Journal of Huntington’s Disease 3 (2014) 5–11 5

DOI 10.3233/JHD-140010
IOS Press

Review

Aquatherapy for Neurodegenerative

Disorders
Alyson R. Plecash and Blair R. Leavitt∗
Centre for Huntington Disease, UBC Hospital and The Centre for Molecular Medicine and Therapeutics and
Department of Medical Genetics, Child and Family Research Institute, University of British Columbia, Vancouver,
BC, Canada

Abstract. Aquatherapy is used for rehabilitation and exercise; water provides a challenging, yet safe exercise environment for
many special populations. We have reviewed the use of aquatherapy programs in four neurodegenerative disorders: Parkinson’s
disease, multiple sclerosis, amyotrophic lateral sclerosis, and Huntington’s disease. Results support the use of aquatherapy in
Parkinson’s disease and multiple sclerosis, however further evidence is required to make specific recommendations in all of the
aforementioned disorders.

Keywords: Chorea, Huntington(’s) disease, Huntington, Huntington chorea, Parkinson(’s) disease, Parkinson, Multiple sclerosis,
Amyotrophic lateral sclerosis, Lou Gehrig’s disease, hydrotherapy, aquatherapy, aquatic therapy, pool therapy

INTRODUCTION both aerobic and resistance type exercises), and a cool-

down. Exercises are tailored to an individual’s ability,
Aquatherapy – also known as aquatic therapy, however kicking and walking drills are commonly used
hydrotherapy, or pool exercise – is used in many for aerobic and movement pattern training, while resis-
exercise programs and with a variety of populations. tive movements (anything involving pushing, pulling,
Several types of water-based therapy have been used or bending) against water are used for strength training
for the purpose of rehabilitation and treatment of of the limbs and postural muscles.
chronic illness since the early 1900s [1]. Water acts as a The benefit of performing weight-bearing exercise
unique medium allowing for weight-bearing exercise without stressing the joints has been utilized in water-
without stressing the joints, movement and stability based programs for special populations including the
drills without the fear of falling, and multi-directional frail elderly and those with osteoarthritis (OA) [2–5].
resistance training without the need for free weights Aquatherapy has been shown to reduce pain and
or bands. Aquatherapy, for general rehabilitation pur- improve function in those with lower limb osteoarthri-
poses and special populations, is commonly performed tis in short-term studies [2]. A pool therapy program
in a warm (above 30◦ C), shallow (chest-deep) pool offers special populations the opportunity to complete
and may involve a variety of exercise modalities movement tasks in the water that are no longer feasible
including aerobic, stretching/range of motion (ROM), on land [2].
resistance, and stability training [2]. Aquatherapy gen- In the frail elderly, weekly aquatherapy has shown
erally includes a warm-up, an exercise base (including improvements in health-related quality of life (HRQL)
∗ Correspondence to: Blair R. Leavitt, Centre for Molecular
and mobility-related activities of daily living (ADL)
Medicine and Therapeutics, 950 West 28th Avenue, Room 2020,
[3, 4]. Although exercise boasts benefits for both one’s
Vancouver, BC, V5Z4H4, Canada. Tel.: +1 604 875 3801; Fax: +1 physical and mental health, the fear of falling is a real
604 875 3840; E-mail: bleavitt@cmmt.ubc.ca. barrier to participation in exercise programs, especially

ISSN 1879-6397/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved
This article is published online with Open Access and distributed under the terms of the Creative Commons Attribution Non-Commercial License.
6 A.R. Plecash and B.R. Leavitt / Aquatherapy for Neurodegenerative Disorders

for populations at risk. Through exercising in water, sclerosis (MS) have shown exercise to be effective
this risk was reduced or alleviated in the frail elderly [3, at improving physical health, in particular muscu-
4]. This benefit would extend into many neurological lar strength and walking gait, as well as emotional
conditions, because falling, as a result of movement health, in particular by fatigue reduction [17, 18]. Stud-
disturbance or postural instability is a real fear in these ies in amyotrophic lateral sclerosis (ALS) have been
populations [3]. conducted looking at the effects of exercise on the pro-
The natural resistance water provides can be utilized gressive focal muscle weakness of ALS; they have
in multi-directional strengthening exercises. Water- showed positive results especially when stretching,
based exercise programs used for stroke rehabilitation strengthening, and aerobic exercises have been used
have shown more strength gains compared to land- [19]. Stretching has been shown to prevent contractures
based exercise programs, however these results have for longer, strengthening has been shown to improve
not been shown in all populations [6, 7]. The natural function and quality of life, and aerobic exercise seems
environment of a pool, allowing for enough resistance to be safe at both early and late stage disease and may
to promote strengthening, while simultaneously help- improve respiratory function [19].
ing to prevent injury through controlling movement
direction and velocity, may be beneficial for patients
with neurodegenerative conditions. AQUATHERAPY IN
NEURODEGENERATIVE DISEASE

THE USE OF EXERCISE THERAPY IN A systematic survey of the literature identified 31

NEURODEGENERATIVE DISORDERS studies that assessed the use of aquatherapy/hydrother-
apy as treatment in one of four neurological condi-
Huntington’s disease (HD) is a predominantly tions: HD, PD, MS, and ALS (Tables 1 and 2) [20–52].
adult-onset neurodegenerative disease with autosomal Two randomized clinical trials (RCTs) explored the
dominant inheritance, manifested symptomatically by use of aquatherapy in PD [22, 23]. Comparison of
progressive motor dysfunction, cognitive impairment land-based versus water-based exercise programs was
and psychiatric changes [8–10]. The motor dysfunc- performed by Vivas et al. [22] and data regarding
tion in HD consists of both disordered and poorly postural stability and self-movement were collected
coordinated voluntary motor function, and involuntary through five functional assessments: the Functional
movements [11]. Chorea is the predominant involun- Reach Test, the Berg Balance Scale, the UPDRS (Uni-
tary movement, although tics and dystonia can also be fied Parkinson’s Disease Rating Scale), the 5-meter
present [10, 11]. Generally, physiotherapy guidelines walk test, and the Timed Up and Go test. Both inter-
have focussed on exercise therapy to maintain, correct, ventions significantly improved performance on the
and coordinate voluntary movements for as long as Functional Reach Test, but only the aquatic therapy
possible in those with HD [10]. The literature suggests intervention significantly improved performance on
that exercise therapy may benefit voluntary gross motor the Berg Balance Scale and the UPDRS. Ayan and
movements, such as walking; it is suggested that phys- Cancela [23] studied the efficacy of water exercise
iotherapy is beneficial for those with HD to train and programs of different intensities. The low-intensity
maintain the ability to perform ADLs [10]. It has also program consisted of warm-up, balance, dynamic, and
been suggested that aquatherapy may reduce chorea cool-down exercises, while the muscular resistance
during and for a time following the exercise session program consisted of warm-up, muscular resistance,
[12]. Recent studies in mouse models of HD support and cool-down exercises. They found improvements
the use of exercise therapy in HD. One study demon- in quality of life (QOL) in both groups, but significant
strated that mice exposed to exercise (wheel running) improvement in functional mobility and Parkinsonian
at a young age had delayed motor-impairment, com- motor symptoms in the muscular resistance group only.
pared to mice not exposed to exercise [13]. Another Giladi discussed the use of an underwater treadmill,
study found that exercise slowed cognitive decline in to help train gait patterns in an expert review paper
an HD mouse model [14]. [24]. Crizzle and Newhouse used a focus group to
Exercise therapy in Parkinson’s disease (PD) has pri- discuss motivators for exercise adherence in PD with
marily targeted slowing of motor progression. Exercise aquatherapy program participants and their caregivers
programs improve motor symptoms (such as bradyki- [25]. Results showed that exercise program leaders
nesia and tremor) in PD [15, 16]. Studies in Multiple were important in encouraging participation; their
 A.R. Plecash and B.R. Leavitt / Aquatherapy for Neurodegenerative Disorders 7

Table 1
Characteristics of included studies

This review includes literature published between 1946 and July 30th 2013 from databases: Medline (1946 – July 2013), Cochrane Central
Register of Controlled Trials (1991 – June 2013), Cochrane Database of Systematic Reviews (2005 – May 2013), Embase (1974 – July 2013), and
CINHAL (1982 - present). Search terms of study sample include: chorea, Huntington(’s) disease, Huntington, Huntington chorea, Parkinson(’s)
disease, Parkinson, Multiple sclerosis, Amyotrophic lateral sclerosis and Lou Gehrig’s disease. Search terms of intervention types include:
hydrotherapy, aquatherapy, aquatic therapy, and pool therapy. Grey background in Table 1 indicates an RCT. Quantitative articles were ranked
by study type: (I) systematic review, meta-analyses of randomized controlled trials; (II) randomized controlled studies; (III) nonrandomized
intervention studies; (IV) observational studies; (V) nonexperimental studies; and (VI) expert opinion [20]. Qualitative articles were ranked
on a four-level system according to their level of good evidence-for-practice: (1) generalizable studies; (2) conceptual studies; (3) descriptive
studies; (4) single case study [21].

reassurance and support was the strongest motivator to aquatherapy in MS. Mori et al., examined the effect
participants. of exercise therapy combined with transcranial mag-
Aquatherapy has been especially beneficial in netic stimulation (TMS) on motor disability in MS,
patients with MS due to the reduction in the risk of and showed that exercise therapy plus TMS showed
falls in water [26]. Four RCTs examined the use of greater and more consistent improvements over TMS
8 A.R. Plecash and B.R. Leavitt / Aquatherapy for Neurodegenerative Disorders

Table 2
Outcomes measured in included studies

Dark grey background indicates improvement from an aquatherapy intervention in measured variables, light gray background indicates observed
or self-reported improvement where measured variables are not available.

alone [27]. Castro-Sanchez et al., assessed the use of to evaluate fatigue and health-related quality of life in
hydrotherapy for pain in MS [28], and found that the MS [29]. Results showed improvements in the exer-
hydrotherapy resulted in significant improvements in cise group but no change in a control group. Bansi
pain intensity, spasm, fatigue, disability, and auton- et al. used land versus water cycling as an intervention
omy. Kargarfard et al. used an aquatherapy program in MS and compared serum markers between groups
 A.R. Plecash and B.R. Leavitt / Aquatherapy for Neurodegenerative Disorders 9

[30]. The authors found increased serum brain-derived For HD, one study described a once-weekly
neurotrophic factor levels in the water-cycling group, aquatherapy program for a 50 year-old male who was
while no change was seen in the land group. in the later stages of disease. Gentle exercises in warm
Two observational studies followed participants water were suggested to be beneficial due to the
with MS through aquatherapy programs and found observed reduction in choreic movements during and
the interventions to be feasible, safe, and associated for a time following the aquatherapy sessions, however
with significant improvements on various motor scales specific outcomes were not measured [18].
[31, 32]. A third observational study examined the
impact of aquatherapy on gait in MS, however none
of the specific parameters analyzed showed signifi- SUMMARY AND CONCLUSIONS
cant improvements [33]. Multiple reviews have looked
at aquatherapy use in MS, and have suggested that The current evidence to support the use of aquather-
aquatherapy may be beneficial for symptomatic treat- apy in HD, PD, MS, and ALS is inconclusive when
ment of MS, especially due to its positive effects on generalized across these four disorders, however there
spasticity [34–37]. There is limited support (in the form is some experimental evidence supporting the use of
of small case studies) for the use of aquatherapy to aquatherapy in PD and in MS. Studies of aquather-
improve fitness variables such as walking endurance, apy in PD and MS include RCTs and larger trials,
upper extremity strength, or muscular endurance, how- which provide stronger evidence supporting a bene-
ever these variables need to be assessed quantitatively fit for exercise therapy in these conditions. Studies
in randomized groups before conclusions can be drawn in PD comparing land-based to water-based exercise
[36, 37]. Expert opinion papers suggest the use of programs demonstrated better results for water-based
aquatherapy as treatment for spasticity, arguing that programs [23, 24]. Large studies in MS showed evi-
therapy may decrease spasticity and the need for med- dence for benefit of aquatherapy on pain, fatigue and
ication use [38, 39]. A single case report suggests that HRQOL [27–30]. Subject characteristics (such as age,
warm water exercise may be used to “promote mus- gender, and stage of disease) were well described,
cular relaxation, decrease pain and increase range of therefore these trials could be replicated. The litera-
motion” in MS [40, p. 1051]. ture would benefit from replication of these studies
Three retrospective survey studies assessed differ- to determine if implementation of aquatherapy pro-
ent aspects of aquatherapy in MS [41, 43]. Motor grams in populations with PD or MS is warranted.
function appeared to improve, and all participants Studies in HD [18] and ALS [50–52] were too few
either maintained or improved strength in these pro- and of too poor methodological rigor to draw any
grams and reported that these programs were enjoyable clear conclusions for or against the use of aquather-
[41, 43]. Multiple surveys have been conducted to apy in these populations. No RCTs have been reported
better understand what proportions of the MS popu- in either population, only reviews and case reports
lation seek complementary medical therapy, and find exist describing any sort of aquatherapy intervention.
that only a small percentage (1.5%) use hydrotherapy Additionally, the populations and methods of these
[44–46]. Lewis [47] and O’Connell [48] both describe studies were not described specifically enough to be
aquatherapy programs and their potential benefits in replicable in future research. There is a need for
MS, however discrete variables are not discussed. larger and more robust experimental studies regard-
Veenstra et al. found that healthy adults and people ing the use of aquatherapy in populations of HD and
living with MS participate in water exercise programs ALS.
for similar reasons, and that adults with MS who partic- A shortcoming of this field of study is the wide
ipated in aquatherapy had greater life satisfaction than variety of assessment tools used in different studies.
those with MS who did not participate in aquatherapy We recommend standardized methods of measurement
[49]. be developed and used so that results are compara-
In a review document by the European Federation ble between studies. Valid and reliable measurement
of Neurological Societies task force, Andersen et al., tools include standardized QOL scales, the Unified
suggest hydrotherapy for symptomatic management Parkinson’s Disease Rating Scale (UPDRS) for PD, the
of cramps and spasticity in ALS [50]. There are no Unified Huntington’s Disease Rating Scale (UHDRS)
controlled studies in ALS and this recommendation is for HD, etcetera. These scales assess multiple disease
supported by an expert opinion paper and a single case domains such as, motor function, cognitive ability,
report [51, 52]. functional ability, and behavior, and their use would
10 A.R. Plecash and B.R. Leavitt / Aquatherapy for Neurodegenerative Disorders

help standardize the clinical impact of aquatherapy on [8] Gusella JF, MacDonald ME, Ambrose CM, Duyao MP.
disease progression in these disorders. Molecular genetics of Huntington’s disease. Arch Neurol.
1993;50(11):1157-63.
Aquatherapy is safe and feasible in PD and MS, and [9] Huntinton’s Disease Collaborative Research Group. A novel
has been shown to help pain and spasticity in some gene containing a trinucleotide repeat that is expanded
RCTs, but it should be evaluated more rigorously for and unstable on Huntington’s disease chromosomes. Cell.
efficacy in these diseases, as well as in HD and ALS. 1993;72:971-83.
[10] EHDN Physiotherapy Working Group. Physiotherapy guid-
Large well-controlled trials of aquatherapy in HD and ance document. 2009:3-178.
other neurodegenerative diseases need to be conducted [11] Bilney B, Morris ME, Perry A. Effectiveness of physiother-
to provide a basis for evidence-based clinical practice. apy, occupational therapy, and speech pathology for people
with Huntington’s disease: A systematic review. Neurorehabil
Neural Repair. 2003;17:12-24.
[12] Sheaff F. Hydrotherapy in Huntington’s disease. Nursing
ACKNOWLEDGMENTS Times. 1990;86:46-9.
[13] Van Dellen A, Cordery P, Spires T, Blakemore C, Hannan A.
Both authors provided concept/idea/research Wheel running from a juvenile age delays onset of specific
design. Ms Plecash provided data collection, writing, motor deficits but does not alter protein aggregate density
in a mouse model of Huntington’s disease. BMC Neurosci.
and review of manuscript before submission. Dr 2008;9(1):34-45.
Leavitt provided writing and review of manuscript [14] Harrison DJ, Busse M, Openshaw R, Rosser AE, Dun-
before submission. Funding support for this study was nett SB, Brooks SP. Exercise attenuates neuropathology
provided by a UBC Summer Research Student Grant, and has greater benefit on cognitive than motor deficits in
the R6/1 Huntington’s disease mouse model. Exp Neurol.
CFRI and The University of British Columbia. 2013;248:457-69.
[15] Konerth M, Childers J. Exercise: A possible adjunct therapy
to alleviate early Parkinson disease. JAAPA. 2013;26(4):30-3.
CONFLICT OF INTEREST [16] Alonso-Frech F, Sanahuja JJ, Rodriguez AM. Exercise and
physical therapy in early management of Parkinson disease.
Neurologist. 2011;17(6s):s47-s53.
The authors declare that they have no conflict of [17] Romberg A, Virtanen A, Ruutiainen J, Aunola S, Karpi SL,
interest. Vaara M, Surakka J, Pohjolainen T, Seppanen A. Effects of a
6-month exercise program on patients with multiple sclerosis:
A randomized study. Neurology. 2004;63:2034-8.
REFERENCES [18] White LC, McCoy SC, Castellano V, Gutierrez G, Stevens
JE, Walter GA, Vandenborne K. Resistance training improves
strength and functional capacity in persons with multiple scle-
[1] Becker B. Aquatic therapy: Scientific foundations and rosis. Mult Scler. 2004;10:668-74.
clinical rehabilitation applications. Phys Med Rehabil. [19] Chen A, Montes J, Mitsumoto H. The role of exercise in
2009;1(9):859-72. amyotrophic lateral sclerosis. Phys Med Rehabil Clin N Am.
[2] Bartels EM, Lund H, Hagen KB, Dagfinrud H, Christensen 2008;19:545-57.
R, Danneskiold-Samsøe B. Aquatic exercise for the treatment [20] United States Department of Health and Human Services.
of knee and hip osteoarthritis. Cochrane Database Syst Rev. Agency for Health Care Policy and Research. Acute pain
2007;4:CD005523 management: Operative or medical procedures and trauma.
[3] Sato D, Kaneda K, Wakabayashi H, Nomura T. Comparison Rockville, MD: AHCPR; 1993:107. (Clinical practice guide-
two-year effects of once-weekly and twice weekly water exer- line No 1, AHCPR publication No 92-0023.)
cise on health-related quality of life of community-dwelling [21] Daly J, Willis K, Small R, Green J, Welch N, Kealy M, Hughes
frail elderly people at a day-service facility. Disabil Rehabil. E. A hierarchy of evidence for assessing qualitative health
2009;31(2):84-93. research. J Clin Epidemiol. 2007;60:43-9.
[4] Sato D, Kaneda K, Wakabayashi H, Nomura T. Comparison [22] Vivas J, Arias P, Cudeiro J. Aquatic therapy versus
of two-year effects of once and twice weekly water exercise conventional land-based therapy for Parkinson’s Disease:
on health-related quality of life of community-dwelling frail An open-label pilot study. Arch Phys Med Rehabil.
elderly people at a day-service facility. Arch Gerontol Geriatr. 2011;92:1202-10.
2009;49(1):123-8. [23] Ayan C, Cancela J. Feasibility of 2 different water-based exer-
[5] Mehrholz J, Kugler J, Pohl M. Water-based exercises for cise training programs in patients with Parkinson’s Disease:
improving activities of daily living after stroke (Review). A pilot study. Arch Phys Med Rehabil. 2012;93:1709-14.
Cochrane Database Syst Rev. 2011;1:CD008186. [24] Giladi N. Mobility and exercise in movement disorders.
[6] Chu KS, Eng JJ, Dawson AS, Harris JE, Ozkaplan A, Gyl- Parkinsonism Relat Disord. 2009;15S3:S46-8.
fadottir S. Water-based exercise for cardiovascular fitness in [25] Crizzle AM, Newhouse IJ. Themes associated with exercise
people with chronic stroke: A randomized controlled trial. adherence in persons with Parkinson’s Disease: A qualitative
Arch Phys Med Rehabil. 2004;85:870-4. study. Occup Ther Health Care. 2012;26(2–3):174-86.
[7] Taunton JE, Rhodes EC, Wolski LA, Donelly M, Warren J, [26] Broach E, Dattilo J. The effect of aquatic therapy on
Elliot J, McFarlane L, Leslie J, Mitchell J, Lauridsen B. Effect strength of adults with multiple sclerosis. Ther Recreation
of land-based and water-based fitness programs on the cardio- J. 2003;37:224-39.
vascular fitness, strength and flexibility of women aged 65-75 [27] Mori F, Ljoka C, Magni E, Codeca C, Kusayanagi H,
years. Gerontology. 1996;42(4):204-10. Monteleone F, Sancesario A, Bernardi G, Koch G, Foti C,
 A.R. Plecash and B.R. Leavitt / Aquatherapy for Neurodegenerative Disorders 11

Centonze D. Transcranial magnetic stimulation primes the [39] Henze T, Rieckmann P, Toyka KV. Symptomatic treatment of
effects of exercise therapy in multiple sclerosis. J Neurol. multiple sclerosis. Eur Neurol. 2006;56:78-105.
2011;258:1281-7. [40] Peterson C. Exercise in 94◦ F water for a patient with multiple
[28] Castro-Sanchez AM, Mataran-Penarrocha GA, Lara-Palomo sclerosis. Phys Ther. 2001;81:1049-58.
I, Saavedra-Hernandez M, Arroyo-Morales M, Moreno- [41] Broach E, Dattilo J. Effects of aquatic therapy on adults with
Lorenzo C. Hydrotherapy for the treatment of pain in people multiple sclerosis. Ther Recreation J. 2001;35:141-54.
with Multiple Sclerosis: A randomized controlled trial. Evid [42] Broach E, Dattilo J. The effect of aquatic therapy on
Based Complement Alternat Med. 2012;2012:473963. strength of adults with multiple sclerosis. Ther Recreation
[29] Kargarfard M, Etemadifar M, Baker P, Mehrabi M, Hayat- J. 2003;37:224-39.
bakhsh R. Effect of aquatic exercise training on fatigue and [43] Broach E, Dattilo J, McKenney A. Effects of aquatic therapy
health-related quality of life in patients with Multiple Sclero- on perceived fun or enjoyment experiences of participants
sis. Arch Phys Med Rehabil. 2012;93:1701-8. with multiple sclerosis. Ther Recreation J. 2007;41:179-200.
[30] Bansi J, Bloch W, Gamper U, Kesselring J. Training in [44] Apel A, Greim B, Konig N, Zettl UK. Frequency of cur-
MS: Influence of two different endurance training protocols rent utilisation of complementary and alternative medicine by
(aquatic versus overland) on cytokine and neurotrophin con- patients with multiple sclerosis. J Neurol. 2006;253:1331-6.
centrations during three week randomized controlled trial. [45] Apel A, Greim B, Zettl UK. How frequently do patients
Mult Scler J. 2012;19(5):613-21. with multiple sclerosis use complementary and alternative
[31] Salem Y, Hiller Scott A, Karpatkin H, Concert G, Haller L, medicine? Complement Ther Med. 2005;13:258-63.
Kaminsky E, Weisbrot R, Spatz E. Community-based group [46] Fawcett J, Sidney JS, Hanson MJS, Riley-Lawless K. Use of
aquatic programme for individuals with Multiple Sclerosis: alternative health therapies by people with Multiple Sclerosis:
A pilot study. Disabil Rehabil. 2011;33(9):720-8. An exploratory study. Holistic Nurse Pract. 1994;8(2):36-42.
[32] Coco M, Maugeri A, Perciavalle V. Effects induced by swim [47] Lewis SM. Therapeutic swimming: A different kind of nurs-
on a patient with Multiple Sclerosis: Case report. Acta Medica ing. J Nurs Educ. 1985;24:125.
Mediterranea. 2006;21:85-92. [48] O’Connell R. Exercise therapy in multiple sclerosis. Physio-
[33] Gehlsen G, Beekman K, Assmann N. Gait characteristics in ther Ireland. 2005;26(1):23-6.
multiple sclerosis: Progressive changes and effects of exercise [49] Veenstra J, Brasile F, Stewart M. Perceived benefits of aquatic
on parameters. Arch Phys Med Rehabil. 1986;6:536-9. therapy for multiple sclerosis participants. Am J Recreat Ther.
[34] Correia de Sa JC, Airas L, Bartholome E, Grigoriadis N, Mat- 2003;2(1):33-48.
tle H, Oreja-Guevara C, O’Riordan J, Sellebjerg F, Stankoff [50] The EFNS Task Force on Diagnosis and Management of
B, Vass K, Walczak A, Wiendl H, Kieseier BC. Symptomatic Amyotrophic Lateral Sclerosis: Andersen PM, Abrahams S,
therapy in multiple sclerosis: A review for a multimodal Borasio GD, de Carvalho M, Chio A, Van Damme P, Hardi-
approach in clinical practice. Ther Adv Neurol Disord. man O, Kollewe K, Morrison KE, Petri S, Pradat P-F, Silani
2011;4(3):139-68. V, Tomik B, Wasner M, Weber M. EFNS guidelines on
[35] Beer S, Khan F, Kesselring J. Rehabilitation interventions in the Clinical management of Amyotrophic Lateral Sclerosis
multiple sclerosis: An overview. J Neurol. 2012;259:1994- (MALS) – revised report of an EFNS task force. Eur J Neurol.
2008. 2012;19:360-75.
[36] Peterson JL, Bell GW. Aquatic exercise for individuals with [51] Bedlack RS, Aggarwal S. ALS update: Signs of progress,
multiple sclerosis. Clin Kinesiol. 1995;49:69-71. reasons for hope. Continuum Lifelong Learning Neurol.
[37] Woods DA. Aquatic exercise programs for patients with mul- 2009;15:83-110.
tiple sclerosis. Clin Kinesiol. 1992;46:14-20. [52] Johnson CR. Aquatic therapy for an ALS patient. Am J Occup
[38] Pappalardo A, Castiglione A, Restivo DA, Calabrese A, Patti Ther. 1988;42:115-20.
F. Non-pharmacologic interventions for spasticity associated
with Multiple Sclerosis. Neurol Sci. 2006;27:S316-9.