Systematic Review
Restorative Effects of Aquatic Exercise
Therapies on Motor, Gait, and Cardiovascular
Function in Children with Cerebral Palsy:
A Review of Literature
James D. Dolbow, MS
David R. Dolbow, PhD, DPT, RKT
Sandra L. Stevens, PhD
Jaime Hinojosa, MD
Authors’ affiliations:
James D. Dolbow, Jaime Hinojosa, School of Mathematics
and Sciences, Lincoln Memorial University, Harrogate, TN.
David R. Dolbow, School of Kinesiology, University of
Southern Mississippi, Hattiesburg, MS.
Sandra L. Stevens, Department of Health and Human
Performance, Middle Tennessee State University, Murfrees-
boro, TN.
Corresponding Author
James Dolbow, MS
225 Brantley Acres Dr.
Speedwell, TN 37870
615/830-8331
jddolbow@gmail.com
james.dolbow@lmunet.edu
Abstract
Background and purpose. Cerebral palsy (CP) is the most
common childhood physical disability and produces highly
varying degrees of motor impairment including muscle
weakness, balance and sensory deficiencies, decreased aero-
bic capacity, decreased motor control, spastic hypertonia,
and atypical gait.
Methods. The physical rehabilitation of children with
CP commonly places therapeutic emphasis on improving
muscle strength, physical and cardiorespiratory fitness,
motor control, and functional independence. The thera-
peutic aquatic environment provides additional benefits
to the rehabilitation process by using the natural gravity-
reducing, resistive, and thermodynamic properties of
water.
Results. This review examines the efficacy of the previously
studied aquatic exercise therapy protocols in producing
22
changes in gross motor function, cardiorespiratory perfor-
mance, and gait in children and adolescents with CP.
Discussion. Given the limited breadth and depth of the
literature at large, conclusive findings as to the efficacy of
specific aquatic therapies can not be stated. However, the
similar trends in the effectiveness of the therapies found in
all examined therapeutic environments support the general
consensus of their benefit and safety.
Conclusions. The documented evidence in aquatic CP re-
habilitation supports the idea that aquatic exercise therapy
may be beneficial for children and adolescents with CP, with
considerable evidence supporting improvements in gross
motor function.
Key words: Cerebral palsy, Aquatic therapy, Gross motor
function, Gait, Cardiovascular performance.
Introduction
Cerebral palsy (CP) is the most common childhood physi-
cal disability.1 The term CP is used to describe a small group
of nonprogressive syndromes concurrent with multiple le-
sions in the brain that occur during pre- or postnatal early
childhood development.2-4 This condition produces highly
varying degrees of motor impairment including muscle
weakness, balance and sensory deficiencies, decreased
aerobic capacity, abnormal joint kinetics, decreased mo-
tor control, spastic hypertonia, bone deformations, and
atypical gait.5,6 Individuals with CP commonly exhibit gait
abnormalities such as a reduced step and stride length, a
widened stance, reduced walking speed, impaired balance,
and varying levels of disability of the upper and lower
extremities.7,8
In the following reviewed studies, and in the rehabilitation
community at large, one of the most widely used scales to
determine the ability of a child with CP to independently
ambulate in his or her environment is the gross motor
function classification system (GMFCS).9 This scale classi-
fies the functional independence of an individual’s gait on
levels ranging from the ability to walk without limitation
or assistance (level I) to the complete inability to self-am-
 The Journal of Aquatic Physical Therapy - Vol 25 No. 1, Summer 2017
bulate (level V). Although the ability of children with CP
to self-ambulate varies widely depending of the severity of
neuromuscular impairment, studies have shown that typi-
cally children with CP are subject to increased energy costs
associated with physical activity and that they are less ac-
tive than nondisabled children.10-12 In addition, studies have
shown that this reduced level of physical activity leads to
decreased fitness and deconditioning as well as increased
risk of cardiovascular disease and obesity.13-15
The physical rehabilitation of children with CP most com-
monly places therapeutic emphasis on improving muscle
strength, physical and cardiorespiratory fitness, motor con-
trol, range of motion, and functional independence.16 Sever-
al studies have shown improvements in these characteristics
as a result of various aerobic exercise programs including
school-based exercise programs,17,18 body-weight supported
treadmill training,19-21 and robotic therapies.22-24 One reha-
bilitation modality that is becoming more commonly used
for children with CP is aquatic-based therapy.25-27
Benefits of Aquatic Gait Therapy
Research in aquatic therapies for children with CP has
shown improvements in gait efficiency and speed, gross
motor function measure (GMFM), range of motion, muscle
strength, endurance, and energy expenditure.28-37 Similar
benefits of aquatic therapies have also been shown for indi-
viduals with other severe neurological impairments such as
spinal cord injury,38-40 stroke,41-44 and multiple sclerosis.45,46
The use of a therapeutic aquatic environment provides
additional benefits to the rehabilitation process due to the
easily controlled nature of an aquatic environment and the
use of the natural properties of water. Due to the inherent
deficiencies in balance, muscle strength, and motor control
of children with CP, the provision of reduced gravitational
GMFM effects results in body weight support provided by
partial water submersion. This support can reduce or elimi-
nate the need for restrictive body harnesses often used in
overground therapies that have been shown to impair car-
diovascular performance and range of motion in patients
with motor disability.47 By using the natural gravity-reduc-
ing effects of an aquatic environment, patients are able to
move submerged limbs with less effort.
An additional benefit to patients with neuromuscular im-
pairment is the hydrostatic pressure provided in an aquatic
environment. This additional pressure on submerged in-
dividuals has been shown to improve venous return and
overall cardiac output.48 Furthermore, the thermodynamic
property of warm water used during aquatic exercise has
been shown to decrease muscle spasticity and hypertonia.49
One therapeutic benefit unique to aquatic therapies is that
of the viscous resistance of the water. This may be of added
benefit to individuals with movement disorders as the resis-
tance provided by the water is dependent on the velocity of
the moving limb.50
Recent studies examining exercise participation in children
with CP found that swimming and the use of an aquatic
environment were frequently used and highly favored ac-
tivities.51,52 Due to the relatively high popularity of aquatic
exercise therapies, many studies have been performed ex-
amining their functional and metabolic benefits for chil-
dren with CP. The purpose of this review is to examine the
findings from the studies exploring aquatic exercise therapy
protocols in producing changes in gross motor function,
cardiorespiratory performance, and gait in children and
adolescents with CP.
Methods
Search Strategy
The literature search was performed by the primary author
in November 2015. Databases include Pubmed (1975 to
November 2015), The Cochran Article Library (1975 to
November 2015), and Google Scholar Article Library (1975
to November 2015). Key words used were cerebral palsy
and physical therapy or water or pool or physiotherapy or
aquatic or treadmill or walking or sports or activity or body-
weight supported treadmill training or rehabilitation or gait
or fitness or exercise. Synonyms and thesaurus suggestions
were used when recommended by the database search en-
gine. Inclusion Criteria: 1) A physical activity–based inter-
vention involving an aquatic environment or measurement
thereof was used with motor function, gait, or physiological
fitness being at least one measured outcome variable; 2) All
or a substantial amount of study participants had received a
diagnosed CP with all or most of the participants being less
than 18 yr old; and 3) Use of a patient-specific standardized
test to assess reported outcome measures. Exclusion Crite-
ria: 1) Studies only published in abstract form; 2) Studies
solely examining the participation in land-based activi-
ties or activities not regularly associated with increases in
metabolic status or eliciting an excitatory cardiorespiratory
response in the participant (eg, yoga, meditation); and 3)
Studies not published in the English language.
Effects of Individualized
Aquatic Exercise Therapies
Fragala-Pinkham et al43 examined the effects of a 14-wk 2
times/wk aquatic aerobic and strength training exercise pro-
gram in 8 children with CP. Participants in this study ranged
in age from 6 to 15 yrs old and possessed a GMFCS level I or
III. Exercise sessions were held individually for each child
and consisted of 40-45 min of aerobic exercise followed by
5-10 min of strength training. Aerobic components of the
exercise program included, among other things, underwa-
ter treadmill training (UTT), swimming, and stair climb-
ing, whereas the strength training portion of the protocol
consisted of exercise using water resistance, leg weights, and
pool noodles. Most lower extremity strength training was
performed using leg weights positioned around the ankle
and focused on weight-resisted movement in all planes of
23
motion. Similarly, upper extremity strength training used
foam pool noodles held by the participant and moved in
all planes of motion against the buoyancy resistance of the
water. Postintervention results from this study showed a
statistically significant improvement in GMFM53 D (stand-
ing) and E (walking, running, jumping) compared to pretest
values. Statically significant improvements were also found
in walking endurance as measured by the 6-min walk test
(6MWT).54 These improved characteristics in walking en-
durance and gross motor function were also maintained
as demonstrated by a 1-mo follow-up. Participants also
showed improvements in aerobic capacity, balance, and
functional strength; however, these values did not reach
statistically significant levels.
A similar study was performed by Dimitrijevic et al44 who
tested the functional benefits of a swimming-intensive
aerobic exercise program on 27 children (14 experimental,
13 control) with GMFCS levels I-V CP. The 6-wk progres-
sive exercise protocol consisted of twice-weekly 55-min
sessions individualized for each participant based on func-
tional capabilities and aimed to maximize both functional
independence and enjoyment in the water. Aquatic exercise
consisted primarily of swim training with short times al-
lotted for warm-up and play. Postintervention results for
the experimental group showed statistically significant im-
provements in both gross motor function and aquatic skills
as measured by GMFM-8855 and the Water Orientation Test
Alyn 2,56 respectively. However these values decreased back
to baseline values by the 3-wk follow-up. No improvements
were shown in the control group.
These results are similar to those found in a case study per-
formed by Retarekar et al45 testing the effects of a 12-wk 3
times/wk aerobic aquatic exercise program for a 5-yr-old girl
with GMFCS level III CP. Aquatic exercise sessions consisted
of 30-40 min of aerobic activities such as UTT and swimming
performed at 50-80% of the heart rate reserve of the subject.
Posttest results showed statistically significant improvements
in gross motor function, walking endurance, and walking en-
ergy expenditure as measured by GMFM-66,57 6MWT, and
Modified Energy Expenditure Index (EEI),58 respectively.
These results, however, are in contrast to those of a study
completed by Kelly et al59 that tested a similar thrice-weekly
12-wk aquatic exercise protocol lasting approximately 60
min per session for 5 children with GMFCS levels I-III CP.
Posttest results from this study showed statistically insignif-
icant improvements in EEI but found significant improve-
ments in Canadian Occupational Performance Measure
(COPM). Variations in energy expenditure and gross motor
function improvements among these study results may be,
in part, due to the differences in initial levels of activity and
ability of the subjects.
Further evidence of the functional benefits of individual-
ized aquatic exercise is supported by a study completed by
24
Thorpe et al47 using a similar 10-wk 3 times/wk exercise
program consisting of relatively equal parts stretching, re-
sistance, and endurance aerobic exercises in 7 children with
GFMCS I-III CP. Statistically significant improvements
in gross motor function were exhibited in the GMFM-88
dimension E, and floor-to-stand transfers improved sig-
nificantly as tested by the Timed Up and Go Test. However,
these functional improvements did not reach significant
levels in GMFM dimension D or Functional Reach Test.
Use of a Group Aquatic
Therapy Environment
A similar swimming-intensive study was performed by Bal-
laz et al48 who examined the effects of group aquatic exer-
cise in improving gait efficiency, muscle strength, and gross
motor function. Ten adolescent participants with GMFCS
levels I-IV CP completed 20 group exercise sessions twice
per week for 45 min. The majority of each session consisted
of swim training and competitive aquatic sport activities.
Postintervention measurements showed improvements in
gait efficiency as shown by a statically significant decrease
in both EEI and participant heart rate while walking over-
ground. In contrast to other studies performing aquatic
exercise on an individual participant basis, participants in
this study did not show a statistically significant improve-
ment in GMFM-D or -E, gait spatiotemporal parameters, or
isometric muscle strength as a group; however, statistically
significant improvements were seen in some participants.
Further study of the therapeutic effects of group aquatic ex-
ercise conducted by Fragala-Pinkham et al49 tested a 14-wk 2
times/wk swimming, strengthening, and play-intensive exer-
cise protocol on 6- to 11-yr-old children with differing neu-
romuscular developmental disabilities. Although this study
only included one child diagnosed with CP (GMFCS level
II), results were similar to other presented studies involving
group exercise for children with CP, as statically significant
improvements in cardiorespiratory endurance were found
as measured by 0.5-mile walk/run. However, little to no im-
provements were found in motor skills or muscle strength.
Use of a Dual-Therapeutic
Environment
Although the previously presented studies have examined
the use of only aquatic exercise therapies, few studies have
used both overground and aquatic exercise therapies. In-
terestingly, in contrast to the commonly held emphasis on
exercise frequency, an additional study by Fragala-Pinkham
et al50 tested a progressive aquatic- and land-based physi-
cal therapy program emphasizing task specific aerobic
and strengthening activities for 4 children with physical
disabilities (2 with GMFCS level I CP). Of the 2 children
in this study diagnosed with CP, 1 child (C1) participated
in twice weekly sessions for 6 wk (8 aquatic sessions and
 The Journal of Aquatic Physical Therapy - Vol 25 No. 1, Summer 2017

Table. Aquatic Exercise Therapy Studies for Children and Adolescents with CP

Study Exercise Protocol Participants Improvementsa

Individualized exercise
  Dimitrijevic et al44 2 times/wk, 6 wk n = 24 (14E, 12C) Gross motor function, aquatic skills
GMFCS levels I-V
  Fragala-Pinkham et al43 2 times/wk, 14 wk n = 8, GMFCS levels Gross motor function, walking endurance,
I, III aerobic capacity, balance, functional strength
  Thorpe et al47 3 times/wk, 10 wk n = 7, GMFCS levels Gross motor function, floor-to-stand
I-III transfer
  Kelly et al46 3 times/wk, 12 wk n = 5, GMFCS levels COPM, energy expenditure
I-III
  Retarekar et al45 3 times/wk, 12 wk n = 1, GMFCS level I Gross motor function, walking endurance,
energy expenditure
Group exercise
  Ballaz et al48 2 times/wk, 10 wk (20 n = 10, GMFCS levels Energy expenditure, gross motor func-
sessions) I-IV tion, muscle strength, spatiotemporal gait
parameters
  Fragala-Pinkham et al49 2 times/wk, 14 wk n = 1, GMFCS level II Cardiorespiratory endurance, muscle
strength
Dual therapeutic environment
  Fragala-Pinkham et al50 2 times/wk, 6 wk n = 2, GMFCS level I Gross motor function, range of motion, bal-
ance, muscle strength, COPM, 3MWT, energy
expenditure
  Olama et al51 4 times/wk (2 aquatic, n = 30 (15E, 15C) Spasticity/muscle tone
2 land) 12 wk GMFCS levels I-IV
  Lae et al52 4-5 times/wk (2 n = 24 (11E, 13C) Gross motor function
aquatic, 2-3 land), 12 GMFCS levels I-IV
wk
Abbreviations: CP: cerebral palsy. E: experimental, aquatic therapy group. C: control group. GMFCS: gross motor function classification system.
COPM: Canadian Occupational Performance Measure. 3MWT: 3-min walk test
a
 For Improvements, bold type indicates statistically significant.

4 land sessions), and the other child (C2) complete 8 mo
of 1-2 times-per-week sessions (76% pool sessions). Both
aquatic- and land-based therapy sessions consisted primari-
ly of treadmill training, stretching, strengthening, and other
aerobic activities. Despite the relatively low frequency of
therapy sessions, poststudy results for C1 showed statistical-
ly significant improvements in gross motor function, lower
extremity range of motion, balance, and muscle strength.
In addition, improvements were seen in COPM, a 3-min
walk test (3MWT), and EEI. Although results for C2 were
complicated due to a nontherapy-related injury and surgery,
significant improvements were found in 3MWT, Floor to
Stand Test,60 Pediatric Evaluation of Disability Inventory,61
and passive ankle range of motion. In addition, improve-
ments were seen in COPM. Due to the complexity of the
case of C2, only data from C1 are summarized in the Table.
Further evidencing the possible importance of therapeutic
diversity is a study performed by Olama et al51 who also test-
ed the benefits of combining both land- and aquatic-based
therapies for children with CP. In this study, 30 children with
spastic hemiplegic CP were evenly and randomly divided
into 2 groups in which 1 group received twice weekly con-
ventional overground exercise therapy (control), whereas
another group participated in a twice weekly aquatic exer-
cise program in addition to the same overground exercise
protocol received by the control group. Individuals in each
group completed 20 sessions in total of one or both thera-
pies and were instructed to wear an ankle foot orthoses
during their general home lives. Aquatic exercise sessions
lasted 45 min and focused primarily on aerobic exercises,
swimming races, and general play activity. Results from the
study showed a significant decrease in spasticity character-
istics for both groups as measured by the Hoffman reflex
via H/M ration.62 In addition, the group that participated in
aquatic exercise showed significantly greater improvements
in spastic characteristics than the control group.
Similar in design is a study performed by Lae et al52 who also
examined the use of both aquatic- and land-based therapies

25
in a rehabilitation protocol. In this study, 24 children with
GMFCS levels I-IV were divided into either a control group
(n = 13) in which 30-min sessions of conventional over-
ground therapy 2-3 times per week were completed, or an
aquatic therapy group (n = 11) that completed twice-weekly
aquatic therapy sessions for 1 hr in addition to participation
in conventional overground rehabilitation therapy. After
completion of the 12-wk therapeutic protocols, both experi-
mental and control groups showed improvements in gross
motor function; however, improvements in the experimen-
tal group were both statistically significant and considerably
greater than those found in the control group. Posttest re-
sults also showed greater increases in gross motor function
for children with GMFCS level II and spastic diplegia CP
subtypes. These studies may provide further testament to
the additional benefits of an eclectic therapeutic approach
to pediatric rehabilitation.
Discussion
This review presents research performed on the restor-
ative effects of aquatic exercise therapies for children and
adolescents with CP from August 2005 to August 2015.
Individuals with CP demonstrate various levels of mobil-
ity impairment and muscle weakness. A therapeutic pool is
an accommodating medium for physical conditioning due
to its mobility-assistive property of water buoyancy and
muscle-strengthening property of water viscosity.
Documented research concerning the efficacy of aquatic
exercise therapy on individuals with CP is limited; thus,
this review expanded on previous reviews63 and included
individualized aquatic exercise, group aquatic exercise, and
dual therapeutic programs with combined aquatic- and
land-based activities. The broader based review effectively
doubled the number of studies examined from 5 to 10. The
common factor among all reviewed studies was the statisti-
cally significant improvement of one or more functional
and/or physiological variables being studied. All five stud-
ies conducted with participant protocols administered in-
dividually resulted in statistically significant improvements
in gross motor function.43-47 Two of the 5 studies included
follow-up measurements 3-4 wk postintervention.43,44 In-
terestingly, the study that provided aquatic therapy 2 times
per week for 14 weeks maintained gross motor function
improvements at follow-up exams, whereas the study that
provided aquatic therapy 2 times per week for only 6 wk
failed to maintain the reported gains.43,44 This may indicate
that the length of intervention is related to the maintenance
of gross motor function improvements after cessation of
the aquatic therapy program. Improved walking endur-
ance and enhanced energy expenditure were found to be
statically significant in separate studies of 14 and 12 wk,
respectively,43,45 whereas balance and functional strength
were shown to have nominal nonstatistically significant
improvements in a study where aquatic therapy was pro-
vided 2 times per week for 14 wk.43 Balance and muscle
26
strength are factors that are typically considered to be as-
sociated with gross motor function; however, the study by
Fragala-Pinkham et al43 indicated that it may be possible to
improve gross motor function in the absence of improve-
ments in balance and muscle strength. Two likely areas of
improvement that were not tested which could account for
the improved gross motor function in this study are the
neurologically based enhancement of motor planning and
sensory integration.
Ballaz et al48 and Fragala-Pinkham et al49 used group
aquatic exercise protocols and found statistically significant
improvements in energy expenditure and cardiovascular
endurance. These group aquatic protocols also demonstrat-
ed nominal nonstatistically significant increases in gross
motor function and muscle strength, respectively. The rea-
son for lack of statistically significant gross motor function
improvements during the group aquatic exercise programs
may be related to protocols that were predominately large
doses of swimming and water play activities that use aerobic
energy systems. These protocols lacked the more traditional
physical therapy–based activities of skilled mobility train-
ing such as gait training and UTT.
Fragala-Pinkham et al50 and Lae et al52 studied protocols that
combined aquatic physical therapy with land-based physical
therapy and found statistically significant improvements in
gross motor function, whereas Olama et al51 found reduced
muscle spasticity. Fragala-Pinkham et al50 also found stati-
cally significant improvements in range of motion, balance,
and muscle strength. However, due to the reviewed results
of Fragala-Pinkham et al50 only being on 1 of the 2 subjects,
due to protocol complexity, perhaps more attention should
be paid to the clinical significance of the improvements,
rather than the statistically significant findings.
There are several limitations within this review. The review
was limited to 10 studies, with 7 of the studies having 10
or fewer participants. The low number of participants does
not allow for generalizability of the results to the greater
population of children and adolescents with CP. Another
limitation was the lack of uniformity of the protocols (ie,
individualized, group, and combined aquatic and land ex-
ercise protocols) and the variability of specific activities
between the protocols (ie, gait training, UTT, resistance
exercises, aerobic exercises, swimming, and water play). In
addition, exercise dosage varied from 2 times per week to 5
times per week and program durations varied from 6 to 14
weeks. These limitations make it difficult to develop defini-
tive conclusions from the results.
Conclusions
The variability between study protocols and the limited
number of participants inhibits specific statements con-
cerning aquatic therapy benefits for individuals with CP.
However, since all of the reviewed studies reported positive
 The Journal of Aquatic Physical Therapy - Vol 25 No. 1, Summer 2017
benefits in at least 1 functional or physiological variable, it is
feasible to state that the documented evidence over the past
decade supports the idea that aquatic exercise therapy may
be generally beneficial for children and adolescents with CP.
Furthermore, the preponderance of the reviewed evidence
supports the idea that gross motor function is 1 variable
that may be improved with aquatic exercise therapy.
Acknowledgments
The authors would like to acknowledge Mr. Don Matthys
for his caring and compassionate work with those with CP.
His good deeds and big heart have made a large positive
difference in the lives of children with CP.
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