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Case Report

Hydrotherapy Rehabilitation of a Post–COVID-19 Patient With Muscle Weakness

Barmatz, Caroline BPT, MHA; Barzel, Oren MD; Reznik, Jacqueline PhD

Author Information
The Journal of Aquatic Physical Therapy: January/April 2021 - Volume 29 - Issue 1 - p 29-34
doi: 10.1097/PXT.0000000000000001
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This study took place in May 2020 in the Hydrotherapy Department at the Sheba Medical Center, located within the rehabilitation hospital, a separate building on the Sheba Campus. In August 2020, Newsweek ranked the Sheba Medical Center among the top 10 hospitals worldwide and it is considered a medical science and biotechnical innovation leader in Israel. It is affiliated with Tel Aviv University and includes centers for nearly all medical divisions and specialties, serving more than 1 million patients per year.

At the beginning of the pandemic in March 2020, all inpatients in rehabilitation wards were tested for COVID-19. Patients who tested positive for COVID-19 were transferred from the rehabilitation hospital to specially designated Corona wards erected on campus. Patients who tested negative for COVID-19 were allowed to continue their rehabilitation program as planned. The on-campus Infection Control Department established new guidelines, allowing each patient in rehabilitation to have one specified caregiver dedicated to the patient.

Within the Hydrotherapy Department, further changes implemented included signs being placed on the floor, on chairs, and in all strategic places to maintain the 2-m social distancing rule. Equipment used was reduced to a minimum to prevent clutter and/or a health hazard. Hygiene was increased; inpatients showered in the wards, and the poolside facilities were maintained only for staff. Staff numbers were reduced to 30% in March, working in small groups only, and were required to take their breaks in isolation from one another. All work surfaces, including keyboards and telephones, were sanitized before and after use, and doors normally closed remained open to increase ventilation.

The highly communicable new coronavirus, called SARS-CoV-2, differs from other respiratory viruses in that human-to-human transmission may occur anywhere from 2 to 10 days before the individual becomes symptomatic with COVID-19.1 The range of disease severity varies between asymptomatic infection and mild upper respiratory disorder through severe viral pneumonia with respiratory failure and even death. Current estimates are that approximately 5% of those affected will require treatment in intensive care units (ICUs), including ventilation and life support.2

Muscle weakness acquired following hospitalization in the ICU has been described3,4 and may contribute to long-standing after effects that may significantly affect recovery.4 Early rehabilitation following the acute phase is therefore needed to limit the severity of ICU-acquired muscle weakness.2 Physical therapy in general and hydrotherapy specifically may have an essential role in providing exercise, mobilization, and rehabilitation interventions to survivors of critical illness associated with COVID-19 in order to reestablish their quality of life.

The spread of infection through the continued use of the pool was a major concern for all involved personnel in the hydrotherapy facility. The International Aquatic Therapy Faculty (IATF) made several recommendations (see the Appendix), stating that hydrotherapy pools were advised to function at national/regional regulators’ discretion during the COVID-19 pandemic. The administrators at the Sheba Medical Center therefore made the decision that the hydrotherapy pool would remain open with all the mandatory national regulations in place.5–7

We continued to follow the usual regulations for pool hygiene. Our pools are always treated with chlorine—(min 1.2.ppm (mg/L) max 2.0 ppm (mg/L) (as before COVID-19), and our continued high standard was maintained. The pH value of pool water was maintained between 7.2 and 7.4, the same as the pH value in human eyes and other mucous membranes; this aids in adequate chlorine disinfection. There were no changes made regarding routine water quality testing. Water treatment was continued according to standard policies and procedures, with manual testing once every 3 hours; digitally computerized records were kept. These regulations are by a recently published work on pool hygiene during the COVID-19 pandemic.8 The dimensions of our small pool are as follows: length 8 m, width 5 m, steps across the width of the pool with a water depth of 60 cm, 85 cm, 1.10 m, 1.35 m, 1.60 m, and water temperature of 34°C. Warmer water 34°C to 35°C is prescribed for passive treatment modalities, reducing muscle spasm and pain, thereby promoting relaxation.9

In our large pool, length 18 m, width 9 m, graded pool 90 cm to 1.70 m, the water temperature is maintained at 33°C. Lower temperatures of 31°C to 33°C are recommended for more active exercise, including aqua-aerobics, swimming, recreation, and water sports. In addition, our hydrotherapy staff wore personal protective equipment, which included a surgical mask (to be kept dry) and a visor (Figure). The surgical mask was worn in the pool area and when performing vertical exercises, for example, balance exercises in standing or walking in water.

Personal protective equipment. C. Barmatz. Used with permission.

Case Description

Approval from the patient and his treating physician was obtained in the writing of this case report. The hospital's Institutional Review Board required no further ethics approval due to the anonymization of the patient's identity and the fact that there was no deviation from the regular hydrotherapy treatment protocol.


The patient was a 29-year-old man. He was obese with a body mass index of 38.6 kg/m2 and smoked 3 cigarettes a day. He lived in a third-floor apartment with 40 stairs and no elevator to access. He was a part-time student and worked as a marketing agent. He had no access to a car and used public transportation for both work and afterwork. The patient was hospitalized and intubated in a Corona Critical Care Unit for 4 weeks following diagnosis of COVID-19. Before contracting COVID-19, except for obesity, the patient had no other premorbidities and was taking no medication. Following decannulation and stabilization of his medical condition related to COVID-19, the patient was transferred to the Sheba Rehabilitation Hospital electively for motor and respiratory rehabilitation. He was suffering from general weakness, muscle atrophy, and chronic pain. On admission to the orthopedic rehabilitation ward, he was placed in isolation and tested for COVID-19; using the PCR test for SARS-CoV-2 (NeuMoDx), negative results were received within 2 hours. The NeuMoDx SARS-CoV-2 Assay is a recently developed rapid automated in vitro real-time RT-PCR (reverse transcriptase-polymerase chain reaction) diagnostic test.

During his first 10 days in the rehabilitation center, the patient received conventional land-based physical therapy but continued to complain of weakness, 2/5 on the Manual Muscle Test (MMT), pain, 7/10 on the visual analog scale (VAS) in his left shoulder, and bilateral lower limb weakness, 3/5 on the MMT. He was able to ambulate independently for short distances (20 m) with a 4-wheeled walker.


Physical Therapy

See Table 1 for his physical assessment before treatment.

Initial Assessment on Admission May 10, 2020

Treatment Goals

  1. The patient will perform basic activities of daily living (ADL) independently.
  2. The patient will perform transfers independently.
  3. The patient's ability to climb stairs will improve to 40 steps to reach his home on the third floor (no elevator).
  4. The patient's ability to descend stairs will improve to 40 steps to allow him to leave his home.
  5. The patient will walk outdoors independently for 15 minutes.

The patient received land-based physical therapy sessions of 45 minutes daily for 8 days, including strengthening exercises for upper and lower extremities, balance exercises, and gait training, progressing from supervised walking indoors to independent wheelchair walking outdoors.

Since the hydrotherapy pool at Sheba Medical Center had remained open and all the required precautions had been put in place,5–7 the patient was referred to hydrotherapy for further rehabilitation. He received 4 hydrotherapy sessions in the pool comprising walking exercises, squats, core control exercises, fall prevention exercises, and exercises to improve his cardiovascular endurance. The patient was also taught to enter and exit the pool via the steps independently. A detailed description of the treatment is shown in Table 2.

Hydrotherapy for a Patient Recovering From COVID-19 Infection With ICU-Acquired Muscle Weakness


Two weeks after admission, the patient was discharged from Sheba Rehabilitation Center, walking outdoors independently for 30 minutes. His gait pattern was with external rotation of hips and a wide-based gait, but he could climb and descend stairs reciprocally step over step holding on to the banister. The patient complained of plantar fascia pain 8/10 on the VAS and hypoesthesia of the left lower extremity.

On discharge, the patient was independent in ADL. The pain in his left shoulder had reduced to 3/10 on the VAS with a full range of motion. Strength in the major muscle groups of his left shoulder was assessed as 3+/5 on the MMT, left elbow flexion as 4/5, and left wrist flexion as 3/5. Sensation was assessed as hypoesthetic on the proximal, lateral side of the left shoulder. Right shoulder muscle strength was assessed as 4/5. Muscle strength in the lower limbs bilaterally was as follows: gluteus maximus, gluteus medius, and iliopsoas 3+/5, quadriceps and hamstrings 4/5, and tibialis anterior 4/5.

Grip strength improved bilaterally to 31 kg on the right and 30 kg on the left. The patient continued to have difficulty with gross motor skills (larger trunk and extremity muscles) and fine motor skills, including fingers on both hands.

Discharge recommendations included continuation of physical therapy, hydrotherapy, and occupational therapy in the community for further muscle strengthening, improvement of range of movement, balance, and gait.


“Hydrotherapy,” derived from the Greek words “hydor” meaning water and “therapeia” healing, has been recognized as a treatment modality for many centuries. Originating from a passive modality, it has developed over time to include active patient participation. Physical therapists are now being encouraged to include hydrotherapy in all forms of rehabilitation, making the most of the physical properties of water such as mass, weight, density, specific gravity, buoyancy, hydrostatic pressure, surface tension, refraction, and viscosity. The use of an aquatic setting allows patients with mobility, balance, or both problems on land to have the opportunity of experiencing the ability to move more freely and independently.9 The use of rehabilitation practices in water has been progressively increasing due to the publication of favorable results achieved using the physical properties of water. In a recent 2020 article by Cuesta-Vargas and colleagues,10 muscle activity of healthy young and older adults was assessed using surface electromyography during the execution of 4 different test/functional movements on land and water. They concluded that trunk muscles played a much more significant role in executing functional tasks in water than on land. The importance of the trunk in the execution of functional activities such as gait has been well documented.11 Therefore, the effect of water immersion on the trunk represents a clinically significant modality when considering the importance of hydrotherapy in rehabilitation. Water can therefore provide a safe and effective rehabilitation setting for patients with weakness, balance problems, and pain.


This single case study was conducted in challenging days of the COVID-19 pandemic to demonstrate the safety and efficacy of treatment in water. In particular, this study provides insight into the possibility of using hydrotherapy as a useful adjunct to land-based therapy in the treatment of ICU-acquired muscle weakness for those critically ill patients recovering from COVID-19. With the correct strategies in place, we demonstrated that water is a safe treatment venue for patients with long-term COVID-19–related weakness.


1. Del Rio C, Malani PN. 2019 novel coronavirus—important information for clinicians. JAMA. 2020;323(11):1039–1040. doi:10.1001/jama.2020.1490
2. Thomas P, Baldwin C, Bissett B, et al Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations. J Physiother. 2020;66(2):73–82. doi:10.1016/j.jphys.2020.03.011
3. Hermans G, Van den Berghe G. Clinical review: intensive care unit acquired weakness. Crit Care. 2015;19(1):274. doi:10.1186/s13054-015-0993-7
4. Kress JP, Hall JB. ICU-acquired weakness and recovery from critical illness. N Engl J Med. 2014;370(17):1626–1635. doi:10.1056/NEJMra1209390
5. The Associate Director General, Ministry of Health, Jerusalem, Israel. Regulations regarding code of conduct during an emergency (new coronavirus) 2020. Accessed May 24, 2020.
6. The National Department of Physical Therapy, Ministry of Health, Jerusalem, Israel. Standards for physiotherapy treatments in patients with Covid-19. 2020. Accessed May 24, 2020.
7. The Chaim Sheba Medical Center, Israel. Instructions in the avoidance of infection in the treatments of patients with Covid-19. 2020.
8. Romano-Bertrand S, Aho Glele LS, Grandbastien B, Lepelletier D; French Society for Hospital Hygiene. Preventing SARS-CoV-2 transmission in rehabilitation pools and therapeutic water environments. J Hosp Infect. 2020;105(4):625–627. doi:10.1016/j.jhin.2020.06.003
9. 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
10. Cuesta-Vargas Á, Martín-Martín J, Pérez-Cruzado D, et al Muscle activation and distribution during four test/functional tasks: a comparison between dry-land and aquatic environments for healthy older and young adults. Int J Environ Res Public Health. 2020;17(13):4696. doi:10.3390/ijerph17134696
11. Hacmon RR, Krasovsky T, Lamontagne A, Levin MF. Deficits in intersegmental trunk coordination during walking are related to clinical balance and gait function in chronic stroke. J Neurol Phys Ther. 2012;36(4):173–181. doi:10.1097/NPT.0b013e31827374c1

IATF COVID-19 Statement

April 30, 2020

This statement is NOT about patients who are recovering from a COVID-19 infection. The statement depends on the state-of-knowledge as per aforementioned date. Knowledge and guidelines, like the WHO guidelines,1will change in time and will be updated when necessary.

*Patients recovering from a COVID-19 infection may show a wide array of complications requiring a rehabilitation pathway that may include aquatic therapy.2

Applications of aquatic therapy will be described in a future document.

The COVID-19 pandemic is a health problem affecting almost every country in the world.

Restricting the pandemic and the virus spreading from one person to another is the top priority. To this end, almost all of the countries concerned adopted rules for their territory that must be observed by their population.

Aquatic therapy as one health care service is impacted by COVID-19. It is currently unclear whether aquatic therapy should be provided during the pandemic or suspended. Ultimately, answering this question depends on national/regional regulations to contain and control the pandemic. In those countries where skilled aquatic therapy (by health professionals) is not explicitly prohibited, and national rules for aquatic therapy are not clearly defined, the Association IATF recommends the following:

A COVID-19 triage should be performed according to the national regulations:

  • If increased COVID-19 risk (based on symptoms3): no face-to-face treatment.
  • If no increased COVID-19 risk: face-to-face treatment can be considered.
    • Face-to-face treatment can be hands-off or hands-on.
  • The health care professional needs to decide if face-to-face aquatic therapy is necessary to prevent irreversible decline, based on normal screening procedures, the benefit-risk balance will direct practice.
  • If patients do not need hands-on treatment, national rules for social distancing should be followed in the pool and all aquatic environment areas.
  • National rules count for the amount of space per person in the pool (eg, one per 10 m2).
  • If hands-on treatments are necessary, both the patient and the therapist must wear a face mask (and other protective means as indicated by national regulations).
  • Caution with hands-on treatments in which faces of the therapist and the patient are close, for example, WST exercises on the therapist's lap, BRRM patterns in which the therapist holds hands or arms, Aqua-T-Relax.
  • If not absolutely necessary, the therapist should not be in the water with the patient at the same time. This is to increase the distance in order to refrain and to ease communication. (
  • Pool staff should be limited in order to reduce the amount of social/therapeutic contacts. If possible, specific staff should be assigned to work in the pool area.
  • Patients and therapists should perform a full-body and hair rinse before therapy for about 60 seconds, as recommended.4,5 This helps decrease the disinfection by-products4 in the pool, which eases to maintain an adequate level of free chlorine.
  • Patients who belong to groups at a higher risk for severe illness from COVID-196 should be judiciously treated in an aquatic environment with careful scheduling to avoid other patients and staff.
  • Also, post–COVID-19 patients should be judiciously treated in an aquatic environment with careful scheduling to avoid other patients and staff.
  • Face masks and other preventive measures used as per national regulations.
  • Pool/poolside/changing room equipment, door handles, etc, must be disinfected after each treatment.

Additional Information

The American Centers for Disease Control and Prevention (CDC) states, “there is no evidence that COVID-19 can be spread to humans through the use of pools, hot tubs or spas, or water playgrounds. Proper operation, maintenance, and disinfection (eg, with chlorine or bromine) of pools, hot tubs or spas, and water playgrounds should inactivate the virus that causes COVID-19,” although this may take some time depending on the concentration of the disinfectant.

**CDC7 recommends a free chlorine concentration of 1 ppm (mg/L) in pools as per the WHO.8 Although chlorine and bromine inactivate the virus, swimming pool water does not sanitize aquatic equipment. Equipment disinfection needs to be done according to existing regulations. The Queensland Government9 suggests a 1000 ppm bleach solution.

There is no evidence at this time that temperature, relative humidity, and the concentration of disinfection by-products above the pool—that is the area where we breathe—negatively or positively affect the activity of COVID-19. No research is currently available regarding COVID-19 survival/growth in different temperatures and relative humidity. Evidence exists only from other coronaviruses such as SARS.10 We recommend reference 11 by the Federation of European Heating, Ventilation and Air Conditioning Associations.11

Pool operators should monitor proper ventilation in the pool basin area in order to prevent development of bioaerosols. The humid air just above water is a bioaerosol, containing microorganisms,12 a possible source of contamination. COVID-19 is airborne and viable in an aerosol for multiple hours.

1. WHO. Coronavirus disease (COVID-19) technical guidance: infection prevention and control/wash. Accessed April 28, 2020.

2. British Society of Rehabilitation Medicine. Rehabilitation in the Wake of COVID-19—A Phoenix From the Ashes. British Society of Rehabilitation Medicine; 2020. Working Document Issue 1. Accessed April 28, 2020.

3. WHO. Q&A on coronaviruses (COVID-19). Accessed April 28, 2020.∼:text=The%20most%20common%20symptoms%20of,should%20seek%20medical%20attention

4. Keuten MGA, Schets FM, Schijven JF, Verberk JQ, Dijk van JC. Definition and quantification of initial anthropogenic pollutant release in swimming pools [Corrigendum: Water Res. 2014. doi:10.1016/j.watres.2013.12.007]. Water Res. 2012;46(11):3682–3692. doi:10.1016/j.watres.2012.04.012

5. Centers for Disease Control and Prevention. 2018 Annex to the Model Aquatic Health Code, scientific rationale. Accessed April 28, 2020.

6. Centers for Disease Control and Prevention. Coronavirus disease 2019 (COVID-19). Groups at higher risk for severe illness. Accessed April 28, 2020.

7. Centers for Disease Control and Prevention. COVID-19. Frequently asked questions. Accessed April 28, 2020.

8. WHO. Guidelines for Safe Recreational Water Environments. Volume 2, Swimming Pools and Similar Environments. WHO; 2006. ISBN 92 4 154680 8

9. Queensland Government website. Accessed April 28, 2020.

10. Casanova LM, Jeon S, Rutala WA, Weber DJ, Sobsey MD. Effects of air temperature and relative humidity on coronavirus survival on surfaces. Appl Environ Microbiol. 2010;76(9):2712–2717. doi:10.1128/AEM.02291-09

11. REHVA COVID-19 guidance document, April 3, 2020. How to operate and use buildings services in order to prevent the spread of the corona disease (COVID-19) virus (SARS-CoV-2) in workplaces. Accessed April 28, 2020.

12. Angenent LT, Kelley ST, St Amand A, Pace NR, Hernendez MT. Molecular identification of potential pathogens in water and air of a hospital pool. Proc Natl Acad Sci USA. 2005;102(13):4860–4865. doi:10.1073_pnas.0501235102

Disclaimer: The Association IATF has based its statement on the best available information.

IATF excludes any liability for any direct, indirect, incidental damages, or any other damages that would result from, or be connected with, the use of the information presented in this document.

On behalf of the Association IATF

Urs Gamper

Paula Geigle

Johan Lambeck

Efthymia Vagena

Appendix used with permission from IATF.


case report; COVID-19; hydrotherapy; infection control; muscle weakness; rehabilitation

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