What question did this study set out to answer?

The aim is to redefine aquatic therapy as a controlled environment to enhance arousal and trunk stability in patients with severe acquired brain injury.

March 25, 2026Open Access

Aquatic Therapy as a Programmable Multisensory Environment for Arousal and Postural Control After Severe Acquired Brain Injury: A Perspective

Key Points

The aim is to redefine aquatic therapy as a controlled environment to enhance arousal and trunk stability in patients with severe acquired brain injury.
Integrating concepts from neurobehavioral assessment, motor control, and immersion physiology.
Proposing a model called the Arousal–Alignment–Action loop.
Defining specific aquatic inputs (depth, turbulence, temperature) as intervention parameters.
Outlining a pragmatic testing ladder and an outcome package for evaluating effectiveness.
Establishes links between state regulation, trunk alignment, and behavior.
Highlights factors that may limit therapy effectiveness (e.g., sedation, pain).
Suggests that treating water as a quantifiable medium can enhance research comparability in aquatic rehabilitation.

Abstract

Background/Objectives: Severe acquired brain injury (sABI) disrupts early rehabilitation because arousal fluctuates, trunk control is fragile, and agitation limits therapy tolerance; land-based practice is frequently constrained by fall risk and staffing. We aim to reframe aquatic therapy as a programmable multisensory environment to stabilize arousal and support axial alignment before conventional impairment targets are feasible. Here, programmable denotes the deliberate titration and reporting of water depth, turbulence or perturbation, temperature, body orientation, and flotation and manual support as intervention inputs. Methods: This perspective integrates principles from neurobehavioral assessment, motor control, and immersion physiology to propose the Arousal–Alignment–Action loop as a falsifiable model and to define manipulable aquatic inputs (water depth, turbulence or perturbation, temperature, body orientation, and flotation and manual support) as dosing parameters. We outline a pragmatic testing ladder (within-session micro-experiments, feasibility studies, and embedded evaluations) and a minimal outcomes and confounder set to support cumulative evidence. Results: The framework links state regulation to alignment and goal-directed behavior, specifies predictions that can fail, and highlights boundary conditions (sedation, autonomic instability, pain, recent surgery or wounds, and cervical or cardiopulmonary constraints). A minimal outcome package spanning arousal/responsiveness, trunk control, behavioral dysregulation, participation/tolerance, and basic physiology is proposed, with optional objective adjuncts for mechanism-oriented studies. Conclusions: Treating water as a measurable and titratable medium, rather than a generic modality, may reduce early intensity bottlenecks and improve implementability and comparability of aquatic neurorehabilitation research in medically stable sABI; however, the model is intended as hypothesis-generating until supported by stronger direct clinical evidence.

Aquatic Therapy as a Programmable Multisensory Environment for Arousal and Postural Control After Severe Acquired Brain Injury: A Perspective

Key Points

Abstract

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