Hydrotherapy in

Parkinson’s
Disease
PT Clerici Ilaria
No conflicts of interest to declare
 INDEX

• Definition and physical properties of water

• Therapeutic effects
• Hydrotherapy in Parkinson’s Disease: why?
• Hydrotherapy in Parkinson’s Disease: our protocol
• A clinical case
PART 1
Definition and physical
properties of water
 DEFINITION
• Hydrotherapy is defined as a particular treatment
based on the integration between the physical,
termic and relational properties of water and
movement

• Aquatic environment as a microgravitary setting

• Different rules compared to land

 PHYSICAL PROPERTIES

• Relative density
• Buoyancy
• Hydrostatic pressure
• Viscosity
• Thermodynamics
1. DENSITY and SPECIFIC GRAVITY
DENSITY is the ratio between the mass of a substance (kg) and the
space it occupies ( m³)

• In case of a fluid, the greater its density the greater the

force it exerts on objects that float or are immersed in it
• The relative density of an object is the ratio of the weight
of the object to the weight of an equal body of water. The
density of various substances is defined by a pure
number value called Specific Gravity
• Specific Gravity of Water=1
• If a body has a specific weight lower than 1, it will float
• If a body has a specific weight greater than 1, it will sink
 Body tissues Specific gravity

Muscles 1,8

Bones 1,05

The human body Fat tissues 0,94

can float because
of its density and Male human body 0,98
specific gravity < 1
Female human 0,968
body
 2. BUOYANCY
Buoyancy is the upward thrust of water acting on body

« When a body is
partially or totally
immersed in a fluid it is
buoyed up by a force
equal to the weight
(volume) of the fluid
that is displaced by the
body»
 Buoyancy is the upward thrust of water acting on body

• Assists motion toward water’s surface

• Sense of weight loss (equal to amount of water that is
dissipated)
• Allows for ambulation and vigorous exercises with little
impact and friction reduction between articular
surfaces
Level of immersion percentage acting on weight-bearing in water
 BUOYANCY: PAY ATTENTION TO

Center of buoyancy affects the body in water

Reference point of an immersed

body on which buoyant
(vertical) forces of fluid
predictably act

STERNUM

 Body stable: center of buoyancy

alligned with the center of gravity
 Body unstable: center of buoyancy
not alligned with the center of gravity
 3. VISCOSITY
Magnitude of internal friction specific to a fluid during motion

• Resistance to all fast movements in water

• If the water temperature rises, its viscosity is reduced
• Air viscosity < water viscosity = more resistance in
water
• Increasing the surface area moving through water will
increase resistance
 4. HYDROSTATIC PRESSURE
Pressure exerted on immersed object

• Pressure exerted by fluid on an immersed object

is equal on all surfaces of the object
• Directly proportional to the density of the liquid,
gravity and the depth to which the body is
immersed
• The deeper the immersion the greater the
pressure that is exerted on the body
 4. HYDROSTATIC PRESSURE: effects
• Fluids are driven from the extremities towards the central
cavity
• Blood flows upwards through the venous and lymphatic
systems towards the thoracic area
• Increased circulation first in the muscles, than in the blood
vessels of the abdominal cavity, and finally in those of the
chest cavity and heart  heart rate decreasing
• The chest wall is compressed  altering pulmonary function
and respiratory dynamics  increasing breathing work
• Intra-abdominal pressure increased ( the diaphragm rises):
 The expiration is facilitated
 Inspiration is more difficult
• Hydrostatic pressure stimulates the cutaneous receptors 
the perception of the movements of the bodies and limbs is
given more by the exteroceptive sensory system
 5. THERMODYNAMICS
Branch of physics concerned with heat and temperature and their
relation to energy and work

• The therapeutic utility of water depends on both its ability to

retain heath and the capacity to transfer heat energy

« A body immersed in cold water transfers heat by

convection and conduction. In water, if the
temperature is close to 26°C, the body undergoes a
heat loss, vice versa if the temperature exceeds 35°C,
it assumes heat.»
5. THERMODYNAMICS: effects
• Peripheral vasodilation with at first slight
tachycardia and then bradycardia
• Muscular tone reduction (miorelaxation)
• Reduction in the peripheral sensitivity (antalgic
effect)
• In order to obtain a situation as close as the
thermo-neutral it is necessary to have a pool with
a temperature similar to that of the skin ( 32-34°
C)
PART 2
Effects of
Hydrotherapy
On the whole systems
 1. CARDIOVASCULAR SYSTEM
Water immersion to
chest or higher

Increased hydrostatic
pressure

Venous compression Limphatic compression

Central blood volume

increases

Pulmonary arterial Cardiac volume

Arterial pressure rises
pressure rises increases

Stroke volume
increases

Cardiac output
increases
Becker and Cole 1997
1. CARDIOVASCULAR SYSTEM: details
For thermoneutral immersion

• Right atrial pressure passing from -4 mmHg to 17 mmHg

(extrasystolis possible)
• Blood pressure from 5 mmHg to 22 mmHg mainly at larger vassels of
the pulmonary vascular bed, not at capillary level diffusion capacity
of lungs changes very little
• Central blood volume increases by 60% repect to land
 1/3 taken up by heart
 remainder by the great vassells of lungs
• Cardiac volume increases by 30%  increase force of contraction
• Stroke volume increases by 35%  exercise maximum for a
sedentary deconditioned individual on land
• Most of the changes are temperature dependent with cardiac output
rising progressively with increasing water temperatures (30% at 33°C
– 121% at 39°C)
2. PULMONARY SYSTEM
 3. RENAL SYSTEM
Head out water
immersion

Central blood volume

Cardiopulmonary
receptor

• Suppression of aldosterone by 35% after 3 hours (sodium loss)

• ADH release by 50% suppressed
• Renin activity reduced by 62% after 3 hours

URINARY OUTPUT INCREASE

 4. NERVOUS/
MUSCOLOSKELETAL SYSTEM

Immersion, temperature and turbolence increases pain

threshold
 4. NERVOUS: the “avant-garde”

Listening errors fewer than land may be a change in

underlying parasympathetic neural drive (> pressure
within atrial and venous structure  baroreflexes
stimulated  vagal tone elevation  parasympathetic
drive)
 GENERAL EFFECTS AND
BENEFITS
EFFECTS
- Increased blood circulation to
the muscles
- Increased heart rate
- Increased respiratory rate
- Increased general muscle
metabolism
- Decreased blood pressure
- Decreased sensitivity of
sensory nerve endings
- General muscle relaxation
BENEFITS
- Decreased pain
- Decreased joint effusion
- Improved range of motion and
flexibility
- Increased strenght and
coordination
- Improved ease of ambulation
and activities of daily living
- Improved mood
- Increased feeling of well-being
Korel L.E., 1996
 LINKING PROPERTIES AND
REHABIITATION

WATER PROPERTIES • NEUROLOGICAL DISEASES

• MUSCOLOSKELETAL DISEASE
• DEVELOPMENT ALTERATIONS
• CARDIO-RESPIRATORY
EFFECTS ON WHOLE DISEASES
SYSTEM • SPORT TRAINING

HYDROTHERAPY
PART 3
Hydrotherapy in
Parkinson’s
Disease: Why?
Scientific evidences
 PARKINSON’S DISEASE
• Chronic and progressive
neurodegenerative disease
• Clinical hallmarks: rigidity,
bradykinesia (or akinesia),
tremor at rest
• Gait problems: shuffling gait,
freezing
• Balance disfunctions
• Postural deformities
(anterocollis, Pisa Syndrome,
camptocormia)
• Cognitive decline
 LINKING PROPERTIES AND
REHABIITATION

WATER PROPERTIES

Parkinson’s disease specific

deficits and alterations
EFFECTS ON WHOLE
SYSTEM

HYDROTHERAPY
 STATE OF ARTS

• No descriptive reviews
• No systematic reviews
• No meta-analysis
• Few studies differently disegned
STATE OF ARTS
 WHAT ABOUT PARKINSON’S
DISEASE?
• 11 patients with PD (H&Y 2 and 3)
randomly assigned to two groups:

- Active control group (land-based

therapy)

- Experimental group (water-based

therapy)

• 4 weeks,twice a week, 45 minutes per

session

Both protocols could be useful for • Assessment: baseline, after 4 weeks,

improving balance in PD.
Only the aquatic group improved
significantly in BBS and UPDRS
follow-up after 17 days
• Outcome measures: Functional Reach Test
(FRT), Berg Balance Scale (BBS), UPDRS,
Timed Up and Go (TUG) and 5-m walk Test

• Protocol: warm-up, trunk mobility

exercises, postural stability, transferring and
changing body positions exercises
 WHAT ABOUT PARKINSON’S
DISEASE?
• 34 patients with H&Y stage 2,5-3,
randomly assigned to 2 groups:

Group 1 (hydrotherapy treatment);

Group 2 (land-based treatment)

• 2 months, 5 days a weeks, 60 minutes per

session

• Based on the EU guideline (originally

Dutch)
Both groups improved significantly. • Outcome measures: stabilometry (30 sec
However, the aquatic group OE and CE), UPDRS II and III,Timed Up
improved more significantly in COP and Go Test(TUG), Berg Balance Scale
sway BBS, Activities-specific (BBS), Activities-specific Balance
Confidence Scale, Falls Efficacy Scale,
Balance Confidence Scale,Falls Parkinson’s Disease Questionnaire-39
Efficacy Scale,Falls Diary,PDQ-39 (PDQ-39)

• Exercises with perturbations and reaching

+ strenghtening (40 min)+ warming upand
cooldown in both groups
WHAT ABOUT PARKINSON’S
DISEASE?

Documented modifications in under

water gait parameters through under
water gait analysis in a group of PD
patients and controls
 WHAT ABOUT PARKINSON’S
DISEASE?
• Few articles have investigated on the therapeutic
effects of water in Parkinson’s Disease
• Hydrotherapy has a positive effect on PD,
because it improves:
 Functional mobility
 QoL of the patients
 Balance
 WHY BALANCE IMPROVE?

• The turbulent water flows destabilize the patients

causing continuous loss and recovery of balance
 maximal stimulation of neurological reactions
• The water setting is safer than land ( no risks to
fall), thus improving self-confidence and motor
skills
• The water microgravitary setting can lead PD
patients to transform an automatic movement in a
voluntary movement, improving learning
• Water is a supportive environment which allows
for extra time to control movement –
proprioception enhancement
PART 4
Hydrotherapy in
Parkinson’s
Disease
Our protocol
 Multisciplinary Intensive
Rehabilitative Treatment (MIRT)

• Numerous scientific evidences has proved that an

intensive treatment is connected not only with a short-
term, but also to a middle-long- term efficacy, slowing
the progression of Parkinson’s (Petzinger et al 2010, Frazzitta 2013)

• Based on these evidences, MIRT lasts 4 weeks and

comprises:
- 5 intensive sessions per weeks (3 hours from Monday to
Friday)
- 1 session of training with specific devices
- 64 hours of training during the month
 Multisciplinary Intensive
Rehabilitative Treatment (MIRT)
• The daily protocol is made up of three different
treatments:
- 1 hour of front to front treatment with a
physiotherapist (+ eventual hydrotherapy)
- 1 hour of training with specific devices (virtual
reality, gait trainer, gait trainer with auditory and
visual cues, stabilometric platform,
cycloergometer) in small groups ( maximum 4-5
patients), supervised by a physiotherapist
- 1 hour of occupational therapy
 MIRT and HYDROTHERAPY
Influenced by the scientific evidences, we decided to use
hydrotherapy only for three categories:
1) Freezing
2) Postural deformities
3) Balance disfunctions/impairment

RATIONALE: MICROGRAVITY AND WATER

PROPERTIES CAN FACILITATE MOTOR
SKILLS IMPROVEMENT PROPEDEUTIC FOR
FUNCTION RECOVERY
 CONTRAINDICATIONS
• Deep vein thrombosis
• Congestive heart failure
• Open wounds, rashes and previous burns
• Seizures
• Severe renal diseases
• Urinary or fecal incontinence
• Severe hydrophobia
 MIRT and HYDROTHERAPY:
PROTOCOL

• 2-3 sessions per weeks for 4 weeks;

• Every single session lasts 1 hour and is divided
into three part:
1) A warm-up phase (5-10 minutes)
2) A central phase (45 minutes)
3) A cooldown phase (5-10 minutes)
 FIRST PHASE: WARM UP

• Initially the patient undergoes a first phase of

familiarization, knowledge and confidence of a
totally new word compared to land by making:
1) free walkways in various directions
2) walkways against resistance (created by the
therapist)
3) walkways with eyes closed (to stimulate and
increase proprioception and voluntary
movement)
 SECOND PHASE: TRAINING
• This phase lasts 45 minutes and it differs depending
on patient clinical specifity
1) Passive mobilizations in horizontal supine floating
2) Mobility exercises in standing position (for voluntary
movements rotation of the trunk and upper limbs)
and sitting on a float
3) Static and dynamic exercises to improve motor skills
and coordination
4) Proprioceptive exercises (maintain balance in
different conditions)
SPECIFIC EXERCISES FOR POSTURAL
ALTERATIONS

• Trunk mobilization
• Trunk segmental coordination
• Muscle recruitment according to muscle
imbalance, EMG assessment, botulinum toxin
injection
• Trunk proprioception
SPECIFIC EXERCISES FOR POSTURAL
ALTERATIONS
 SPECIFIC EXERCISES FOR BALANCE

• Limits of stability
• Postural control
• Ankle and hip strategies
• Perturbation and water turbolence
• Water resistance
• Obstacles and function
SPECIFIC EXERCISES FOR
BALANCE
SPECIFIC EXERCISES FOR FREEZING

• Weight shifting
• Coordination
• Gait patterns
• Turning strategies
SPECIFIC EXERCISES FOR
FREEZING
 THIRD PHASE: COOLDOWN

• Relaxation phase in which the patient performs:

1) Stretching
2) Walkways in different directions
3) Hydromassage
A clinical case
• 70 years old
• Severe anterocollis,
camptocormia and
Pisa Syndrome
• Parkinson’s disease
diagnosed in 2002
• Anterocollis
manifested for the first
time in 2012
• ADL reduced
FIRST DAY
FIRST SESSION
ACTIVE EXERCISES
ACTIVE EXERCISES
END OF FIRST SESSION
 MONDAY SLIDE
• Acquatic environment creates a microgravitary setting thanks to specific water properties

• Water properties (relative density, buoyancy, hydrostatic pressure, viscosity and

thermodynamics) provide special issues for rehabilitative intervantions

• Hydrotherapy brings effects on cardiovascular, pulmunary, renal, nervous and

muscoloskeletal systems

• Few data in literature report hydrotherapy interventions in Parkinson's disease

rehabilitation

• According to literature hydrotherapy can be a valid instruments for Parkinson's

rehabilitation: balance and QoL seem to largely report benefits by including hydrotherapy
interventions in the rehabilitative programs

• MIRT protocol is a Multidisciplinary Intensive Rehabilitative Treatment based on 3 main

neurophysiologic principles: aerobic, intensity and goal based activities. Hydrotherapy fully
exerts neurophysiologic principles for effective neurologic rehabilitation

• MIRT protocol designs hydrotherapy intervention mainly for patients presenting: freezing of
gait, postural alterations and balance impairments

• MIRT-Hydrotherapy consists of 3 phases: body warm up, training and cooldow activities.
Patients are treated according to specif protocols (freezing, postural alteration, balance
deficits)
Thanks for your
attention