Hydrotherapy for Older Adults: Balance, Falls Prevention & Pain Relief

Key Takeaways

A 2023 systematic review found aquatic exercise was more effective than land-based exercise at improving balance, gait, quality of life, and reducing fear of falling in community-dwelling older adults.
As little as 90 minutes per week of pool-based exercise for 6 weeks can improve balance and reduce fall risk in older adults.
Water supports up to 90% of your body weight when submerged to neck level, making movement possible for people who cannot exercise safely on land due to arthritis, joint replacements, or frailty.
Falls are the leading cause of injury in adults over 65. Hydrotherapy addresses the three main fall risk factors: weak muscles, poor balance, and stiff joints — all at once, in a safe environment.
Pool temperature for older adults should be 30–34°C. Standard swimming pools (27–29°C) are often too cold; hot tubs (37–40°C) are often too warm for exercise.

Why Hydrotherapy Works So Well for Older Adults

Ageing brings three changes that feed into each other: muscles get weaker, joints get stiffer, and balance gets worse. These three things together are what cause falls — and falls are the leading cause of injury and injury-related death in people over 65.

Exercise is the best way to reverse all three. But here is the problem: the very conditions that make exercise necessary — weak muscles, painful joints, poor balance — also make exercise on land difficult, painful, or frightening. An older person with knee arthritis who is afraid of falling is unlikely to do the squats and balance exercises their physiotherapist recommends.

Water changes this equation. When you stand in a pool at chest depth, water supports 60–75% of your body weight. Your arthritic knees carry a fraction of the load they bear on land. If you stumble, you do not fall — water catches you. And the warmth (30–34°C) reduces joint stiffness and muscle pain before you even start exercising.

This is why multiple systematic reviews have found aquatic exercise particularly effective for older adults — it removes the barriers that prevent them from exercising on land.

The Evidence: What Studies Show

Balance and falls prevention

A 2023 systematic review and meta-analysis published in PLOS ONE reviewed randomised controlled trials from 2003 to 2023 on aquatic physical therapy for older adults. The findings were clear: aquatic exercises were more effective than land-based exercises at improving balance, gait (walking pattern), quality of life, and reducing fear of falling in community-dwelling older adults.

A 2019 review in BMC Geriatrics found that hydrotherapy improved commonly reported fall risk factors in older adults, including strength, balance, and flexibility. The review noted that a minimum of 90 minutes per week for 6 weeks of pool-based training was needed to see improvements.

A 2019 brief review specifically examining falls in geriatric populations and hydrotherapy concluded that pool exercise improves balance, motor and cognitive tasks, with improved motivation and positive attitude towards exercise — noting that the safe, supportive environment of water encouraged older adults to attempt movements they would not try on land.

Arthritis pain and joint function

A 2022 systematic review and meta-analysis found that patients with osteoarthritis who did aquatic exercise experienced a significant 0.61-point decrease in pain. There is moderate-quality evidence that aquatic exercise has clinically meaningful effects on pain, disability, and quality of life in people with knee and hip osteoarthritis.

A 2024 meta-analysis of 6 randomised controlled trials confirmed hydrotherapy significantly reduces knee osteoarthritis pain at 1, 4, and 8 weeks, with the greatest improvement at 8 weeks and no serious side effects (Lei et al., 2024).

After hip or knee replacement

A study comparing aquatic exercise to land exercise after total knee replacement in elderly women found that both groups improved, but the aquatic group showed greater improvements in knee function and less pain during rehabilitation. The water allowed earlier and more intensive exercise because the buoyancy protected the new joint while it was still healing.

What Exercises Are Done in the Pool?

A typical hydrotherapy session for an older adult might include:

Walking in water. Walking across the pool at chest depth. This sounds simple, but the water resistance makes it a genuine cardiovascular and leg-strengthening workout.
Standing balance work. Standing on one leg, turning your head, reaching for objects — movements that challenge balance. If you wobble, the water supports you. No risk of a hard fall.
Leg lifts and kicks. Holding the pool edge and lifting legs forward, backward, and to the side. Water resistance strengthens hip and knee muscles.
Squats and lunges. Movements that would stress arthritic joints on land become manageable when water supports most of your weight.
Arm exercises. Pushing and pulling through water strengthens arms and shoulders without the need for weights.
Gentle stretching. The warmth and buoyancy make it easier to stretch stiff joints — particularly shoulders, hips, and knees.

Sessions are usually led by a physiotherapist or trained instructor and last 30–45 minutes, 2–3 times per week.

How to Access Pool-Based Exercise

NHS hydrotherapy (UK): Ask your GP to refer you to physiotherapy with aquatic access. Availability varies — not all areas have hydrotherapy pools. Waiting times can be long.

Local leisure centres: Many pools run “gentle aqua” or “50+ swim” sessions in their warmer teaching pools. These are not clinical hydrotherapy but still provide the core benefits of warm water, buoyancy, and gentle exercise. They typically cost £3–£8 per session.

Private hydrotherapy: Private physiotherapists with pool access offer one-to-one sessions tailored to your conditions. Expect £40–£80 per session. Worth it if you have specific medical needs.

Arthritis support groups: Many Arthritis Action and Age UK groups run warm water exercise classes. These are social as well as therapeutic — and the social element matters. Isolation is a major health risk for older adults, and group exercise classes address this alongside the physical benefits.

Safety Considerations for Older Adults

Temperature. Pool water should be 30–34°C for exercise. Hot tubs at 37–40°C are too warm for more than 15 minutes and increase the risk of dizziness, blood pressure drops, and overheating.
Blood pressure medication. Warm water lowers blood pressure. Combined with medication, this can cause lightheadedness. Enter and exit the pool slowly. If you feel dizzy, sit on the pool steps until it passes.
Never swim alone. Even in shallow water, always have someone nearby. Pool sessions with an instructor or exercise partner are safer than solo swims.
Slip risk on pool decks. Wet pool surrounds are the highest-risk area. Wear non-slip pool shoes. Use handrails. Take your time.
Heart conditions. The combination of warm water and hydrostatic pressure increases cardiac workload. If you have a heart condition, get clearance from your doctor first. Most older adults with stable cardiovascular conditions can safely use warm pools.
Continence concerns. This stops many older adults from trying pool exercise. Speak to your doctor — there are practical solutions (waterproof protective garments, timing sessions around medication, etc.) that make pool use manageable.

The Bottom Line

Hydrotherapy is one of the most effective and safest forms of exercise for older adults. The evidence consistently shows it improves balance, reduces pain, strengthens muscles, and decreases fear of falling — all in an environment where the consequences of a misstep are zero.

If you or someone you care for struggles with exercise on land due to arthritis, frailty, or fear of falling, pool-based exercise is worth trying. Start with a local warm water class, or explore home-based options if pool access is limited. If it helps, ask your GP about physiotherapist-led hydrotherapy for more targeted rehabilitation. Our equipment guide covers both home and clinical options.

References

Martins, R.S. et al. (2023). Effectiveness of aquatic physical therapy exercises to improve balance, gait, quality of life and reduce fall-related outcomes in healthy community-dwelling older adults: a systematic review and meta-analysis. PLOS ONE. DOI link
Bordoni, B. & Marelli, F. (2019). Falls in geriatric populations and hydrotherapy as an intervention: a brief review. Cureus. PMC6371164
Irandoust, K. & Taheri, M. (2019). Does aquatic exercise improve commonly reported predisposing risk factors to falls within the elderly? A systematic review. BMC Geriatrics. DOI link
Lei, C. et al. (2024). The efficacy and safety of hydrotherapy in patients with knee osteoarthritis: a meta-analysis. International Journal of Surgery. PubMed
Mooventhan, A. & Nivethitha, L. (2014). Scientific evidence-based effects of hydrotherapy on various systems of the body. North American Journal of Medical Sciences, 6(5), 199–209. PMC4049052
Harrison, R.A., Hillman, M. & Bulstrode, S. (1992). Loading of the lower limb when walking partially immersed. Physiotherapy, 78(3), 164–166.

Last reviewed: February 2026. This article is for informational purposes and does not replace medical advice. Consult your GP or physiotherapist before starting any new exercise programme.

Hydrotherapy for Older Adults: Balance, Pain, Falls Prevention, and What the Research Shows

Why Hydrotherapy Works So Well for Older Adults