Hydrotherapy for Stroke

It has been demonstrated that hydrotherapy increases the muscle strength of the paretic leg of patients with a stroke.

The Royal Dutch Society for Physical Therapy (KNGF) Clinical Practice has Guideline for Physical Therapy in patients with stroke. The guideline development team recommends considering hydrotherapy to increase muscle strength.

Hydrotherapy can be implemented during the mobilization phase. Based on the ICF classification, this phase can be subdivided into the domains that physical therapy is concerned with:

  • walking ability and other mobility-related abilities
  • dexterity
  • ADLs.


What is Hydrotherapy?

Hydrotherapy is a form of exercise therapy that uses the mechanical and thermal characteristics of water during partial immersion for therapeutic purposes, such as improving balance, muscle strength, aerobic endurance, and/or agility. It sometimes involves the use of ‘hands-on’ techniques, such as joint mobilization, stretching techniques, or relaxation. The therapy can be given individually or in groups. The supervised therapy ideally takes place in a specially designed exercise pool.

Hydrotherapy applies various concepts, such as:

  • Halliwick method (balance and stability exercises)
  • Bad Ragaz Ring Method (muscle strength exercises based on principles of proprioceptive neuromuscular facilitation or PNF)
  • deep-water running or aquajogging
  • Watsu method (for relaxation)
  • Ai Chi method (a combination of deeper breathing and exercises for the extremities carried out in broad, slow movements).

The guideline development team recommends considering hydrotherapy to increase muscle strength. This may involve aerobic training, functional gait training, or exercises using the Halliwick and Ai Chi methods.


What are the KNGF Guidelines?

KNGF Guidelines are national professional recommendations, based on scientific evidence, intended to optimize patient* care. Guidelines are intended to serve as an instrument to support physical therapists in making clinical decisions. Guidelines aim to provide guidance for everyday practice and at the same time to be flexible enough to enable therapists to deviate from them to meet individual needs, depending on the situation and the patient, provided this deviation is based on sound arguments.
This revised KNGF Guideline Stroke offers recommendations for appropriate care. The individual recommendations have been pro- vided with indicators to assess the quality of physical therapy care. In the opinion of KNGF, checking the implementation of the guide- lines is the responsibility of the physical therapists, in consultation with and supported by KNGF.



  1. KNGF Clinical Practice Guideline for Physical Therapy in patients with stroke F.1.19 Hydrotherapy, page 33. , can be downloaded from www.fysionet.nl. © 2014 Royal Dutch Society for Physical Therapy (Koninklijk Nederlands Genootschap voor Fysiotherapie, KNGF)
  2. Halliwick® Aquatic Therapy – IATF (International Aquatic Therapy Faculty), Valens, Switzerland
  3. Bad Ragaz Ring Method – IATF (International Aquatic Therapy Faculty), Valens, Switzerland
  4. Clinical Ai Chi – IATF (International Aquatic Therapy Faculty), Valens, Switzerland
  5. Study: Watsu Approach for Improving Spasticity and Ambulatory Function in Hemiparetic Patients with Stroke
  6. Study: Effects of aquatic physiotherapy on the improvement of balance and corporal symmetry in stroke survivors
  7. Study: The effect of Ai Chi and Halliwick on Postural Balance and Muscle Strength in Stroke Survivors
  8. Effects of Halliwick on Functional Mobility in Subacute Stroke Patients: A Randomized Controlled Trial