Aquatic Therapy for Multiple Sclerosis: Current Clinical Practice Guidelines

Multiple sclerosis (MS) is a chronic autoimmune disease affecting the central nervous system, characterized by inflammation, demyelination and progressive neurodegeneration. Common symptoms include fatigue, muscle weakness, impaired balance, gait disturbances, spasticity, pain and cognitive dysfunction. Physical therapy plays a central role in managing these symptoms and maintaining functional independence. A 2025 narrative review examined the latest international clinical practice guidelines on physical therapy and rehabilitation for MS, synthesizing recommendations from three high-quality evidence-based guidelines.

Why aquatic therapy is valuable for multiple sclerosis

The aquatic environment offers several therapeutic advantages for people with MS.

Buoyancy decreases weight-bearing, allowing patients with weakness, balance impairments or fatigue to move more freely. Water resistance provides gentle strengthening throughout the range of motion, while hydrostatic pressure enhances sensory input and postural stability. Warm water may promote muscle relaxation and improve movement efficiency, although excessive water temperatures should be avoided because many individuals with MS experience heat sensitivity.

Aquatic therapy within international MS guidelines

The review analyzed three internationally recognized rehabilitation guidelines:

NICE (United Kingdom)
Malaysian Clinical Practice Guidelines
European Society for Blood and Marrow Transplantation (EBMT)

All guidelines recommend individualized, multidisciplinary rehabilitation centred on the patient’s functional goals. Exercise therapy forms the foundation of treatment, combining aerobic training, resistance exercises, flexibility and balance training. Aquatic therapy is specifically included as an intervention for gait, mobility and spasticity management within several guideline recommendations.

Therapeutic benefits of aquatic therapy

Improved gait and mobility

Hydrotherapy is recommended as part of gait and mobility rehabilitation.

The guidelines describe aquatic therapy as an effective option to improve joint mobility while supporting walking practice in a safe environment. It may be combined with treadmill training, functional electrical stimulation and assistive devices depending on the patient’s disability level.

Reduction of spasticity

Spasticity is one of the most disabling symptoms of MS.

The reviewed guidelines consistently recommend hydrotherapy alongside stretching, positioning and soft-tissue mobilization to reduce muscle stiffness, improve comfort and facilitate movement. When necessary, aquatic therapy can complement pharmacological management, including muscle relaxants or botulinum toxin injections.

Balance and fall prevention

Balance impairments significantly increase the risk of falls in people with MS.

The guidelines recommend structured balance and coordination exercises as a standard component of rehabilitation. Aquatic therapy provides a supportive environment where patients can safely challenge postural control while minimizing fall risk.

Functional independence

The primary goal of rehabilitation is preserving independence in daily life.

Water-based exercise enables patients with moderate disability to continue exercising despite weakness, impaired coordination or reduced endurance, thereby supporting long-term mobility and participation in everyday activities.

Exercise recommendations

The reviewed guidelines recommend combining multiple exercise modalities.

Typical recommendations include:

Moderate-intensity aerobic exercise
Walking, cycling or swimming
20–40 minutes per session
At least three sessions per week
Resistance training twice weekly
Flexibility exercises for spasticity management
Balance and coordination training to reduce falls

Aquatic therapy can be incorporated within this broader rehabilitation programme rather than replacing land-based exercise.

Heat sensitivity: an important consideration

Many people with MS experience thermosensitivity, where elevated body temperature temporarily worsens neurological symptoms.

For this reason, the guidelines recommend adapting rehabilitation using:

Cooler pool temperatures when appropriate
Activity pacing
Cooling strategies before or during exercise
Individual monitoring of symptom response

Exercise intensity should always be adjusted according to fatigue and heat tolerance.

Multidisciplinary rehabilitation

Aquatic therapy should be integrated into a comprehensive rehabilitation programme involving:

Physiotherapists
Neurologists
Occupational therapists
Speech therapists
Psychologists

Depending on patient needs, aquatic therapy may be combined with:

Strength training
Balance training
Gait retraining
Cognitive rehabilitation
Fatigue management
Home-based exercise programmes
Tele-rehabilitation follow-up

This multidisciplinary approach aims to maximize long-term functional outcomes and quality of life.

Emerging technologies

The guidelines also highlight several technologies that may complement aquatic rehabilitation, including:

Robotic gait training
Functional electrical stimulation
Virtual reality balance training
Wearable movement sensors
Tele-rehabilitation
Home-based digital exercise programmes

These technologies may improve accessibility and allow rehabilitation to continue beyond the clinic.

Clinical implications

Aquatic therapy is particularly suitable for individuals with MS who experience:

Spasticity
Gait impairments
Balance deficits
Muscle weakness
Fear of falling
Fatigue limiting land-based exercise
Reduced functional mobility

Because water reduces joint loading while providing continuous resistance and postural support, aquatic therapy enables many patients to perform exercises that would otherwise be difficult on land.

Limitations

This publication is a narrative review of clinical practice guidelines, rather than a systematic review of randomized controlled trials. Its conclusions therefore summarize expert recommendations from existing international guidelines rather than providing new clinical outcome data. Nevertheless, the included guidelines were selected based on methodological quality using the AGREE II framework, making them representative of current best clinical practice.

Conclusion

Current international clinical practice guidelines support aquatic therapy for multiple sclerosis as an important component of multidisciplinary rehabilitation. Hydrotherapy is recommended to improve gait, mobility, balance and spasticity while promoting functional independence. When integrated with aerobic exercise, resistance training and individualized rehabilitation planning, aquatic therapy provides a safe and effective treatment option for many people living with MS.