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by Alison Bonnyman, PT

I only work in water… or I would if I could! My career was a steady path to the sole practice of aquatic physical therapy. Call it happenstance or horoscope; I am privileged to be the Founder of Canadian Aquatic Rehab Instructors, CARI. There is a growing network of physiotherapists utilizing this modality in their practice, and what is most interesting is that they provide therapy in pools that remain accessible to their clients after discharge, bridging therapy to community and enabling lifelong physical activity. Lately, it seems like doctors, case managers and insurance adjudicators are understanding the aquatic advantage, too. I applaud the clinics that are investing in their own pools at quite an expense, but I think they are encouraged by the aging demographics and retirement living advertisements with happy people in a pool.

A great milestone was quietly accomplished with the first Canadian Aquatic Therapy Conference successfully offered this past October 2019 at the Fairview Seniors Centre in Cambridge, Ontario. Three kindred spirits organized this event only limited by pool size, not creativity – Connie Jasinskas, Tamara Coliazzi and myself. Thirty therapists from across Canada and Australia hopped in and out of the pool, practicing new techniques and creating new ways to target and achieve our clients’ goals. Sure, all our outcome measures must relate to land-based function; however, other treatment exaggerates gait asymmetry and slows it down so feedback is possible. The research supports aquatic therapy in the orthopaedic, neurological and cardiorespiratory silos of physiotherapy, but water immersion puts it all together by addressing the cardiopulmonary system with warmth and pressures. There is no denying that buoyancy can assist movement, but put a noodle in your hands, press down into the water and you will get immediate trunk engagement. Add walking and you get increased drag resistance, yet you feel secure walking across the pool holding a noodle in front… magic! Walk with another person and you create turbulence that challenges everyone’s gait and balance. Aquatic therapy is based on the manipulation of hydrodynamics and until you experience it, prescribing it is difficult.

A therapy pool is expected to be at least 32°C/90°F. This warmth induces a more relaxed state and enables comfortable low intensity activity; the buoyancy off-loads joints while also challenges upright stance; viscosity and turbulence add resistance that slows and directs movement. What a great place to challenge balance since a fall will be a slowed descent, enabling reaction time, and the end result may only be drinking the water and ruining the hairdo. 

Aquatic exercise has gained popularity in both community and private pools. Community centres, rehab hospitals, condominiums and clinics are building warm water pools with ramped access and lifts to address the needs of the very young, the older adult and injured/special populations. There are therapeutic aquafit programs such as “Better Backs”, “Moving Waters for MS”, “Stroke Breakers” and “Oh My Aching Body” (City of Mississauga).

Research continues to grow in this area. There are studies providing evidence that aquatic exercise improves brain vascularity as the graduated hydrostatic pressure opens up the carotid arteries and speeds up the blood flow in the cerebral arteries (Carter, 2013). When immersed to the clavicle, there is dampening of the anxiety-inducing Sympathetic Nervous System as a result of the graduated hydrostatic pressure and fluid movement after 10 minutes (Becker, 2009).  Research of individuals with chronic pain (FM, LBP) showed benefit from an aquatic exercise program (Andrade, 2019; Irandoust, 2015). Fifty-nine seniors, average age of 71 years, participated in a 24-week aquatic exercise program, two times per week for one hour, resulting in comparatively better balance tests (TUGT) than the land-based exercise group (Bergamin et al, 2013). They also demonstrated a gain in muscle mass of the legs and arms. Other studies have shown significant gains in plantarflexor and shoulder horizontal flexor strength, as well as walking speed (Graef, 2010, Katsura, 2010). A study comparing post-exercise hypotension after water-walking versus land-walking concluded that walking performed in chest-deep water had a better effect on exercise-induced hypotension in untrained healthy women (aged 26 to 40 years) than walking at a similar intensity on land (Rogriguez et al, 2011). Villalta et al, 2013, showed that there is no risk to infection with immersion of post-op incisions. Arnold et al, 2010, investigated the effect of aquatic exercise and education on 79 women, average age of 75 years, with hip osteoarthritis and found an improvement of fall-risk factors, primarily the chair-stand test and falls efficacy. Fujishima, 2003, demonstrated that the Rate of Perceived Exertion (RPE) scale was effective in controlling the work effort equally, whether during land- or water-based exercises. The aquatic programming in all of these studies is variable, but included a warm-up targeting strength and CV work and a cool-down in chest-deep warm water. There is increasing evidence to support aquatic exercise as an effective intervention with positive land-based outcomes.

Barriers to aquatic exercise participation and adherence, particularly in the senior population, can include fear of falling, the presence of comorbidities and avoidance of pain. Hydrodynamic properties alleviate these barriers with low fall-risk, off-loading gravity and thermal effects. There is also the added work of undressing and redressing, but with adapted bathing suits and more 100% polyester workout gear, there are options. I know colleagues who manage clients with a colostomy bag/catheters/G-tube/trach in their pool sessions. It all comes down to the client, their goals and what is doable. In my practice, it has been seeing the resultant empowerment and glee(!) of walking unaided that overcomes the difficulties of getting to, and into, the pool.

As physiotherapists and physiotherapy assistants, we are advocates, communicators and managers of our clients’ care and we want to bridge them to an active lifestyle that extends beyond discharge. Aquatic exercise is one more tool in our toolbelt and one more option for your clients – explore it! 

Canadian Aquatic Rehab Instructors (CARI) offers a free Aquatic Therapy Fundamental Refresher course through Embodia.  I encourage you to source the pools in your neighbourhood; reach out to the retirement homes with a pool – there is a good chance they are not optimizing its use. Support specialized programming in your local community pool because access is key. Any questions, don’t hesitate to contact me at I look forward to meeting more aquatic therapists as CARI continues to teach across Canada.


Bio: Alison Bonnyman is a physiotherapist and Founder of Canadian Aquatic Rehab Instructors (CARI). She resides in the GTA and teaches Aquatic Therapy across Canada. When not in the water, she is the Academic Coordinator for the Internationally Educated Physical Therapy Bridging Program at the University of Toronto.



Carter HH, Spence AL, Pugh CJA, Ainslie P, Naylor LH, Green DJ. 2014. Cardiovascular responses to water immersion in humans: impact on cerebral perfusion. Am J Physiol Regul Integr Comp Physiol 306: R636–R640

Becker BE, Cole AJ.  2010. Comprehensive Aquatic Therapy, 3rd Ed. Butterworth Heinemann. Pennsylvannia.

Andrade CP, Zamuner AR, Forti M, Tamburus NY, Silva E. 2019. Effects of aquatic training and detraining on women with fibromyalgia: controlled randomized clinical trial. Eur J Phys Rehabil Med; 55(1):79-88.

Irandoust K, Taheri M. 2015. The effects of aquatic exercise on body composition and nonspecific low back pain in elderly males. J Phys. Ther. Sci. 27: 433–435.

Bergamin M, Ermolao A, Tolomio S, Berton L, Sergi G, Zaccaria M. 2013. Water- versus land-based exercise in elderly subjects: effects on physical performance and body composition. Clinical Interventions in Aging:8 1109–1117.

Graef FI, Pinto RS, Alberton CL, de Lima W, Kruel LF. 2010.The effects of resistance training performed in water on muscle strength in the elderly. J Strength Cond Res; 24:3150–56. 

Katsura Y, Yoshikawa T, Ueda SY, Usui T, Sotobayashi D, Nakao H, Sakamo H, Okumoto T, Fujimoto S. 2010. Effects of aquatic exercise training using water resistance equipment in elderly. Eur J Appl Physiol:108:957–64.

Rodriguez D, Silva V, Prestes J et al. 2011. Hypotensive response after water-walking and land-walking exercise sessions in healthy trained and untrained women. Int J Gen Med 4:549-554.

Villalta EM, Peiris CL. 2013. Early Aquatic Physical Therapy Improves Function and Does Not Increase Risk of Wound-Related Adverse Events for Adults After Orthopedic Surgery: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil;94:138-48

Arnold CM, Busch AJ, Schachter CL, Harrison EL, Olszynski WP. 2008.A randomized clinical trial of aquatic versus land exercise to improve balance, function, and quality of life in older women with osteoporosis. Physiother Can;60:296-306.

Fujisawa H, Suenaga N, Minami A. 1998. Electromyographic study during isometric exercise of the shoulder in head-out water immersion. J Shoulder Elbow Surg. 7(5):491-494.