128 Physiotherapy Research International
Physiother. Res. Int. 14(2): 128–136 (2009)
Published online 30 September 2008 in Wiley InterScience
(www.interscience.wiley.com) DOI: 10.1002/pri.421

Watsu approach for improving spasticity
and ambulatory function in hemiparetic
patients with stroke
SEUNG CHUL CHON Physiotherapy Section, Department of Rehabilitation Medicine,
Hanyang University Hospital, Seoul, Korea
DUCK WON OH Department of Physical Therapy, Health & Sports Science College,
Daejeon University, Daejeon, Korea
JAE HUN SHIM Department of Rehabilitation Medicine, Yongdong Severance Hospital,
Seoul, Korea
ABSTRACT Background and Purpose. This study reports the effect of Watsu as rehabilitation method for hemiparetic patients with stroke. Method. Watsu consisted of 40 treatment sessions for 8 weeks, delivered underwater or at water surface level, it applied in
three patients. Outcome measures included tools for assessing spasticity and ambulatory
function. Results. All patients showed decreased scores in the TAS and RVGA after Watsu
application. Conclusions. Watsu was helpful in controlling spasticity and improving ambulatory function of the patients with hemiparesis. Copyright © 2008 John Wiley & Sons,
Ltd.
Key words: ambulation, spasticity, Watsu
INTRODUCTION
Loss and impairment of ambulation ability
is one of the major devastating outcomes of
post-stroke hemiparesis (Francisco and
Boake, 2003). The restoration and improvement of ambulation ability in the hemiparetic patient with stroke constitutes a major
treatment goal of physical therapy (Laufer
et al., 2001). The loss of the ambulation
ability may be the result of hemiparetic
paralysis and the loss of voluntary muscle
control (Sahrmann and Norton, 1997). These
problems are further aggravated by spastic-

Copyright © 2008 John Wiley & Sons, Ltd

ity (Lamontagne et al., 2001). Regaining the
ambulation ability depends not only on
restoring normal motor function, but also on
managing spasticity.
Spasticity is defined as an increase in
muscle tone and resistance to movement
caused by lesions in upper motor neurons
(Bogey et al., 2004). It also causes pain,
muscle stiffness, contracture, limb deformity and problems with ambulation
(Fheodoroff et al., 2001). Spasticity may be
a factor that negatively impacts the effects
of rehabilitation in people with hemiparesis
(Hesse et al., 2001). There are many

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Watsu as rehabilitation method 129
treatment methods to control spasticity,
including medication, Botox, the positioning
of spastic limbs, assist devices and plaster
cast, as well as physical modalities such as
diathermy, ultrasonic therapy, electric stimulus therapy and electromyogram biofeedback (Rösche, 2002). However, the roles and
efficacy of these current remedies, for the
most part, have been poorly researched, and
diverse treatment methods have been under
study (Watanabe, 2004).
Watsu is a new therapeutic technique that
incorporates static passive stretches and a
structured sequence and of passive limb,
head and neck movements or patterns performed at water surface level. Watsu employs
the Zen Shiatsu theories of meridians and
energy flow in submerged condition. The
name ‘Watsu’ means ‘water shiatsu’. Watsu
was created in the early 1980s by Herold
Dull, a Shiatsu practitioner, when he applied
the moves and stretches of Zen Shiatsu
to people floating in warm water of 95°F
(Vargas, 2004). Warm water is beneficial to
release muscle tone and to reach deep physical and mental relaxation (Vargas, 2004).
Once the patient is relaxed, physical flexibility and mobility are more easily achieved in
the submerged condition with weightlessness. The patient is cradled and supported
by the practitioner while the various movement sequences are carried out at water
surface level. In this way, Watsu may
be beneficial for patients with movement
disorder.
Treatment in submerged condition has
commonly been used to improve physical
symptoms of patients with chronic musculoskeletal problems such as rheumatic diseases,
osteoarthritis and chronic low back pain
(Lineker et al, 2000). However, submerged
rehabilitation, especially Wastu, in patients
with neurological deficits has received little
attention, despite having many potential

Copyright © 2008 John Wiley & Sons, Ltd

advantages for patients. Accordingly, the
present study attempted to identify specific
effects of Watsu performed in submerged
condition on spasticity and ambulation in
patients with hemiparesis caused by stroke.
CASE DESCRIPTION
This study included three patients with
hemiparesis caused by stroke. Selection criterion for participation were as follows: 1)
first attack, 2) no significant cognitive deficit
— more than 25 points in the Mini-Mental
Status Examination (Folstein et al., 1975), 3)
10 points or more in the tone assessment
scale (TAS) and 4) independent walking,
either with or without ambulation aids. Subjects who complained of severe pain or had
orthopedic problems were excluded from the
study. All patients were able to walk independently with ankle foot orthorsis (AFO)
and/or cane. Patient 1 showed independent
ambulation with the eyes open and on normal
floor surface, but loss of balance when
turning the opposite direction of his body
and when standing on a foam surface. Patient
2 used a wheelchair for community ambulation due to decreased walking endurance;
however, he could walk short distances with
the assistance of a cane. Patient 3 needed an
AFO for ambulation due to ankle spasticity.
The characteristics of the three participants
are presented in Table 1.
MEASUREMENTS
Measurements were performed before the
initiation and after the completion of Watsu
session. We assessed spasticity and ambulation ability to determine the effect of the
Watsu approach.
To assess the subjects’ muscle tone, we
used the TAS, which is composed of items
assessing posture at rest, response to passive

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130 Chon et al.
TABLE 1: General characteristics of subjects
Participant

Sex

Age
(years)

Affected
side

Onset
(months)

Stroke
type

Functional
level

1

Female

62

Right

10

2

Female

51

Left

8

Independent walking
with plastic leaf
splint
Independent walking
with quadri-cane

3

Male

49

Left

20

Hemorrhage in left
middle cerebral
artery
Hemorrhage in the
right internal
capsule
Infarction in right
middle cerebral
artery

movement and associated response to active
movement attempt, and TAS is widely applicable because it can assess tone in muscles that
are involved with a number of Joints (Barnes
et al., 1999). The total score is ranged from 0
(no muscle tone) to 40 (severe muscle tone).
The Rivermead Visual Gait Assessment
(RVGA) comprises two observations of the
arms covering both swing and stance of gait,
and 18 observations of the trunk and lower
limb (11 observations during the stance phase
and seven during the swing phase of gait).
The RVGA is a 4-point scale to quantify the
degree of abnormality for each of the component items. A total score can be calculated
by summing the total numbers of deviation
scores, ranging from 0 (normal gait) to 59
(grossly abnormal gait) (Lord et al., 1998).
The RVGA is both a valid and sensitive
measure of gait impairment in patients with
neurological disease (Lord et al., 1998).
THERAPEUTIC INTERVENTION
The procedure for Watsu approach was
described to patients prior to the initiation of
the intervention, and consent was sought for
each treatment session. Treatment using
Watsu was carried out by a physiotherapist

Copyright © 2008 John Wiley & Sons, Ltd

Independent walking
with ankle foot
orthorsis and
quadri-cane

who had completed an 80-hour special course
for Watsu application and had 3-years Watsu
experience in the clinical setting. The therapeutic pool was 4.5 × 6 m, its depth could be
adjusted between 1.2 m and 1.7 m, and the
water temperature was 93.2°F. The air temperature of the pool room was 81°F, with
50% humidity.
The Watsu used in this study consisted of
11 basic components (Dull, 1997; Vargas,
2004), and the details of the Watsu are
described in Table 2. In accordance with the
Watsu method as recommended by Vargas
(2004), the patient’s support was mainly
taken under back and head by physiotherapist’s forearm. Patients were moved
in flowing water with rhythmical motions,
including intermittent gentle hydromassage
and stretching. No conversation was had with
the patient in order to facilitate deep relaxation in the Watsu sessions. The Watsu intervention consisted of a total of 40 sessions,
averaging 40 minutes each, five times per
week for 8 weeks.
TREATMENT OUTCOME
Figures 1 and 2 demonstrate the improvement with the intervention as measured by

Physiother. Res. Int. 14: 128–136 (2009)
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Watsu as rehabilitation method 131
TABLE 2: Watsu approach used for the patients
Components

Description

Water breath dance

A deep breathing relaxation is performed. Facing each other, both the therapist
and the patient hold both hands in standing posture with slight knee flexion in
submerged state. Breathe in through the nose and out through the mouth slowly.
Repetitions: 10 repetitions for 3 minutes
Putting head and neck of the patient on the cubital fossa of the left arm, the
therapist brings the patient into a horizontal supine position.
Repetitions: No
The therapist places the dorsum of the right hand on the patient’s sacrum; the
patient’s body is allowed to float freely and the therapist performs a rocking
movement side to side.
Repetitions: 10 repetitions for 3 minutes
The therapist swiftly moves the right forearm to the patient’s popliteal fossa. The
bilateral lower extremity flexion-extension pattern is executed. It is important
for the therapist to match the passive knee-to-chest movement with the patient’s
breathing pattern. The patient exhales with knee flexion and inhales with knee
extension.
Repetitions: 15 repetitions for 3 minutes
The bilateral lower extremity rotational flexion-extension pattern is used. Adding
up to the accordian technique, the patient’s deep breathing pattern continues to
be coordinated with rotation movements. It is critical to perform the component
with the flow of water not being forced by the therapist.
Repetitions: 15 repetitions for 5 minutes
This technique is carried out in the same way as Rotating accordion but only
affected lower extremity is used. This not only increases hip and knee joint
flexibility and mobility, but also guides dissociated movement in spastic lower
extremity from trunk.
Repetitions: 15 repetitions for 5 minutes
The therapist holds the patient’s occipital and upper cervical region with one hand
while the other hand holds the popliteal surface of the near knee.
Repetitions: No
After moving towards patient’s head, the therapist performs contralateral passive
stretches to the patient’s shoulder flexors and adductors by one hand and to the
hip extensors and adductors by the other hand alternately.
Repetitions: 10 repetitions for 5 minutes
While maintaining hold on the patient’s right knee with his left hand, the therapist
places his right hand over the patient’s right shoulder, and then, twists the upper
and lower halves of the body in different directions. Unlike other components
done in rhythmical flow of water, this technique is used in static position,
directly transmitting rotation force to the trunk of the patient.
Repetitions: 10 repetitions for 5 minutes
An atlantoaxial and lumbosacral joint rotation is performed. The therapist
supports the back of the patient’s head with one hand while holding the knee at
the popliteal surface with the other hand and rocks the patient back and forth.
Repetitions: 10 repetitions for 5 minutes
Going back to top of patient’s head, the therapist holds the patient’s pelvis
bilaterally with both hands. And then, the therapist begins to push lateral pelvis
to the other side like seaweed movement, alternately. This movement includes
transverse pelvic and sacroiliac joint rotation with lateral tilt.
Repetitions: 10 repetitions for 5 minutes

Head cradle

Open arm position

Accordion

Rotating accordion

Near leg rotation

Capture

Arm-leg rock

Twist

Knee head rock

Hip rock

Copyright © 2008 John Wiley & Sons, Ltd

Physiother. Res. Int. 14: 128–136 (2009)
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132 Chon et al.

FIGURE 1: Changes in the Tone Assessment Scale (TAS) score for all three patients.

FIGURE 2: Changes in the Rivermead Visual Gait Assessment (RVGA) score for all three patients.

the TAS and RVGA scales. All patients
showed decreased scores for spasticity and
ambulation ability after all Watsu sessions.
Subjective patient satisfaction associated
with the Watsu application was high in afterintervention interview. Details in the TAS
and RVGA scores for all patients were presented in Appendices 1 and 2.
DISCUSSION
This case study reports on the treatment procedure and outcome of hemiplegic patients
with stroke. Improvements in spasticity and

Copyright © 2008 John Wiley & Sons, Ltd

ambulatory function after the Watsu
approach were shown. Although the findings
of this case report are limited with only
three-patient involvement, this evaluation is
meaningful as the first trial to investigate the
effect of the Watsu for managing physical
symptoms of patients with hemiparesis.
Activities performed in the submerged
condition can facilitate sensory/perceptual
processing needed for more efficient
coordination and special orientation
(Vargas, 2004). Because of the supporting
effect of water, it is often possible to
facilitate more distally, therefore allowing

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Watsu as rehabilitation method 133
more opportunity for the patient to be active
proximally. Also treatment in the water can
bring variety, challenge and motivation, especially in long-term rehabilitation. Despite
having many advantages, Watsu is not considered as main conventional practice in
clinical setting (Graham-Pole, 2001).
The primary objective of Watsu is to
allow the body to drift into a deeper state of
relaxation. Watsu has developed into a gentle
form of body therapy combining elements of
massage, joint mobilization, muscle stretching and dance. The rhythmic movement in
the submerged condition has positive effects
to facilitate relaxation, decrease pain, address
abnormal muscle tone, ease muscle spasms,
as well as encourage deep breathing and
relaxation (Dull, 1997; Vargas, 2004).
However, precautions are advised, particularly in the presence of osteoporosis, acute
ligamentous instability, hypersensitivity to
vestibular stimulation and potential of water
in the ears (Dull, 1997).
The impairment of motor function limits
independence and interferes with daily
activities and the quality of life (Meythaler
et al., 1997). It should be considered an
important goal that patients with hemiparesis recover the walking ability and motor
function (Francisco and Boake, 2003).
Spasticity is influenced by the effort to

Copyright © 2008 John Wiley & Sons, Ltd

maintain balance and to move against
gravity. Exercising in water where the effect
of gravity is different, may contribute to
reductions in spasticity. This can be a starting point to develop appropriate sensorymotor experiences. The findings of this case
study highlight the potential clinical effect
of the Watsu in treatment of spasticity and
ambulation of patients with stroke hemiparesis, which is supported by previous studies
related to hydrotherapy (Zamparo and
Pagliaro, 1998).
This case study is of course limited with
respect to small samples and no control
group. However, all three participants
showed an improvement in TAS and RVGA.
It may be considered clinical evidence of
previous study that the reduction of spasticity may contribute to improve ambulatory
function (Richards et al., 1995). The Watsu
may be used to augment the effect of physical therapy in stroke patients who exhibit
an unstable walking pattern. However, the
Watsu process must be clearly understood to
work in parallel with other therapies to
provide an effective means to control spasticity and increase the efficacy of stroke
treatment. Further studies with increased
sample size and longer interventions are
required to clearly determine the clinical
benefits of the Watsu.

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134 Chon et al.
APPENDIX 1: TONE ASSESSMENT SCALE SCORES FOR ALL THREE
PATIENTS ASSESSED BEFORE/AFTER WATSU
Subjects

Posturing at rest
1. Is the hand resting on the leg?
2. Are the shoulders level?
3. Is the foot flat on the floor?
Response to passive movement
4. Can you straighten the fi ngers with the forearm in midposition
and the wrist extended?
5. Can you flex the hand to the mouth and then fully extend the
elbow within 2 seconds?
6. Is the lower limb flexible and the knee easily extended in
sitting?
7. Can you dorsiflex the foot from 20° to 10° of plantarflexion?
8. Can you passively flex the hip/knee to 90° and return to full
extension within 2 seconds?
9. Can you flex the knee with the hip extended, to move the foot
over the edge of the bed, without resistance?
Associated reaction
10. Does the hand remain stationary on the leg as the subject
elevates the opposite arm above the head?
11. Can the hand remain at trochanter level or lower on standing
up?
12. Can the foot remain on the floor on standing?
Total score

Copyright © 2008 John Wiley & Sons, Ltd

Before-Watsu

After-Watsu

1

2

3

1

2

3

1
1
0

1
1
1

1
1
1

0
0
0

0
0
0

0
0
0

2

2

4

1

1

2

3

2

4

1

0

2

2

1

3

1

0

1

2
2

1
2

4
3

1
1

0
1

2
1

3

2

3

1

1

1

2

1

2

1

0

1

2

1

1

1

1

0

1
21

1
16

1
28

1
9

1
5

0
10

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Watsu as rehabilitation method 135
APPENDIX 2: RIVERMEAD VISUAL GAIT ASSESSMENT SCORES FOR ALL
THREE PATIENTS ASSESSED BEFORE/AFTER WATSU
Subjects

Before-Watsu
1

Upper limb position
1. Shoulder
2. Elbow flexed
Stance Phase
3. Trunk flexed/extended
4. Trunk side flexed
5. Trunk and pelvis: lateral displacement
6. Contralateral drop pelvis
7. Hip extension decreased
8. Hip extension decreased with backward rotation
9A. Knee flexion excessive at initial contact
10A. Knee flexion excessive throughout range
or
9B. Knee extension excessive at initial contact
10B. Knee extension excessive throughout range
11A. Ankle in excess plantar flexion
or
11B. Ankle in excess dorsi flexion
12. Inversion excessive
13. Plantar flexion decreased at toe-off
Swing phase
14. Trunk flexed
15. Trunk side flexed
16. Hike pelvis (elevation)
17. Backward rotation pelvis
18. Decreased hip flexion
19. Decreased knee flexion
20. Ankle in excess plantar flexion
Total score

Copyright © 2008 John Wiley & Sons, Ltd

After-Watsu

2

3

1

2

3

1
1

1
1

2
2

0
0

0
0

0
0

1
1
1
1
1
0

0
1
0
1
1
0
1
1

1
2
2
2
1
1

0
1
1
1
0
0

0
0
0
1
1
0
0
1

0
1
0
1
0
0

2
2
2

1
1
0

2
1
1

0
1
1

1
2

1
1
0

2
2

0
1

1
0
0

1
1

1
1
1
1
1
1
1
21

0
1
1
1
1
1
1
15

1
2
1
1
2
2
2
34

0
1
1
0
0
1
0
9

0
1
0
0
1
1
0
7

0
1
1
0
1
0
1
10

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136 Chon et al.
REFERENCES
Barnes S, Gregson J, Leathley M, Smith T, Sharma
A, Watkins C. Development and inter-rater reliability of an assessment tool for measuring muscle
tone in people with hemiplegia after a stroke.
Physiotherapy 1999; 85: 405–409.
Bogey RA, Geis CC, Bryant PR, Moroz A, O’neill BJ.
Stroke and neurodegenerative disorders. 3. Stroke:
rehabilitation management. Archives of Physical
Medicine and Rehabilitation 2004; 85(suppl 1):
15–20.
Dull H. Watsu: Freeing the Body in Water. Middletown, CA: Harbin Springs Publishing, 1997;
20–27.
Fheodoroff K, Wissel J, Entner T, Freimüller M.
Measuring outcome in spasticity rehabilitation.
Wiener Klinische Wochenschrift 2001; 113:
11–15.
Folstein MF, Folstein SE, McHugh PR. ‘Minimental
state’: a practical method for grading the cognitive state of patients for the clinician. Journal of
Psychiatric Research 1975; 12: 189–198.
Francisco GE, Boake C. Improvement in walking
speed in poststroke spastic hemiplegia after
intrathecal baclofen therapy: a preliminary study.
Archives of Physical Medicine and Rehabilitation
2003; 84: 1194–1199.
Graham-Pole J. ‘Physician, heal thyself’: how teaching holistic medicine differs from teaching CAM.
Academic Medicine 2001; 76: 662–664.
Hesse S, Brandi-Hesse B, Bardeleben A, Werner C,
Funk M. Botulinum toxin A treatment of adult
upper and lower limb spasticity. Drugs Aging
2001; 18: 255–262.
Lamontagne A, Malouin F, Richards CL. Locomotorspecific measure of spasticity of plantarflexor
muscles after stroke. Archives of Physical Medicine and Rehabilitation 2001; 82: 1696–1704.
Laufer Y, Dickstein R, Chefez Y, Marcovitz E. The
effect of treadmill training on the ambulation of
stroke survivors in the early stages of rehabilitation: a randomized study. Journal of Rehabilitation Research and Development 2001; 38:
69–78.

Copyright © 2008 John Wiley & Sons, Ltd

Lineker SC, Badley EM, Hawker G, Wilkins A.
Determining sensitivity to change in outcome
measures used to evaluate hydrotherapy exercise
programs for people with rheumatic diseases.
Arthritis Care and Research 2000; 13: 62–65.
Lord SE, Halligan PW, Wade DT. Visual gait analysis: the development of a clinical assessment
and scale. Clinical Rehabilitation 1998; 12:
107–119.
Meythaler JM, McCary A, Hadley MN. Prospective
assessment of continuous intrathecal infusion of
baclofen for spasticity caused by acquired brain
injury: a preliminary report. Journal of NeuroSurgery 1997; 87: 415–419.
Richards CL, Malouin F, Dumas F, Tardif D. Gait
velocity as an outcome measure of locomotor
recovery after stroke. In: Craik RL, Oatis CA
(eds), Gait Analysis: Theory and Application. St
Louis, MO: Mosby 1995; 25: 355–364.
Rösche J. Treatment of spasticity. Spinal Cord 2002;
40: 261–262.
Sahrmann SA, Norton BJ. The relationship of voluntary movement to spasticity in the upper motor
neuron syndrome. Annals of Neurology 1997; 2:
460–465.
Vargas LG. Aquatic Therapy: Interventions and
Applications. Ravensdale, WA: Idyll Arbor 2004:
87–106.
Watanabe T. The role of therapy in spasticity management. American Journal of Physical Medicine &
Rehabilitation 2004; 83: 45–49.
Zamparo P, Pagliaro P. The energy cost of level
walking before and after hydro-kinesi therapy in
patients with spastic paresis. Scandinavian
Journal of Medicine & Science in Sports 1998;
8: 222–228.
Address correspondence to: Seung Chul Chon, Physiotherapist, Physiotherapy Section, Department of
Rehabilitation Medicine, Hanyang University Hospital, 17 Haengdangdong Seongdonggu, Seoul, Korea,
133–791 (E-mail: biomechanic1@hotmail.com).
(Submitted February 2008; accepted July 2008)

Physiother. Res. Int. 14: 128–136 (2009)
DOI: 10.1002/pri