Blog #4: Aquatic Therapy for Endo

As a practicing physical therapist, my appreciation for the water developed from experience and outcomes of patients.


I was blessed to treat patients across a spectrum of diagnoses and functional abilities at inpatient and outpatient centers. Those I most worked with involved  neurological  (ie. stroke, brain tumors, spinal cord injuries, guillaine-barre syndrome, parkinsons disease) or orthopedic conditions (ie. spine and degenerative conditions, joint replacements and overuse injuries), but other diagnoses were mixed in (ie. COPD, complex comorbid conditions).


I never treated a person for effects of endometriosis in a water environment.  That is, until, the practitioner became the patient.

Water’s Properties

Let’s first discuss the unique properties of water and their application to rehabilitation.    Water is a wonderful medium that can restore, improve or maintain strength, flexibility, body awareness, agility, coordination, endurance, cardiac and respiratory conditioning; all while promoting emotional and physical relaxation.  Water’s unique properties include: bouyancy, density,  hydrostatic pressure, turbulence and viscosity.

Moving slowly through water requires less effort than on land. Thanks to buoyancy. Buoyancy makes us to float.  To move faster through water, more effort is required. Unlike movement on land, water causes movements to stop when effort is discontinued. This occurs due to viscosity. A body’s shape and speed as it moves through the water determines the amount of drag produced.  Faster the movement, greater the drag.

Practical Example

Practical Demonstration:

Stand up.  Start with your arms straight, and by your sides. Swing one arm (from the shoulder) forward then continue backward one time.  Once the arm reaches as high as you can behind you, stopping using any effort to make your arm move.  What happened?   

Expected Result on Land: 

On land, when you stop using effort after your arm reaches its highest point in the air, behind your back; force of gravity, and pull of stretched tissues will cause the arm to move downward and pass forward of your body passively.  The arm may continue to move in progressively smaller forward-backward pendular motions until eventually stopping alongside your body, where it began.

Now, lets perform the same motion, completely submerged under water.  What do you think would happen? 

Expected result under water: When effort is stopped as the arm reaches its highest point in the backswing, the absence of inertia (present on land) prevents the limb from continuing pendular motions of progressively smaller arcs before the limb comes to rest.  This can be advantageous for those whose symptoms are easily provoked.  The limb may remain fairly stationary, behind you, near the height of where you stopped using internal effort.  If the stretch of tissues across the chest and anterior limb are taut enough, it may cause the arm to drift downward a small amount toward the starting position but would not be sufficient enough to create any pendular motions.

Another property of water is hydrostatic pressure.  The deeper you are immersed under the water’s surface, the greater the forces of hydrostatic pressure on your body.  Hydrostatic pressure contributes to an elevated work of the cardiovascular system and efforts of the respiratory system.

When the body’s immersed below the water’s surface, pressure from the surrounding water results in a greater amount of venous blood flow back to the heart than that on dry land for the same position or activity.  Deeper immersion equates to greater venous return.  In depth at the shoulders/neck, immersion can increase venous blood return to the heart by 35% compared to the same task on land.  

As returning blood flow increases, the heart adapts by increasing its stroke volume.   (Stroke volume: the amount of blood distributed to the body during a single heart contraction).  An increased stroke volume is the primary accommodation for greater blood returning to the heart.  As a result, much less change occurs in blood pressure and heart rate with exertion under the water’s surface. 

As more deoxygenated blood returns to the heart and lungs, more oxygenated, ‘good blood’ is available to working muscles.  Up to an addition 1/3 of available nutrients and oxygen is available to individuals who are submerged mid chest-to-shoulder depth when compared to land.  The amount of additional peripheral blood flow parallels the depth of immersion (ie. waist deep immersion provides less of an increase in peripheral blood flow when compared to chest deep).

A water program can be an adjunct to a land-based program in the management and treatment of endometriosis symptoms and post-operative reconditioning. The following is my own testimonial of water’s impact on symptom’s pre and postoperative, and its properties as they relate to rehabilitation of the condition.  As the ‘great masquerader’, we know endometriosis and its comorbid conditions have a vast presentation.  Hence, each person’s needs and appropriate interventions will differ accordingly.

The Physical Therapist as the patient:

I had an appreciation for the water environment as a Physical Therapist. Now.

I have Love and Deep Respect for water.  It began when endometriosis took away my ability to work, manage our home, cook meals and walk without pain. Water was an excellent adjunctive therapy environment.  My water sessions complimented my land treatments to address pelvic floor, abdominal viscera, diaphragm, thoracic and myofascial restrictions with a Women’s Health Physical Therapist.  For many months prior to, and following excision surgery, the pool was a reprieve.  Before surgery, I couldn’t walk, sit, lye down or move from one position to another without sharp pains emitting from adhesions of my ribcage, liver, abdomen and pelvis, nausea, even  an odd vomit.

Simply sitting below the water’s surface was relaxing, yet my cardiopulmonary system was challenged.

The water slowed my movements waaaaaay down; more than I had already slowed in the preceeding years.  However, the reduced speed of motion, coupled with warm temperature and pressure of the water, dampened the pain I usually experience walking on land.  The water invited me to M-O-V-E .  The deeper the water, the more effort was needed to work.  Increased effort was needed to overcome water’s viscosity and the drag induced when moving at greater speeds.  Hydrostatic pressure and buoyancy  reduced the loading impact and pain associated with adhesions and also ‘cushioned’ my internal organs during movements.  The deeper I immersed, the more sloth-like I moved.  But it was gooooood.

The normal pain I experienced walking on land was much gentler under water.  The best part; I had more control!  Control, and the lack of it; something familiar to those with endo.  In the water, I had far greater control of symptoms attributed to adhesions, hyper sensitivity, exposure of my digestive and urinary systems and irritation of disease of the respiratory system.  Slowing of movements under water and dampened pain sensation gave me extra time to assess and adjust to symptoms.  The water was a great micromanager of symptoms through movements that could only be macro managed on land; particularly with the additional effects of brainfog and anxiety for unexpected pain dividing my compromising my attention.

Water, Nervous System and Desensitization:

The warm water and submersion prompted me to relax and move!  My sympathetic nervous system, ALWAYS on overdrive from self-perpetuating aspects of the disease, took short-term hiatus during my water sessions.  It was during these sessions my parasympathetic nervous system was most active; providing both short and longer term benefits.  Water sessions gave me a ‘feeling of wellness’.  By progressing depth, amount of turbulence and duration of these sessions over many months, my sympathetic nervous system gradually became less ‘jumpy’. 

Like many others with endo, my tolerance to touch or pressure across my abdominal area was poor.  It was difficult to wear anything around my midsection or rest my hand on my stomach without a wave of nausea or stabbing sensations.  By adjusting how deep I immersed myself in the water, I controlled the amount of hydrostatic pressure the water emitted on my body.  Some days sessions were shallow, other days deeper immersion. 

In the long term, I was able to progress to deeper and longer immersion consistently.  The effects: my skin and visceral organs desensitized to pressure. My brain stopped interpreting pressure variations across my abdominal skin and organs as ‘bad’ and the nausea resolved.  My sympathetic nervous system settled down.  (There are numerous aquatic therapy techniques beyond the discussion of this blog for desensitization, relaxation, flexibility ie. Watsu )

Water, Digestive and Urinary System:

Deeper immersion and greater movements of speed and range also encouraged my slowed digestive system to move along a bit quicker and with less ‘stressful’ bowel movements (yeah!!! goodbye Mirilax!).  I felt like I received a bonus prize!

In regards to the bladder, after facing numerous episodes of interrupted pool sessions to emptying my bladder (and, despite immediately voiding before starting each pool session), my bladder underwent ‘retraining’ for premature urgency to void before the bladder was adequately filled (overactive bladder).  The water’s hydrostatic pressure added indirect additional force’s externally to the bladder.  This, in addition to the water’s promotion of increased urine production through kidneys was an efficient method to reduce my urinary urgency.  It was annoying early on, having to leave the pool within a session to to void, but, over a period of time this improved did not interfere with extended pool sessions.

Water, Fatigue and Chronic Fatigue Syndrome (CFS):

Struggling with heavy fatigue and inability to move on land, the water encouraged me to move.  I was not unlike many with endometriosis.  We often find ourselves close to a bed, sofa, recliner, or not far from home.  Excision of endometriosis lesions often resolves the immense fatigue that often accompanies the disease.  For some, degrees of fatigue persists.  There are many non-endo variables which can contribute to fatigue (beyond this blog’s focus) and should always be explored (ie. anemia, dietary sensitivities/allergies, autoimmune or other medical conditions).

Among other conditions (ie. fibromyalgia), endometriosis has a higher association with Chronic Fatigue Syndrome (CFS) than the average population.  For those who experience fatigue, (with or without CFS), the properties of water can provide benefits for those intolerant to most dry land activities.  As water facilitates deliver of oxygen and nutrients to muscles, (through increased peripheral blood flow), the amount of time needed post-activity to recover is reduced. There are also concerns for the use of a water environment for some with CFS.  Some may have difficulty exiting the water as the effects of gravity become immediate; have an inability to monitor for waning energy to safely exit the pool; respond adversely to water temperature or a busy pool environment. If there is consideration to undergo an aquatic therapy program, it must be discussed with your physician and initiated and applied 1:1 by a certified Aquatic Physical Therapist.

Scientific Note: Aerobic vs Anaerobic Respiration and Concentric vs Eccentric Muscle Contractions

Evidence suggests dysfunction of the aerobic system (Krebs cycle) among those with CFS.  This equates to an reduced ability to create ‘ATP’.  ‘ATP’ is the body’s ‘energy molecule’ used by muscles to create a contraction.  During normal activity, when we are not ‘oxygen starved’, the body breaks down energy stores with oxygen to generate ‘ATP’. It is theorized that a person’s with CFS defaults to creation of ‘ATP; from the less efficient and productive anaerobic cycle.  Unlike the aerobic energy production system, the anaerobic system is only designed for brief periods of time.  As a result, fatigue sets in and the production of ATP ceases.  A water environment provides ease of slow movement and concentric muscle contractions, both which require less consumption of ATP.  With an inability to produce a continuous supply of ATP that would be generated through normal aerobic kreb cycle production, sedentary immersion in chest to neck depth creates an elevated respiratory demand up to 60% greater than experienced on land.  The increased workload on inspiratory muscles provides conditioning and endurance.

Recall that buoyancy makes it easier to move under water.  Water also creates an environment in which body uniquely moves through concentric muscle contractions.  Concentric contractions are easier for the body to repair, recover and build muscle tissue, compared to eccentric muscle contractions.  Movements under water are created mostly through concentric muscle contractions, unless resistive devices are used.  On land, movement is created from both concentric and eccentric muscle contractions.  Eccentric contractions create more metabolic by-products and damage to the skeletal muscles.  Those with CFS have limited spoons.  Literally.

Effect of water temperature and recovery rate:

If water temperature too warm, it can result in the muscles creating byproducts faster than the blood stream can remove it, despite the enhanced venous return and stroke volume water provides.  The effect leads to earlier fatigue and slower rate of recovery.

I am three years removed from time when water was central in my life (since excision surgery).  After I reached a functional level, I didn’t stop entering the water. For many with fatigue, the water is easier to tolerate for conditioning than land based activities.

Always the practitioner treating the patient-in-the pool, never expecting to be THE patient-in-the-pool.  Like many role reversing experiences, it can be life changing.

A special note about hydrostatic pressure and the respiratory diaphragm:

As mentioned, hydrostatic pressure rises as depth of immersion increases.  As pressure rises, the position of the diaphragm changes.  With higher hydrostatic pressure, the diaphragm resting position becomes more dome-like (arched).  These changes increase the ease and ability to produce greater contraction force of the diaphragm.  As the primary muscle of respiration, the enhanced position of the diaphragm created through hydrostatic pressure  forces augments stronger more efficient contractions for inspiration.  Meanwhile, supplemental and accessory muscles of inspiration undergo increased resistance from water’s counterpressure on the chest wall.  Up to 60% greater effort is necessary for the intercostal and accessory inspiratory muscles to contract when submerged to mid-chest.

With water’s ability to optimize the position and shape of the diapragm many activities can be incorporated from a dry land program with guidance. A carefully graded program can improve endurance of the diaphragm and intercostals without recruitment of accessory muscles (ie sternomastoid, pectoralis minor, scalenes etc) that are less efficient and contribute to postural imbalances. Progression from land based pelvic therapy program can be carried over to further neuromuscular training of the pelvic floor and diaphragm movement through the respiratory cycle.  The incorporation of functional movements can be overlayed , with enhanced body awareness provided by the water.

A special note about Osteoporosis:

Those with osteoporosis (natural or surgically induced menopause or from exposure to GnRHa use) CAN benefit from Aquatic Therapy.  Although Hydrotherapy (Aquatic Therapy) does not promote bone density, it does promote cardiovascular conditioning, strength, coordination and agility; necessary traits for balance on land.  Improved balance equates to reduced risk of a fall.  Reduced fall risk equates to reduced risk for broken bones.

“…aquatic exercise does have a fitness role in women at risk for, or with osteoporosis as there is considerable data that such programs would build strength and endurance, and there is generally an accompanying improvement in balance skills, self-efficacy and well being”                                                    – Bruce E. Becker (2009)

Those with osteoporosis should still be encouraged to participate in some form of weight bearing, resistance activities on dry land with a supplemental water environment program.

Is Water Therapy appropriate?

  • When is hydrotherapy inappropriate?  For those with an acute or unstable heart condition or chronic fatigue syndrome (congestive heart failure, recent heart attack or CFS episode) hydrotherapy should not be considered.
  • For those with sensitivity to warm temperatures (ie multiple sclerosis) a pool program can be beneficial if operating pool temperatures are cool.
  • For those with indwelling catheters or ostomy bags, discussion with your care team and an aquatic therapist on limitations or requirements for their management are necessary.
For those post-operative:

Surgical clearance (ie. hysterectomy – is vaginal cuff healed; surgical incisions/ drainage sites (ie chest tubes) fully healed or covered with waterproof bandages).

Trish     (July 29th, 2019)             Tweet Trish’s Blog    

(Note: The content of this blog is for discussion and should not be substituted for consultation with medical provider)


Aquatic Therapy: Scientific Foundations and Clinical Rehabilitation Applications. Bruce E. Becker, MD, MS. Phys Med Rehab. 2009;1:859-872. 10.1016/j.pmrj.2009.05.017

A Randomized Clinical Trial of Aquatic versus Land Exercise to Improve Balance, Function, and Quality of Life in Older Women with Osteoporosis. Arnold CM, Busch AJ, Schachter CL , Harrison EL, Olszynski WP. Physiother Can. 2008 Fall;60(4):296-306. doi: 10.3138/physio.60.4.296. Epub 2008 Nov 12.

The real story about chronic fatigue syndrome. Eric Ries (Associate Editor: PT in Motion). PT in Motion. September 2017.

How Physical Therapists are getting it about Chronic Fatigue Syndrome (ME/CFS) The Workwell Foundation Pt. 1. Cort Johnson. Oct 10, 2017.