke: a systematic review and meta-analysis

Objective:

To summarize evidence on the effects of hydrokinesiotherapy (HT) on postural balance in hemiplegic patients after stroke and compare them with conventional land therapy.

Data sources:

A literature search until October 2017 was conducted on CINAHL, PubMed, Cochrane EBM Reviews, Cochrane Clinical Trials, DARE, MEDLINE, Physiotherapy Evidence Database (PEDro), PsycInfo and Rehabilitation and Sports Medicine Source.

Review methods:

Only randomized controlled trials with pre-intervention and post-intervention assessment on postural control have been included. Assessment of the quality (by Downs and Black quality assessment tool) of the included studies was performed by two reviewers, and a meta-analysis was undertaken.

Results:

A total of 11 trials on postural control with 305 stroke patients were included. The majority of studies showed a beneficial effect of HT in postural control of the patients. The meta-analysis showed statistically significant improvement ( P < 0.05) in Berg Balance Scale (BBS), mediolateral (ML) and anteroposterior (AP) sway velocity of center of pressure with eyes closed (EC) in both groups, but the mean differences in BBS (3.85 points), ML sway velocity of center of pressure (1.38 points) and AP sway velocity of center of pressure (1.64 points) were statistically improved ( P < 0.05) in HT over land therapy program.

Conclusion:

HT is superior to land therapy program regarding postural balance in terms of BBS, ML and AP sway velocity of center of pressure.

Prospective Evaluation of Postural Control and Gait in Pediatric Patients with Cancer After a 4-Week Inpatient Rehabilitation Program

OBJECTIVE

The aim of the study was to investigate the effects of a 4-wk inpatient rehabilitation program on postural control and gait in pediatric patients with cancer.

DESIGN

Eighty-eight patients with brain tumors (n = 59) and bone/soft tissue sarcomas (n = 29) were evaluated. Postural control was assessed examining the velocity of the center of pressure and single-leg stance time on a pressure distribution platform. Walk ratio, a measure of neuromotor control, was used to evaluate intervention effects on gait.

RESULTS

Repeated measures analysis of variance showed improvements in postural control measures, indicated by a decrease in velocity of center of pressure of -0.4 cm/sec (F1,80 = 7.175, P = 0.009, ηp = 0.082) and increase in single-leg stance time (mean [median] = 1.1 [2.6] sec, respectively; F1,80 = 12.617, P = 0.001, ηp = 0.136). Walk ratio increased by 0.2 mm/steps per min (F1,82 = 3.766, P = 0.056, ηp = 0.044). Mean changes in dependent variables did not differ between both patient groups (P > 0.05).

CONCLUSIONS

The results indicate benefits of an inpatient rehabilitation program comprising standard physical therapy as well as aquatic and hippo therapy on postural control and gait after treatment of pediatric patients with cancer.

Effects of the Bad Ragaz Ring Method on muscle activation of the lower limbs and balance ability in chronic stroke: A randomised controlled trial

Background

Recovery of balance and walking abilities is important for the rehabilitation of stroke patients.

Objectives

To evaluate the effects of the Bad Ragaz Ring method on functional recovery in chronic stroke patients.

Methods

Twenty-two chronic stroke patients were randomly assigned to two groups: a Bad Ragaz Ring method group (the experimental group) or a control group. Stroke patients in the experimental group underwent Bad Ragaz Ring exercise and comprehensive rehabilitation therapy, whereas patients in the control group underwent comprehensive rehabilitation therapy alone. The participants in both groups received therapy 3 days per week for 6 weeks. Muscle activations, balance indices, and Timed Up and Go test results were assessed before and after the 6-week therapy period.

Results

The experimental group showed significant improvements in activations of tibialis anterior and gastrocnemius muscles, balance index, and Timed Up and Go test results as compared with preintervention results (p < 0.05), whereas the control group showed significant improvement in Timed Up and Go test (p < 0.05). Significant differences in posttraining gains in the activations of tibialis anterior and gastrocnemius muscles and in balance index were observed between the experimental and control groups (p < 0.05). Effect sizes for gains in the experimental and control groups were strong for tibialis anterior and gastrocnemius muscles (effect sizes, 1.04 and 1.45 respectively).

Conclusion

The Bad Ragaz Ring method may be beneficial for improving balance and leg muscle activation of chronic stroke patients.

Balance evaluation techniques and physical therapy in post-stroke patients: A literature review

A stroke (cerebrovascular accident - CVA) is a significant social-economic issue. Approximately 15-30% of all patients develop life-long disability, 20% require over 3 months of specialized care in healthcare institutions, and the majority of the patients never recover the ability to maintain a proper vertical position. Such CVA sequelae as balance disturbances not only negatively affect patients' daily physical activity, but also result in social isolation. A number of standardized clinical scales, tests, and instrumental examination techniques have been proposed for evaluating not only post-CVA balance function, but also any changes in this function following various interventions. Even though scientific literature lists numerous methods and instruments for the improvement of balance after a CVA, not all of them are equally effective, and there have been rather controversial evaluations of some techniques. Nevertheless, the application of the majority of the techniques as complementary or alternative measures to traditional physical therapy (PT) frequently yields better results.

An Ai Chi-based aquatic group improves balance and reduces falls in community-dwelling adults: A pilot observational cohort study

BACKGROUND

Falls are associated with morbidity, loss of independence, and mortality. While land-based group exercise and Tai Chi programs reduce the risk of falls, aquatic therapy may allow patients to complete balance exercises with less pain and fear of falling; however, limited data exist.

OBJECTIVE

The objective of the study was to pilot the implementation of an aquatic group based on Ai Chi principles (Aquabalance) and to evaluate the safety, intervention acceptability, and intervention effect sizes.

DESIGN

Pilot observational cohort study.

METHODS

Forty-two outpatients underwent a single 45-minute weekly group aquatic Ai Chi-based session for eight weeks (Aquabalance). Safety was monitored using organizational reporting systems. Patient attendance, satisfaction, and self-reported falls were also recorded. Balance measures included the Timed Up and Go (TUG) test, the Four Square Step Test (FSST), and the unilateral Step Tests.

RESULTS

Forty-two patients completed the program. It was feasible to deliver Aquabalance, as evidenced by the median (IQR) attendance rate of 8.0 (7.8, 8.0) out of 8. No adverse events occurred and participants reported high satisfaction levels. Improvements were noted on the TUG, 10-meter walk test, the Functional Reach Test, the FSST, and the unilateral step tests (p < 0.05). The proportion of patients defined as high falls risk reduced from 38% to 21%. The study was limited by its small sample size, single-center nature, and the absence of a control group.

CONCLUSIONS

Aquabalance was safe, well-attended, and acceptable to participants. A randomized controlled assessor-blinded trial is required.