1) Could you briefly tell us about your professional background and what inspired you to specialize in aquatic therapy?

I was introduced to aquatic physiotherapy as a student physiotherapist, studying at Salford school of physiotherapy 1983-1986. I was lucky enough to have one of my clinical placements in aquatic physiotherapy and saw amazing results for many patients, initially in musculoskeletal, trauma and elective orthopaedics. On qualification as a chartered physiotherapist, I worked initially in a trauma and orthopaedic hospital and treated my patients in the hydrotherapy pool, as early post operation inpatients and as outpatients both individually and in groups.

I trained as an aqua aerobics instructor, teaching in the evenings at the leisure centre and developed pre- and post- aqua natal sessions and deep water aqua fit.

I then moved to a big teaching hospital in Bristol and rotated through all the specialties including aquatic physiotherapy. It was here that I started to take more complex neurological patients into the pool with great effect. This inspired me to specialise in aquatic physiotherapy.

I secured a senior post in the Brighton and Sussex Hospitals trust in 1992 and had the opportunity to set a service up from scratch. I attended the 4-week Bath Hydrotherapy Course in 1992. I was in awe of the knowledge and skills of my tutors, Alison Skinner and Helen Whitelock, learning skills and techniques that could be applied across many patient populations both on one to one and in group sessions.

I established a very comprehensive and inclusive adult and paediatric service across all specialties for in and outpatients,

I worked with charities to set up aquatic physiotherapy sessions for people with long term conditions including the Parkinsons Disease Society, Arthritis Care, the National Osteoporosis Society, the Ankylosing Spondylitis Society. These sessions help to keep people with long-term conditions off hospital waiting lists for treatment. We also established aquatic therapy groups for clients who wanted to continue working in the pool but didn’t feel confident to continue exercise at the leisure centre. Both initiatives helped to income generate to support the department.

I worked with the local leisure services to establish an exercise referral scheme so the physiotherapists could ease the transition to the local pool and gym to facilitate exercise behaviour change and healthy lifestyles.

2) What do you think aquatic therapy can offer compared to land-based training?

The term hydrotherapy is derived from the Greek words Hydor meaning water and Therapea meaning healing

Aquatic physiotherapy treatment is a very wholistic intervention, it has physical, physiological and psychosocial benefits, it can specifically be defined as

There are many claimed benefits of aquatic physiotherapy, not all substantiated by research, mainly due to the complexity and comorbidities of patients referred to aquatic physiotherapy, making it difficult to include a large proportion of patients into a randomised controlled trial.

Aquatic physiotherapy combines the benefits of immersion with exercise resulting in:

• Reduction of muscle spasm and pain
• Ease of movement, joint range and flexibility
• Reduction of oedema and improved circulation
• Improved strength and endurance
• Re-education of functional activities
• Improved cardiovascular fitness
• Enhanced relaxation
• Enhanced feeling of wellbeing

Immersion has profound biological effects, extending across essentially all the homeostatic systems of the body. This knowledge is available from research into head-out water immersion (HOWI). Subjects are immersed upright to the sternal notch in thermoneutral water (34.5-35ºC) often for up to 2 hours. These effects should be considered, but it should always be remembered that aquatic physiotherapy is a combination of immersion with exercise using a variety of postures and depth in thermoneutral temperatures.

 

3) How do you assess the current evidence for the use of aquatic therapy in physiotherapy?

There is a body of evidence available that supports the use of aquatic physiotherapy, however there is so much more that needs to be done to provide necessary evidence to support ongoing funding of services. Patient reported outcome measures have been used in clinical practice showing statistically significant results, including my own work - Effectiveness of Aquatic Physiotherapy in Clinical Practice:

https://scholarworks.bgsu.edu/cgi/viewcontent.cgi?article=1071&context=ijare

Dr Bruce Becker is a great example of someone who has tirelessly researched and promoted the benefits of aquatic physiotherapy https://www.aquaticdoc.com/

Other active organisations are the subgroup of World Physiotherapy, the IOAPT Aquatic Specialty Group promoting aquatic physiotherapy and research globally https://world.physio/subgroups/aquatic and the organisers of the International Conference for Evidence Based Aquatic Therapy ICEBAT who run a conference every 2 years to showcase evidence, knowledge and skills internationally. The next one in Toronto Canada https://www.aquaticrehab.ca/icebat2026

4) Are there specific patient groups where aquatic therapy has a documented effect?

Yes, so many, across most specialties, cradle to grave, those with only a flicker of a muscle contraction to elite athletes.

5) Are there some which have no effect?

It really depends on the expertise of the physiotherapist, their understanding of their patients signs and symptoms, application of the physical properties of the water, hydrostatics and hydrodynamics, the physiological effects of immersion and the screening process,

All pool users will benefit from the physiological effects of immersion.

Some non-swimmers may be reluctant to participate but many find it so beneficial that they go on to become water confident.

6) How do you adapt aquatic therapy to the needs and functional levels of different patients?

An aquatic physiotherapists should have the knowledge and skills to select patients appropriately for therapy. Having a thorough dry land assessment of the patient is essential along with risk assessment and screening for the physiological effects of immersion and the environment. Clinical reasoning and technique selection is required to provide the appropriate input for the individual.

7) What clinical challenges do you typically encounter when working with aquatic therapy, and how do you handle them?

• Health & safety risk
• Infection risk
• Fear of water
• Time limitations
• Isolation of movements
• Patient dependency

a full risk assessment including entry and exit, emergency evacuation, medications required, in case of epilepsy, diabetes, asthma, angina, etc

This highlights the training need for all therapists and the rest of the team (pool maintenance, cleaners etc)

An understanding of the main health and safety legislation, and its implication in running an aquatic therapy service. Demonstrate an understanding of water disinfection related to the pool environment. Relate the above to maintaining a safe environment for staff and users including the ability to risk assess.

A hydrotherapy pool requires specific policies and procedures to ensure both its smooth running and to maintain health and safety standards. All hydrotherapy pools should have a named, designated aquatic physiotherapist, who has appropriate skills, experience and competence to manage the service and report into the site water safety group.

8) How can aquatic therapy be integrated into a comprehensive rehabilitation program?

Aquatic physiotherapy can be used at any stage in recovery. It really does depend on the skills and understanding of the therapist.

Multidisciplinary collaboration with physiotherapists, OTs, SLTs, psychologists, and others enhances patient outcomes.

• early rehab to off load joints and decrease swelling
• fitness along with gym work for all progression and maintenance
• maximise fitness during injury

9) What barriers or challenges do you see when implementing aquatic therapy in clinical practice?

Access to hydrotherapy pools is getting harder! Post Covid 19 many pools closed for financial reasons e.g. increased energy costs etc

Lack of understanding of the wholistic benefits of aquatic therapy and immersion among other health care professionals, service managers and accountants!

10) What professional skills are important for physiotherapists who want to work professionally with aquatic therapy?

Starting with a degree level or equivalent qualification in physiotherapy, progressing to a post graduation qualification in aquatic physiotherapy, then gaining experience of handling patients in water, continually exploring movement possibilities to develop skills.

ATACP Aquatic Therapy Association of Chartered Physiotherapists run The ATACP foundation Programme in Aquatic Physiotherapy https://aquaticphysiotherapy.co.uk/atacp-foundation#58101acf-4900-4d9b-a5bf-166aa95c36bb

11) What advice would you give to physiotherapists considering starting to use aquatic therapy?

Work with specialist aquatic physiotherapists across all specialties to see the life changing effects aquatic physiotherapy can bring.

12) How do you see the role of aquatic therapy in physiotherapy in 5–10 years?

I see the role of aquatic therapy becoming a continuum of input for those who have the greatest need being seen by qualified aquatic physiotherapists who can then refer on to other aquatic practitioners / therapists who may have different training e.g. aqua rehab classes, aquarobics, swimming teachers/ fitness instructors e.g. the Swim England qualification SEQ Level 3 Aquatic Activity for Health https://instituteofswimming.org/course-information/swim-england-level-3-aquatic-activity-health
Collaboration would improve patient journey, empowering the patient to change behaviours to improve health and wellbeing.

13) Which areas do you consider particularly important for further research or professional development?

All areas:

Physical – strength, endurance stability performance and function

Physiological systems – circulation, cardiac, respiratory, renal, pain

Mental Health and psychological well being

Dementia

In the long term improve the fitness of all and decrease drug and healthcare costs