ATF ENCYCLOPEDIA · CLINICIAN HUB
For Clinicians
Free, sourced reference tools for physical therapists, occupational therapists, speech-language pathologists, recreational therapists and assistants who use water in rehabilitation: published evidence, plain-language definitions, safety guidance and public resources in one place.
© 2026 ATU Educational Services, LLC. Licensed to the Aquatic Therapy Foundation, Inc. for public education. See competing-interest statement.
Last reviewed: October 19, 2026
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What this page offers clinicians
For Clinicians is the Aquatic Therapy Foundation’s free reference page for licensed clinicians and assistants who use water in rehabilitation. It points you to published evidence, shared definitions, safety guidance and public resources. It does not teach techniques, give treatment protocols or replace training and clinical judgment.
Evidence in minutes.
Pre-filled searches open the Evidence Library at a condition you treat.
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Each paper’s summary links to PubMed, the DOI and free full text when it exists, so you can go straight to the original study.
Shared definitions.
Encyclopedia entries give one-sentence definitions with sources, so your team, students and referral sources can use the same words.
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Every entry shows an evidence label, its references and a “How to cite” box.
Safety first.
Published guidance asks that every pool user be screened individually before treatment, including the pool environment.
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Read the general summary in the Safety section, and the full guidance in the documents it cites (ATACP, Guidance on Aquatic Physiotherapy Practice, 2021, amended 2025).
Free and public.
Everything here is free to read. The page links to public sources, such as CDC guidance and open-access reviews.
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No sign-up, no paywall and no advertising.
Use the Evidence Library in clinical reasoning
The Evidence Library (our Hot List™) is the Foundation’s searchable list of published English-language research on aquatic therapy, mainly peer-reviewed journal articles. The beta covers more than 600 papers published in 2024–2026.
From clinical question to evidence in five steps
- Ask one question. Name the patient group, the water-based intervention you are considering, what you would compare it with and the outcome that matters. This is called the patient, intervention, comparison and outcome (PICO) format.
- Search one word first. Start with a condition or population (buttons below), then narrow with the filters for type of paper, condition, outcome measure, profession and year.
- Start with syntheses. Open the “Find high quality studies” tab, or filter for meta-analyses and systematic reviews, before single trials.
- Check harms. The “Safety and adverse effects” tab gathers papers that report harms or safety.
- Read the original. Appraise the full paper and weigh it with your clinical judgment and the patient’s goals and values.
Pre-filled searches by condition
Each button opens the Evidence Library with that word already in the search box. Results change as papers are added.
Tips
- Use the Evidence Library as a starting point, not a complete search. For a complete answer, run a documented search of databases such as PubMed, CINAHL, PEDro and the Cochrane Library.
- Always read and cite the original study, not the Evidence Library summary.
- A small or low-quality study is a reason to look further, not a reason to change practice on its own.
Look up a term in the Aquatic Therapy Encyclopedia™
The Aquatic Therapy Encyclopedia™ gives plain-language definitions, sources and search links for aquatic therapy techniques, concepts and terms. It is in beta (version 0.1). The entries below are grouped for clinical use; items marked Coming soon are not published yet.
Safety and the pool environment
- Contraindications and precautions in aquatic therapy Coming soon
- Chloramines and air quality in the natatorium Coming soon
- Aquatic therapy equipment (flotation, resistance and positioning devices) Coming soon
Physics and core terms
Techniques and approaches
Practice, credentials and coverage
- Medical necessity for aquatic therapy Coming soon
- Aquaticist (ATU credential; issuer: ATU Educational Services, LLC, dba Aquatic Therapy University) *
- ATRI Certification (ATRIC), the credential from the Aquatic Therapy & Rehab Institute (ATRI)
- Clinical Competency Certificate (APTA Academy of Aquatic Physical Therapy)
Credential entries describe each program as its issuer publishes it. They do not rank, compare or recommend programs. The Medical necessity entry reports what Medicare documents say; it is not billing advice.
Methods that originated at ATU *
ATU material
[Expert opinion]
These entries are described from Aquatic Therapy University (ATU) material. They are labeled [Expert opinion] and are not rated as evidence.
How clinicians use an entry
- Explain a term in one sentence to a patient, a family member or a new colleague, using the entry’s Encyclopedia definition.
- Check the source behind a definition before you repeat it. Each statement carries an evidence label and numbered references.
- Jump to the research. Each entry has a “Search the Hot List” link that opens related papers in the Evidence Library.
- Cite the version you used. Entries are in beta and may change; each one has a “How to cite” box.
* Competing-interest disclosure: ATU (Aquatic Therapy University) was founded by Andrea Salzman, who is also CEO of the Aquatic Therapy Foundation. Entries that describe ATU methods or the ATU credential are disclosed as a competing interest and labeled [Expert opinion]. ATF does not endorse any program.
Safety, precautions and contraindications
In aquatic therapy, a contraindication is a condition in which aquatic therapy is not to be considered, and a precaution is a condition in which it may go ahead only after a risk–benefit analysis and with extra care (ATACP, Guidance on Aquatic Physiotherapy Practice, 2021, amended 2025).
General education, not a screening tool
This section summarizes published guidance in general terms. It is not a checklist, a protocol or medical advice. The specific conditions on each list are in the guidance documents themselves. Follow your facility’s policies, your practice act and the guidance that applies where you work.
What the published guidance says
- Screen every pool user individually before treatment. The screen includes the environment, such as pool air and water temperature and humidity (ATACP, Guidance on Aquatic Physiotherapy Practice, 2021, amended 2025; Welsh Physiotherapy Advisory Group, 2016).
- The lists differ. The UK guidance uses two groups, contraindications and precautions. The Welsh guidance uses three, adding relative contraindications that need further consideration and caution (Welsh Physiotherapy Advisory Group, 2016).
- Knowledge widens safe practice. The UK guidance notes that many conditions once thought to rule out pool treatment can be treated safely in a well-managed pool when the physiotherapist knows the pathology and the effects of immersion and temperature (ATACP, Guidance on Aquatic Physiotherapy Practice, 2021, amended 2025).
- Immersion changes physiology. Immersion causes many physiologic changes, and understanding them helps clinicians plan safe, appropriate programs (Becker, PM&R, 2009).
- Depth and temperature affect breathing. Even at rest, the work of breathing rises as immersion depth increases, and cold water can greatly reduce vital capacity (ATACP, Guidance on Aquatic Physiotherapy Practice, 2021, amended 2025).
- The poolside is a high-risk area. The guidance calls for supervision of patients, emergency and evacuation procedures, routine checks of hoists and alarms, and mopped, clear walkways (ATACP, Guidance on Aquatic Physiotherapy Practice, 2021, amended 2025).
What systematic reviews report about harms
- After orthopedic surgery, a meta-analysis of 8 controlled trials (287 participants) found that early aquatic physical therapy did not increase wound-related adverse events compared with land-based therapy (Villalta & Peiris, Archives of Physical Medicine and Rehabilitation, 2013).
- In a Cochrane review of 13 trials of aquatic exercise for knee and hip osteoarthritis, no serious adverse events related to aquatic exercise were reported (Bartels et al., Cochrane Database of Systematic Reviews, 2016).
- In a Cochrane review of 16 aquatic exercise studies for fibromyalgia, adverse effects were poorly reported, and no serious adverse effects were reported (Bidonde et al., Cochrane Database of Systematic Reviews, 2014).
Keep in mind: no reported harm is not proof of safety. Small trials often report harms poorly.
Your own health at the pool
- Chloramines form when chlorine reacts with sweat, urine and dirt that swimmers bring into the water. They build up in the air without enough fresh air, especially indoors, and settle just above the water surface (CDC, Chloramines and Pool Operation, 2025).
- Pool workers’ airways: in a study of 624 indoor pool workers, those with higher trichloramine exposure reported upper respiratory symptoms, such as hoarseness and sinusitis, more often (Jacobs et al., European Respiratory Journal, 2007).
- Immersion time for staff should be risk assessed individually, for example on return to work or during pregnancy (ATACP, Guidance on Aquatic Physiotherapy Practice, 2021, amended 2025).
Pool and environment considerations
The pool is part of the treatment. Water temperature, depth, air quality, water chemistry and access all change what is safe and possible in a session.
Temperature and humidity
Water temperature, air temperature and humidity are part of each pool user’s screen (ATACP, Guidance on Aquatic Physiotherapy Practice, 2021, amended 2025).
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Check the pool’s readings before each session and record them if your facility asks you to. The UK guidance, for example, does not recommend aquatic physiotherapy in pregnancy if the water is above 35°C (ATACP, Guidance on Aquatic Physiotherapy Practice, 2021, amended 2025).
Depth and joint load
Buoyancy counterbalances gravity, so deeper water supports more of the body (Torres-Ronda & del Alcázar, Journal of Human Kinetics, 2014).
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In a study with instrumented hip and knee implants, joint forces were 36–55% lower in chest-high water than on land, but fast movements and resistive fins raised them by up to 59% (Kutzner et al., PLoS One, 2017).
Air quality
Indoor pool air can carry chloramines that irritate the eyes and airways.
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CDC says most health departments limit combined chlorine in the water to 0.4 ppm or less, and that air handling must bring in enough fresh air and exhaust polluted air (CDC, Chloramines and Pool Operation, 2025).
Water quality and hygiene
The most common swimming-related illnesses are diarrhea, skin rashes, swimmer’s ear, flu-like illness or pneumonia, and eye or lung irritation (CDC, Preventing Swimming-related Illnesses, 2025).
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Chlorine does not kill germs instantly: Cryptosporidium can survive more than 7 days in properly chlorinated water (CDC, Preventing Swimming-related Illnesses, 2025). The UK guidance makes checking pool water quality the physiotherapist’s responsibility (ATACP, Guidance on Aquatic Physiotherapy Practice, 2021, amended 2025).
Access and entry
Under the 2010 ADA Standards, new and altered public pools must have accessible means of entry (ADA.gov, Accessible Pools Means of Entry and Exit).
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Large pools (more than 300 linear feet of wall) need two accessible means of entry, at least one a pool lift or sloped entry; smaller pools need one, which must be a pool lift or sloped entry (ADA.gov, Accessible Pools Means of Entry and Exit).
Pool codes
CDC’s Model Aquatic Health Code (MAHC) is guidance that jurisdictions can use to write and update pool codes for public pools, hot tubs and splash pads (CDC, About the Model Aquatic Health Code).
Read more
Your state or local pool code, and your facility’s policies, are the rules that apply to your pool.
Documentation and patient education
Clear notes and plain-language teaching make aquatic care easier to follow, review and continue.
Citing evidence in notes and reports
- Cite the original study (authors, year, journal and DOI), not the Evidence Library summary.
- When you use an Encyclopedia definition, cite the entry and its version, because beta entries change.
- Record the environmental factors you screened, such as water temperature, when your facility’s policy asks for them; the guidance treats them as part of screening (ATACP, Guidance on Aquatic Physiotherapy Practice, 2021, amended 2025).
- For what Medicare documents say about coverage, see the Encyclopedia entry Medical necessity for aquatic therapy (coming soon). It reports the documents and is not billing advice.
Patient education with free public material
- Explain the water in one sentence. For example, use the Encyclopedia’s buoyancy definition: water pushes up on the body and supports it, so it can move with less load on the joints.
- Share CDC’s healthy swimming steps: stay out of the water if you have diarrhea, don’t swallow the water, use the toilet before getting in and rinse off before entering the pool (CDC, Preventing Swimming-related Illnesses, 2025; CDC, Chloramines and Pool Operation, 2025).
- Point to a plain-language overview. CDC’s Swimming and Your Health page describes reported benefits of water-based exercise for people with arthritis, fibromyalgia and older adults (CDC, Swimming and Your Health, 2024).
Outside the scope of this page: treatment protocols, technique instruction, exercise dosage, and billing or coding instructions. Hands-on skills need supervised training and your own clinical judgment.
Free public resources for aquatic clinicians
Free websites from public agencies, professional bodies and research databases. Listed alphabetically. Linking is not endorsement.
APTA Academy of Aquatic Physical Therapy
The aquatic physical therapy academy of the American Physical Therapy Association, with resources for PTs, PTAs and patients.
ADA.gov: accessible pools
U.S. Department of Justice summary of the 2010 ADA Standards for pool entry and exit.
Aquatic Therapy Association of Chartered Physiotherapists (ATACP)
UK professional network that publishes the Guidance on Aquatic Physiotherapy Practice.
CDC Healthy Swimming
Public guidance on swimming-related illness, pool chemicals and healthy swimming habits, including an Aquatics Professionals Toolkit.
CDC Model Aquatic Health Code
Science-based guidance for the design, operation and management of public aquatic venues.
Cochrane Library
Systematic reviews of health interventions, including reviews of aquatic exercise.
PEDro
Free database of physiotherapy trials, reviews and guidelines, with independent quality ratings of trials on the PEDro scale.
PubMed
Free search of the biomedical literature from the U.S. National Library of Medicine.
WHO International Classification of Functioning, Disability and Health (ICF)
A shared framework for describing body function, activity and participation, useful for goals and outcomes.
Common questions from clinicians
What is the For Clinicians page?
It is the Aquatic Therapy Foundation’s free reference page for licensed clinicians and assistants who use water in rehabilitation. It links to the Evidence Library (our Hot List™), the Aquatic Therapy Encyclopedia™, a general summary of safety guidance and free public resources.
Is the Evidence Library a systematic review?
No. It is a beta list of more than 600 published English-language papers from 2024–2026, mainly peer-reviewed journal articles. Use it as a starting point. When you need a complete answer, run a documented search of databases such as PubMed, CINAHL, PEDro and the Cochrane Library.
Does this page tell me whether a patient can use the pool?
No. It summarizes published guidance in general terms. Screening decisions belong to the treating clinician, working with the patient’s physician where needed and within your facility’s policies. Each pool user is screened individually before treatment (ATACP, Guidance on Aquatic Physiotherapy Practice, 2021, amended 2025).
Is aquatic exercise safe for people with osteoarthritis or fibromyalgia?
Cochrane reviews of aquatic exercise for knee and hip osteoarthritis (13 trials) and for fibromyalgia (16 studies) reported no serious adverse events or effects, although harms were not always well reported (Bartels et al., Cochrane Database of Systematic Reviews, 2016; Bidonde et al., Cochrane Database of Systematic Reviews, 2014). Every person still needs individual screening.
Can I cite the Encyclopedia or the Evidence Library?
Yes. Every Encyclopedia entry has a “How to cite” box. For the Evidence Library, cite the original study you read. To cite the list itself, use:
Salzman, A. (Ed.). (2026). Evidence Library (Hot List™). ATU Educational Services, LLC; published by the Aquatic Therapy Foundation. https://aquatictherapyfoundation.org/evidence-library/
Because the list changes over time, always include the date you accessed it.
Does the Foundation endorse courses, certifications or products?
No. The Foundation does not endorse any program. Encyclopedia entries on credentials describe each program as its issuer publishes it and do not rank, compare or recommend programs.
How do I report an error or suggest a resource?
Email info@aquatictherapyfoundation.org. Tell us the page, the section and the source you suggest.
How to cite this page
Last reviewed October 19, 2026 · Permanent URL: https://aquatictherapyfoundation.org/for-clinicians/
How to cite
Salzman, A. (Ed.). (2026). For clinicians. ATU Educational Services, LLC; published by the Aquatic Therapy Foundation. https://aquatictherapyfoundation.org/for-clinicians/
Permissions: You may quote and cite this page with attribution. Reproducing or adapting the full page requires written permission from ATU Educational Services, LLC.
Cite the date you accessed this page, because content may change.
References
Every source cited on this page, in AMA style. External information was checked on October 19, 2026.
Show all 14 references
- Aquatic Therapy Association of Chartered Physiotherapists (ATACP). Guidance on Aquatic Physiotherapy Practice 2021 (amended March 3, 2025). Accessed October 19, 2026. ATACP guidance (PDF)
- Welsh Physiotherapy Advisory Group. All Wales Evidence Based Guidance for Access to Hydrotherapy for NHS Patients in Wales. December 2016. Accessed October 19, 2026. Welsh guidance (PDF)
- Becker BE. Aquatic therapy: scientific foundations and clinical rehabilitation applications. PM R. 2009;1(9):859-872. doi: 10.1016/j.pmrj.2009.05.017 PMID 19769921
- Villalta EM, Peiris CL. Early aquatic physical therapy improves function and does not increase risk of wound-related adverse events for adults after orthopedic surgery: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2013;94(1):138-148. doi: 10.1016/j.apmr.2012.07.020 PMID 22878230
- Bartels EM, Juhl CB, Christensen R, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 2016;3(3):CD005523. doi: 10.1002/14651858.CD005523.pub3 PMID 27007113
- Bidonde J, Busch AJ, Webber SC, et al. Aquatic exercise training for fibromyalgia. Cochrane Database Syst Rev. 2014;(10):CD011336. doi: 10.1002/14651858.CD011336 PMID 25350761
- Centers for Disease Control and Prevention. Chloramines and pool operation. Healthy Swimming. June 23, 2025. Accessed October 19, 2026. cdc.gov
- Jacobs JH, Spaan S, van Rooy GB, et al. Exposure to trichloramine and respiratory symptoms in indoor swimming pool workers. Eur Respir J. 2007;29(4):690-698. doi: 10.1183/09031936.00024706 PMID 17107995
- Torres-Ronda L, del Alcázar XS. The properties of water and their applications for training. J Hum Kinet. 2014;44:237-248. doi: 10.2478/hukin-2014-0129 PMID 25713684
- Kutzner I, Richter A, Gordt K, et al. Does aquatic exercise reduce hip and knee joint loading? In vivo load measurements with instrumented implants. PLoS One. 2017;12(3):e0171972. doi: 10.1371/journal.pone.0171972 PMID 28319145
- Centers for Disease Control and Prevention. Preventing swimming-related illnesses. Healthy Swimming. June 6, 2025. Accessed October 19, 2026. cdc.gov
- U.S. Department of Justice, Civil Rights Division. ADA requirements: accessible pools, means of entry and exit. ADA.gov. Accessed October 19, 2026. ada.gov
- Centers for Disease Control and Prevention. About the Model Aquatic Health Code. Accessed October 19, 2026. cdc.gov
- Centers for Disease Control and Prevention. Swimming and your health. Healthy Swimming. May 8, 2024. Accessed October 19, 2026. cdc.gov
About this page
Competing interests
This page was prepared under the direction of Aquatic Therapy Foundation (ATF) leadership. ATF’s CEO also founded Aquatic Therapy University (ATU) and directs it. ATU teaches some of the methods described in the Encyclopedia. This page does not sell, rank or recommend any course, credential or product, and ATF does not endorse any program.
Copyright
© 2026 ATU Educational Services, LLC. Licensed to the Aquatic Therapy Foundation, Inc. for public education. Cited third-party works keep their own copyright and licenses.
Corrections and questions
If you spot an error or an outdated link, or want to suggest a free public resource for clinicians, contact us at info@aquatictherapyfoundation.org.
Last reviewed: October 19, 2026. External information was checked against official sources on October 19, 2026, and may have changed since then. This page is general education. It is not medical advice and does not replace clinical judgment, a physician’s orders or your facility’s policies and procedures.
Author: Andrea Salzman, MS, PT · ORCID: https://orcid.org/0009-0009-5255-7074
Copyright: © 2026 ATU Educational Services, LLC. Licensed to the Aquatic Therapy Foundation, Inc. for public education. Cited third-party works keep their own copyright and licenses.
Competing interests: The author is the founder of Aquatic Therapy University (ATU) and Chief Executive Officer of the Aquatic Therapy Foundation (ATF). ATU sells aquatic therapy education products. ATU methods mentioned in the Encyclopedia are labeled [Expert opinion] and are not rated as evidence. ATF has a conflict-of-interest policy.