More Than Movement: Aquatic Physical Therapy as a Gateway to Participation and Belonging for Older Adults

Physical therapists are trained to restore movement. We measure it, document it, and justify it using range of motion, strength, balance, and endurance. Yet for many older adults, the most significant loss is not movement itself but participation. Older adults can experience gradual withdrawal from meaningful activities, social roles, and community engagement, even if they live in communities that offer such services.1 Pain, fear of falling, chronic disease, and deconditioning are common conditions in older adults and may exacerbate their tendency to avoid participation and make movement feel unsafe or unattainable. When this occurs, there may be a marked decrease in rehabilitation participation.2 Aquatic physical therapy offers a compelling alternative. Beyond established biomechanical and physiologic benefits, the aquatic environment uniquely supports confidence, engagement, and social connection. Empirical evidence from both quantitative and qualitative data confirms that community aquatic activities significantly expand social networks, reduce loneliness and depressive symptoms, and enhance life satisfaction.3 For older adults, aquatic physical therapy can be a gateway back into participation and belonging. CHANGING THE ENVIRONMENT, NOT THE PERSON Older adults often present with complex, overlapping conditions—osteoarthritis, balance impairments, cardiopulmonary limitations, neurologic diagnoses, and/or chronic pain.4 Although land-based therapy is effective for many, it can unintentionally amplify fear, pain, or fatigue. Repeated difficulty with weight-bearing tasks or balance challenges may reinforce avoidance behaviors and erode confidence over time. Aquatic physical therapy reframes this experience by changing the environment rather than the individual. This is the premise of the person-environment fit model for older adults.5 Buoyancy reduces gravitational load, hydrostatic pressure enhances support, and the consequences of a loss of balance are minimized.6 For older adults who have disengaged from traditional therapy, the pool often represents the first setting in which movement feels possible again. PROPERTIES OF WATER AND THEIR BROADER IMPLICATIONS The therapeutic properties of water are well described. Buoyancy decreases joint compression and pain, enabling more comfortable movement. Hydrostatic pressure provides uniform support and sensory input that may enhance postural control and body awareness. Viscosity and turbulence allow graded, self-regulated resistance, supporting strength, and endurance training without external loads. Thermal properties can facilitate relaxation and improved movement tolerance.7 These properties do more than facilitate exercise; they foster confidence for movement, a prerequisite for participation, as per the physical literacy model for aging adults.8 Reduced pain and perceived risk create a psychological environment where older adults are more willing to explore movement, both in therapy and in daily life.2,9 EVIDENCE FOR PHYSICAL AND PSYCHOLOGICAL OUTCOMES Recent evidence supports the value of aquatic physical therapy for older adults across multiple domains. A 2023 systematic review and meta-analysis found that aquatic physical therapy exercises were more effective than land-based exercises in improving balance, gait, and quality of life and reducing fear of falling among community-dwelling older adults, although methodological limitations suggest continued investigation is needed.10 Balance is especially critical for independence and fall prevention. A 2021 systematic review and meta-analysis reported that aquatic therapy positively impacts dynamic balance in older adults compared with control conditions, highlighting its role in functional mobility.11 Beyond physical performance, aquatic exercises also influence quality of life and psychosocial outcomes, resulting in increased participation and adherence in rehabilitation. This increased participation will often result in improved outcomes.12 Aquatic interventions have also been shown to improve quality of life measures, mood, anxiety, and fall efficacy in sedentary community-dwelling older adults,13 suggesting benefits that extend well beyond traditional impairment-level outcomes. PARTICIPATION AND SOCIALIZATION AS THERAPEUTIC OUTCOMES One of the most underrecognized benefits of aquatic physical therapy is its impact on social participation. Aquatic programs often involve shared spaces or small groups, creating opportunities for interaction that are less common in traditional rehabilitation settings.8 In the water, movement variability is normalized, and assistive devices or altered gait patterns are less visible and less stigmatized.14 For older adults, particularly those at risk of social isolation, this shared environment can be transformative. Informal conversation, encouragement, and mutual recognition often emerge naturally. Therapy becomes something done with others rather than in front of them. Given the increasing recognition of loneliness as a significant health risk for older adults in the 2023 Surgeon General’s Report, this social dimension warrants intentional attention in both practice and research.15 Participation is not an ancillary outcome; it is a crucial core determinant of health and health equity according to the World Health Organization.16 Aquatic physical therapy uniquely positions clinicians to address this domain while still delivering skilled, goal-directed intervention. IMPLICATIONS FOR PRACTICE AND ADVOCACY If aquatic physical therapy offers multidimensional benefits, why is it still often framed as an adjunct or optional service? Part of the answer lies in how clinicians describe and document their work. When outcomes focus narrowly on impairment-level measures, the broader value of aquatic interventions may be overlooked by referral sources, administrators, and payers. As a profession, we should ask: Are we documenting changes in confidence, participation, and engagement? Are older adults being referred early enough to prevent functional and social decline? Are aquatic programs intentionally designed to support physical and psychosocial outcomes? Advocacy begins with language. Aquatic physical therapy is not simply exercise in water; it is a skilled intervention that utilizes the unique properties of water to restore access to movement, participation, and community. According to the American Physical Therapy Association, aquatic physical therapy includes, but is not limited to, the rehabilitation, prevention, and overall wellness of a wide patient population. (American Physical Therapy Association, Our History, p. 1)17 Wellness is multidimensional and interconnected. According to the Global Wellness Institute, most wellness models include at least 6 domains: physical, mental, spiritual, emotional, social, and environmental.18 The physical, mechanical, thermal, and chemical properties of water enable aquatic therapy to provide a unique, therapeutic environment and impact the spiritual, mental, physical, emotional, and social domains as well. A PLACE WHERE MOVEMENT FEELS POSSIBLE AGAIN For many older adults, the pool becomes more than a treatment location. It becomes a place where fear is quieted, movement is reclaimed, and connection is renewed.19 Aquatic physical therapy does something profound: it restores not only physical capacity but belonging. As physical therapists, our charge is not only to restore motion but to support lives fully lived and augment participation in activities of daily living and the community. Through its uniquely therapeutic and supportive environment, aquatic physical therapy offers a powerful means to do both. This first edition of the Journal of Aquatic Physical Therapy 2026 highlights a manuscript entitled The Effects of an Aquatic Exercise Program on Participation and Social Isolation in an Active Older Adult Community, written by Natalie Norman Michaels, Whitney E. Dupree, Lily Simmons, Abby Hightower, Hayden Goode, Matthew Gunn, and Angelina Kelley. This article focuses on the effects of a community aquatic exercise program on feelings of loneliness and social isolation within an older adult population. The findings support the use of group aquatic exercise as an effective way to encourage older adult participation and community engagement and provide insight for all therapists who utilize water for rehabilitation or exercise. Attending the American Physical Therapy Association Combined Section Meetings in Anaheim, California? Safe travels and be sure to check out the Academy of Aquatic Physical Therapy poster presentations, platform sessions, and educational programming! For your convenience, the poster and platform presentation abstracts are included in this issue of JAPT as well!