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Effects of aquatic exercise on arterial stiffness and endothelial function in adults: A systematic review and
Emily Dunlap1, Yanbing Zhou1, Manny M Y Kwok2
1Department of Kinesiology and Health Education, The University of Texas at Austin, Austin, Texas, United States of America.
Objective:
To evaluate the effects of aquatic exercise compared with non-exercise controls and land-based exercise on arterial stiffness and endothelial function.
Design:
Systematic review and meta-analyses of randomized controlled trials assessed using the Cochrane risk-of-bias tool and Grading of Recommendations Assessment, Development and Evaluation.
Data Sources:
PubMed/MEDLINE, CINAHL Plus, SPORTDiscus, and reference lists, searched from database inception to April 16, 2025.
Eligibility Criteria:
Studies evaluating chronic aquatic exercise (multi-session interventions) compared with land-based exercise or non-exercise comparison groups in adults, measuring arterial stiffness via pulse wave velocity (PWV) or endothelial function via flow-mediated dilation (FMD).
Results:
This review includes 18 randomized controlled trials with 845 participants (mean age 65 ± 7 years). Studies compared aquatic exercise with non-exercise controls (8 studies), land-based exercise (6 studies), or both (4 studies). Exercise sessions averaged 50 minutes, 3 times weekly for 11 weeks. Most studies (17 out of 18) implemented moderate-to-vigorous intensity protocols. Aquatic exercise resulted in improvements in arterial stiffness compared with non-exercise controls (7 studies; SMD = -2.37, 95% CI: -4.46 to -0.29; I2 = 98%: low certainty), with most evidence reflecting systemic and peripheral PWV. Changes in arterial stiffness did not differ from those observed after land-based exercise (6 studies; SMD = -0.07, 95% CI: -0.34 to 0.20; I2 = 0%, moderate certainty). For endothelial function, aquatic exercise may improve outcomes versus non-exercise controls (6 studies; SMD = 0.91, 95% CI: 0.39 to 1.43; I2 = 68%; low certainty) and may lead to greater improvements than land-based exercise (7 studies; SMD = 0.55, 95% CI: 0.05 to 1.06; I2 = 75%; low certainty).
Conclusion:
Aquatic exercise improves systemic and peripheral arterial stiffness as well as endothelial function compared with non-exercising controls. Changes in arterial stiffness do not differ from those observed after land-based exercise. Aquatic exercise may provide greater improvement in endothelial function than land-based exercise, though this is supported by low-certainty evidence, and substantial heterogeneity limits confidence in the generalizability of this finding.
Prospero Registration:
CRD42025642087.
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