Use of aquatic environment for assessing functional tests: feasibility, benefits, and challenges compared to land-based testsABSTRACT:
This study aimed to investigate the feasibility, benefits, and challenges of using aquatic environment to assess physical function tests compared with land-based assessments. A total of 40 individuals underwent the 6-minute walk test (6MWT), 2-minute step test (2MST), and timed get-up-and-go (TUG) test, both on land and in a 1.2-meter water depth pool. Perceived exertion was measured using the Modified Borg scale. Paired Student’s t-tests and Cohen d were used to compare assessments in water and on land . Significance was set at 5%. Compared to land, participants walked less in water during the 6MWT (d =3.69, p<0.001) and took longer to complete the TUG test (d =2.76, p=0.001). No differences were observed in perceived exertion between land and water during the 6MWT (p=0.055) and TUG test (p=0.32). Regarding 2MST, there was no difference in performance between the environments (p=0.45). Conversely, participants experienced lower perceived exertion during the 2MST in water (=1.15, p=0.001). In conclusion, an aquatic environment is a feasible option for conducting functional tests. Although water may have increased the difficulty of certain assessments, the perceived exertion in water was either lower than or comparable to that of land.
Keywords:
Aquatic Therapy; Hydrotherapy; Physical Functional Performance; Evaluation Study
RESUMO:
O objetivo deste estudo foi investigar a viabilidade, os benefícios e os desafios do uso do ambiente aquático para avaliar testes funcionais na comparação com avaliações realizadas em solo. Neste estudo, 40 indivíduos foram submetidos ao teste de caminhada de seis minutos (TC6), ao teste de subida de degraus de dois minutos (TSD2’) e ao teste timed-up-and-go (TUG), tanto em solo quanto em uma piscina de 1,2 metros de profundidade. O esforço dos participantes foi medido pela escala de Borg. Testes t de Student e Cohen d foram usados para comparar avaliações entre ambientes. Significância foi estipulada em 5%. Em comparação com o teste em solo, os participantes caminharam menos na água durante o TC6 (d=3,69, p<0,001) e levaram mais tempo para completar o TUG (d=2,76, p=0,001). Não foram observadas diferenças no esforço entre ambientes para o TC6 (p=0,055) e o TUG (p=0,32). Em relação ao TSD2’, não houve diferença no número de degraus entre ambientes (p=0,45) e os participantes experimentaram um menor esforço na água (d=1,15, p=0,001). Em conclusão, ambientes aquáticos são uma opção viável para realizar testes funcionais. Embora a água possa ter aumentado a dificuldade de certos testes, o esforço na água foi igual ou menor do que em solo.
Descritores:
Fisioterapia Aquática; Hidroterapia; Desempenho Físico Funcional; Estudo de Avaliação
RESUMEN:
El objetivo de este estudio fue investigar la viabilidad, beneficios y desafíos del uso de ambiente acuático para evaluar pruebas funcionales en comparación con el suelo. En este estudio, cuarenta individuos fueron sometidos al 6-minute walk test (6MWT), al 2-minute step test (2MST) y al timed up and go test (TUG), tanto en suelo como en una piscina con 1,2 metros profundidad de. El esfuerzo de los participantes se midió con la Escala de Borg. Los testes t de Student y Cohen d fueron utilizados para comparar las evaluaciones entre ambientes. La significancia se quedó en 5 %. En comparación con el suelo, los participantes caminaron menos en el agua durante el 6MWT (d =3,69, p<0,001) y tardaron más en completar el TUG (d =2,76, p=0,001). No se observaron diferencias en el esfuerzo entre los ambientes para el 6MWT (p=0,055) y el TUG (p=0,32). En cuanto al 2MST, no hubo diferencia en el número de escalones (p=0,45) pero los participantes experimentaron un menor esfuerzo en el agua (d =1,15, p=0,001). En conclusión, los ambientes acuáticos son una opción viable para realizar pruebas funcionales. Aunque el agua puede haber aumentado la dificultad de ciertas pruebas, el esfuerzo en el agua fue igual o menor que en suelo.
Palabras clave:
Terapia Acuática; Hidroterapia; Rendimiento Físico Funcional; Estudio de Evaluación
INTRODUCTION
Aquatic therapy or aquatic exercises are an important treatment option for individuals with physical disabilities1. Its potential has been demonstrated since ancient Egyptian and Greek medicine, promoting healing and reducing pain2. With technological advancements and improvements in scientific methods, the effects of aquatic therapy have been increasingly studied, and the number of patients who benefit from it has expanded3,4.
Such effects have been linked to fluid mechanics. Hydrostatic pressure, density, buoyancy, viscosity, and resistance play crucial roles in patient treatment5,6. Individuals with musculoskeletal or neurologic disorder who receive aquatic exercise may experience shorter recovery periods than those who undergo other treatments7,8.
Historically, the number of aquatic exercise sessions has been typically lower than the number of sessions performed on land. It occurs because not all cities have a suitable pool adapted for therapy with temperature control and water depth regulation. Furthermore, there may not always be sufficiently qualified professionals to perform water therapy protocols. Finally, the costs of maintenance and treatment seem to be higher for water than for land9.
Despite the challenges and adversities-especially those related to immersion and fear of water-it is important to recognize the value of aquatic exercises. Such approach has yielded positive outcomes for individuals with impaired mobility and capacity, including older adults and conditions such as stroke, traumatic brain injuries, or spinal cord injuries1,4,10. Aquatic therapy offers valuable benefits for individuals with cognitive impairment, improving behavioral and psychological symptoms, muscular resistance, and various performance-based measures11.
Although aquatic therapy is recommended to treat several diseases, many professionals choose to assess patient physical function on land. This seems to be attributed to the limited number of studies evaluating the feasibility and benefits of using aquatic environment for assessing the patient’s physical functioning, as well as the absence of studies standardizing normal scores of function tests in an aquatic setting12,13.
When evaluating an individual for physical therapy, information obtained solely on land might be insufficient. Both land and aquatic environments are necessary to ensure that appropriate clinical decisions are made. Water-based evaluations provide important information for physical therapists as it explores the mechanisms exerted by water, such as pain reduction, reduced weight-bearing, and increased range of motion. Aquatic and land evaluations should be carried out together, considering water has the potential to assist in motor functions, especially when land-based activities are not feasible. Hence, we raise the following research question: why do we not evaluate individuals in water instead of simply treating them in this environment?
This study aimed to investigate the feasibility, benefits, and challenges of using aquatic environments to assess functional tests compared with land-based assessments. We hypothesized that assessing patients in water would facilitate the performance of functional tests and result in a lower perceived exhaustion.
METHODOLOGY
This study included 40 community-dwelling young individuals, 22 women, with a mean age of 22.8 (SD 2.9) years. The study was conducted at the Integrated School Clinic of the Federal University of Mato Grosso do Sul, Campo Grande, Brazil. The STROBE statement checklist, Declaration of Helsinki, and guidelines for good clinical practice were followed. All eligible participants signed a consent form before the assessment.
Convenience sampling was employed, as only participants who were willing to undergo a medical examination prior to the pool activities were included. The recruitment involved direct contact with potential participants and social media platforms to reach a wider audience. This process was extended across all districts of Campo Grande, Brazil, to guarantee a comprehensive and impartial sample that accurately represented the city’s diverse population.
Individuals were eligible for inclusion as follows: young adults of both sexes; living in a private residence in the community; were of any creed or race, and did not have any walking problems. Exclusion criteria consisted of a previous history of neurological or psychiatric disorders as well as participants who were deemed medically unfit for engaging in pool activities.
After providing written consent, the participants completed a general questionnaire that included information on sex, age, weight, and height. An anthropometric scale capable of assessing weights of up to 300kg and heights of up to 2m was used to verify the accuracy of these measurements. Using these parameters, body mass index of each participant was calculated and collected data on the participants’ blood pressure were collected while they were in a resting state.
A 0-100kgf scale dynamometer (Saehan Electronics Co. Ltd., South Korea) was used to characterize the participants regarding muscular strength. Three measurements of handgrip strength were obtained for each segment and the mean scores were reported. The data contributed to the characterization of the study sample, providing insights into its physical strength and potential implications for research findings.
The average heart rate and oxygen saturation variability were measured to gain insight into the participants’ physiological status during inactive and active periods. For these measurements, the Artery Check SB 220® (RossMax, Taiwan) was used, which is known to measure from 30 to 250 beats per minute (bpm) and saturation rates between 70% and 99%. The device features an artery check technology that assesses arterial occlusion across six different classifications. None of the participants in this study showed signs of arterial occlusion. Table 1 shows the participants’ general characteristics.
The experimental protocol included three physical function tests often used in clinical practice: the 6-minute walk test (6MWT)14, 2-minute step test (2MST)15, and timed get-up-and-go (TUG) test16. The tests were performed both on land and in a pool. The aquatic environment involved an indoor pool of 6 m in length and 5 m in width, with a water depth limited to 1.2 meters, and a temperature between 30°C and 32°C. The order of the tests (6MWT × 2MST × TUG), as well as the starting location (pool × land), were randomized to minimize any potential bias. All assessments were conducted in the afternoon to maintain consistency in the participants’ conditions and to capture the performance when individuals are typically more alert and responsive. A 10-minute rest period was provided between each assessment to ensure that participants had adequate recovery time. Perceived exertion in each test was measured using the modified Borg scale17.
The 6MWT is commonly used to evaluate exercise capacity and functional endurance. It measures the distance an individual can walk in six minutes within a controlled environment, typically a flat and straight corridor. During the 6MWT, participants were instructed to walk as far as possible within a given time frame while maintaining a steady pace. On land, a 30-meter course was marked out for the test, while in the water, the test was conducted in a 6-meter lane (limited to the size of the pool). A shorter walking distance typically indicates poorer exercise capacity and functional endurance. Variables analyzed included distance covered (m), average heart rate (bpm), oxygen saturation (%), and perceived exertion (pts).
The 2MST is a simple test used to estimate an individual’s aerobic fitness and cardiovascular endurance. It measures the number of steps a person can climb within two minutes. For both land and pool activities, the steps were standardized with dimensions of 20cm in height, 25cm in length, and 40cm in width. The variables analyzed were the number of steps taken (n), average heart rate (bpm), oxygen saturation (%), and perceived exertion (pts). A lower number of steps climbed during the test indicates poorer aerobic fitness and cardiovascular endurance.
The TUG test was used to evaluate participants’ mobility. This test is a common tool in healthcare and rehabilitation settings, measuring functioning components, including dynamic balance, gait speed, coordination, and the ability to perform transitional movements. The test measures the time and number of steps required for individuals to stand up from a chair, walk three meters, and return to the chair. The same chair dimensions were used for land and water tasks. As the TUG test is a nonaerobic assessment instrument, average heart rate and oxygen saturation were not assessed. The variables included in this test were time (s), steps (n), and perceived exertion (in points). A longer time to complete the task and greater number of steps taken indicate poorer mobility and functional performance.
The Modified Borg Scale, commonly used to evaluate an individual’s perceived exertion during physical activity, provides a subjective measure of effort based on personal sensations and feelings. In this study, participants were requested to rate their physical exertion using the scale upon completion of the 6MWT, 2MST, and TUG test. The participants’ perception of physical stress and fatigue was considered, disregarding factors such as leg pain or breathlessness. The scale ranged from 0 to 10, with 0 indicating no exertion and 10 indicating maximum effort.
Statistical analysis
The data were reported as mean (standard deviation), after checking the Gaussian distribution. Paired Student’s t-tests were conducted to analyze the main effect of the aquatic environment on the 6MWT, 2MST, and TUG test. For all analyses, significance was set at 5%. In cases in which statistically significant differences were observed between the assessments, effect sizes (Cohen’s d ) and mean differences with 95% confidence intervals (CI) were reported.
RESULTS
Table 2 shows the results of the 6MWT. The participants covered greater distances when walking on land than when walking in water (mean difference = 259.3m, p<0.001; d =3.69, 95% CI [2.81;4.55]). No significant differences were observed in average heart rate and oxygen saturation between the two assessments. Furthermore, there was no significant difference in perceived physical exertion between the land and water assessments for the 6MWT.
Regarding the 2MST, the number of steps climbed was similar between land and water environments and oxygen saturation showed a comparable pattern between both environments. However, the test conducted in the pool demonstrated lower perceived exertion among participants (mean difference = 2.02 pts, p=0.001; d =1.15, 95 % CI [0.75;1.55]), with lower heart rate (mean difference=29.3bpm, p=0.001; d =1.05, 95% CI [0.66;1.43]). Table 3 shows the scores of the participants in the 2MST.
Table 4 shows the TUG test results. On land, participants demonstrated faster completion times (mean difference=8.05s, p=0.001; d =2.76, 95% CI [2.07;3.44]) and fewer steps (mean difference=2.3 steps, p=0.001; d =1.03, 95% CI [0.64;1.41]) compared with the water assessment. However, physical exhaustion was similar in both environments.
All the participants completed the tests and did not report any adverse effects. None of the participants experienced fatigue, nervousness, headaches, muscle soreness, increased perspiration, or dizziness during the test.
DISCUSSION
Aquatic therapy offers a wide range of possibilities, including the management of injuries and health promotion. This study aimed to explore the use of the aquatic environment as an evaluation tool rather than just a treatment option. The following findings are particularly relevant for fundamental and clinical purposes: (1) n the pool, participants had a shorter distance covered during the 6MWT, along with a longer completion time and increased step counts for the TUG test; (2) there were no significant differences in the number of steps climbed during the 2MST performed on land or in water; (3) no differences in perceived exertion were noted for the 6MWT and TUG tests between land and water conditions, and (4) during the 2MST, participants experienced lower perceived exertion and decreased heart rate in the assessment of water compared to land. Understanding these parameters is important for the effective use of aquatic environments as evaluation resources.
This study focused on a specific group of young individuals who had no previous neurological or psychiatric conditions and had normal blood pressure18, oxygen saturation19, weight20, and handgrip muscle strength21. They were chosen because this study is one of the first attempts to assess performance-based tests in an aquatic environment. By initially examining the results in community-dwelling healthy young individuals, we prioritized safety before expanding to include other specific groups.
The 6MWT is a valuable and widely recognized evaluation method that provides a cost-effective way to assess functioning and endurance in diverse patient populations22. It was surprising to find a limited number of studies investigating the use of the 6MWT in water-based environments considering the potential benefits water could offer to individuals with musculoskeletal or neurologic disorders. Water-based protocols have the advantage of reducing weight bearing, which can alleviate joint pressure and provide a more comfortable walking pattern for individuals with mobility limitations23. Therefore, we anticipated a greater number of studies addressing this question, but unfortunately, that did not occur.
The 6MWT assessment indicated that the participants covered a significantly lower distance during the test in water than on land. This difference can be attributed to fluid mechanics. In water, the resistance created by fluid requires individuals to exert more effort and engage in additional muscular groups during rapid movements24. The drag force experienced in water is influenced by various factors, including the shape and size of the object, lower limb area, and the velocity square function. Therefore, when the speed is doubled, the drag force quadruples in addition to the other variables25,26. This may explain the lower distance covered during the 6MWT in water compared with that on land.
Despite the observed difference in the distance covered during the 6MWT, perceived exertion and average heart rate of the participants were similar in both environments. This suggests that the resistance experienced in water may have made the test more demanding. However, some aerobic aspects such as heart rate and perceived effort, were comparable between the assessments in water and on land. Further studies should be conducted to analyze whether this pattern holds for different groups, including older adults and individuals with musculoskeletal or neurological disorders. By examining a broader range of participants, we can acquire further understanding of how water-based 6MWT performance and perceived exertion vary across populations.
The 2MST is widely used to assess aerobic fitness and cardiovascular endurance in clinical settings. An attractive feature of the 2MST is simplicity, as it requires only a simple step without specialized equipment27. Our findings revealed that oxygen saturation variability showed similar results between water and land environments. However, unlike the 6MWT, the 2MST was not significantly affected by the aquatic setting on its primary main outcome. The participants achieved similar results in terms of number of steps regardless of whether the assessment took place in water or on land. Conversely, when the 2MST was performed in the pool, the participants reported lower perceived exertion and had lower heart rate. This suggests that the aquatic environment may contribute to the reduced effort during 2MST compared with land-based assessments. Another plausible explanation is that with the stimulation of volume and pressure receptors, a readaptation of the cardiovascular system occurs, which leads to an increase in cardiac output and stroke volume, consequently reducing heart rate28.
We attribute the lower perceived exertion and reduced heart rate observed in water during the 2MST to the combination of the Vertical Ground Reaction Force (vGRF) and counter force performed by the center of the buoyant. vGRF is the force exerted by any supporting surface in the vertical direction when a person contacts it, such as while standing, walking, or running. It represents the upward force generated by the body to support its weight and facilitate movement. The center of buoyancy is the point through which the buoyant force act vertically upward, balancing the weight of the object immersed in the fluid. In water, the center of buoyancy may have altered the vGRF, making the test easier with smoother movements and potentially reducing the effort required29,30.
The TUG test demonstrated comparable results to those of the 6MWT, which can be attributed to its shared characteristic of rapid horizontal displacement. Consequently, it is likely that both the resistance and drag force influenced the time and number of steps required to perform the TUG test without significantly affecting the perceived exertion of the participants. The 2MST focuses on the rapid vertical displacement. In contrast to the 6MWT and TUG test, the 2MST benefited from the center of buoyancy in water and possibly experienced minimal impact from the water resistance and drag force.
All three tests established normative values that served as references for determining normal or below-average scores in the assessments and they vary based on factors such as age, sex, and the clinical condition of the individuals. As observed in this study, physical function tests proved to be feasible when conducted in water, with perceived exertion either lower or comparable to that of land-based assessments. Thus, further studies are necessary to propose new normative values for the 6MWT, 2MST, and TUG tests when administered in an aquatic environment. These studies will help to establish appropriate benchmarks and standards for evaluating the performance of these functional tests in water.
The effort intensity is important in any exercise program. In water, heart rate seems to be lower than on land due to factors such as stimulation of volume and pressure receptors, immersion depth, and type and intensity of the exercise. When dealing with similar studies, authors should consider possible bradycardia and equations for this environment31.
We believe that this study is important to promote the use of water not only for treating individuals with physical disabilities but also for enhancing understanding of patients’ functional capacities. Unfortunately, not all professionals pay adequate attention to the evaluation process32. This study serves as a reminder to physical therapists to thoroughly evaluate patients and to consider incorporating water environments into this process.
Limitations
Our findings should be interpreted in the light of some limitations. First, they were restricted to community-dwelling young individuals without preexisting musculoskeletal or neurological disorders. Second, the sample size was relatively small, which may limit the precision. Third, there was a disparity in the test setup between the land-based 6MWT and water-based assessments. While a 30-meter course was marked for the land test, the water test was conducted in a 6-meter lane, reflecting the dimensions of the pool. While we acknowledge the reduced length of 6 meters may have increased the number of laps in the water, thereby heightening the flow (or even the drag force) and potentially influencing the results, it is important to recognize that most pool centers and clinics lack space for a 30-meter length pool. Therefore, we chose to conduct tests in a pool size that better reflects typical clinical settings, although this may introduce biases due to the increased number of laps in water compared to that on land. Fourth, this study did not account for certain fluid mechanics aspects, such as water viscosity and refraction rate, nor did it consider some individual characteristics, such as the velocity of participants in water. It is plausible that higher speeds could have increased the water resistance and drag force, making the task more difficult. We encourage further studies to carefully check these aspects to obtain more accurate results. Finally, the study results are limited to a specific water depth of 1.2 meters, in which is close to clinical practice. Different water depths could influence the assessment outcomes.
Suggestions for new studies
As an initial endeavor to evaluate performance-based tests in an aquatic setting, we limited our sample to individuals without mobility issues. Nevertheless, the findings should encourage the inclusion of diverse population groups in functional assessments of aquatic environments. This could involve older adults, individuals with neurological or musculoskeletal disorders, and postoperative patients. Such inclusive practices would offer valuable guidance to physical therapists in their clinical approaches. Perhaps considering a specific heart rate calculation for water activities in the future would also be appropriate.
CONCLUSION
Aquatic environment was a feasible option for conducting physical function tests in community-dwelling young adults. Water resistance and drag force potentially increase the difficulty of rapid horizontal displacement tests, such as the 6MWT and TUG tests. However, rapid vertical displacement tests, such as the 2MST, may benefit from the center of buoyancy in water. Despite the increased challenge in some physical function tests, the perceived exertion experienced in water was either lower (2MST) or comparable (6MWT and TUG test) to that on land.
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This study was developed in the Graduate Program in Movement Sciences of the Federal University of Mato Grosso do Sul
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Financing source:
Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq, Process number 403238/2023-4) and Fundaçao de Apoio ao Desenvolvimento do Ensino, Ciencia e Tecnologia do Estado de Mato Grosso do Sul (Fundect, #119/2024, Siafic: #814)
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Approved by the Research Ethics Committee: Protocol No.: 5.705.095
Publication Dates
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Publication in this collection
28 Apr 2025 -
Date of issue
2025
History
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Received
14 Nov 2023 -
Accepted
30 July 2024
