Poster on hydrotherapy in PHysiotherapy

1. INTRODUCTION
Osteoarthritis (OA) is defined as a progressive-degenerative chronic disease
affecting all the joint structures (Osteoarthritis Research Society
International, 2020).
Aquatic therapy is a form of exercise utilizing the water properties
(buoyancy, resistance, hydrostatic pressure, and the thermal conduction)
designed by a qualified physiotherapist, ideally realized in a purpose built
heated swimming pool (Aquatic Therapy Chartered Physiotherapists, 2014).
Search History
Aim: To examine the evidence in the effectiveness of Aquatic Therapy in
people with knee OA and its effect on pain and body function.
Databases: PUBMED, CINAHL, MEDLINE, manual search in reference lists.
Key Words: Aquatic Therapy, Aquatic Exercise, Water Based Exercise,
Hydrotherapy, Knee Osteoarthritis.
EXERCISE PHYSIOLOGY
According to the National Institute of Clinical Excellence (NICE) in 2020, the
current approach for knee OA management is divided into two types: non-
pharmacological and pharmacological. The non- pharmacological includes
verbal and written information to the patient about OA disease, it’s symptoms
and progression of disease, and education of self- care techniques such as
thermotherapy, electrotherapy, footwear advice, bracing, joint support for
unstable joints. Moreover, weight loss interventions and advice for obese OA
patients, land- based exercise programmes for strengthening and general
aerobic fitness are considered core treatments of OA management. These will
help to reduce pain, increase function and quality of life (NICE, 2020).
MSc Advanced Physiotherapy, Rehabilitation Strategies.
The effect of Aquatic Therapy in pain and in function for people with knee osteoarthritis
EVIDENCE BASE
NICE guidelines 2008
5 RCTs
Australian Guidelines 2018
1 meta analysis (13 RCTs)
OARSI guidelines 2019
5 RCTs
‘’Exercise should be a core
treatment for people with OA,
irrespective of age, comorbidity,
pain severity or disability. Exercise
should include: local muscle
strengthening, general aerobic
fitness. The selection of the type of
exercise will depend on the
patient’s individual needs,
circumstances, self-motivation and
the availability of local facilities.’’
‘’It may be appropriate to offer
aquatic exercise/hydrotherapy for
some people with knee and/or hip
OA. This will depend upon personal
preference and the availability of
local facilities.’’
‘’Aquatic exercise, gait aids, cognitive
behavioral therapy with an exercise
component, and self-management
programs were the recommended
non-pharmacologic options for
individuals with Knee OA with or
without comorbidities’’
OUTCOME MEASURES
GUIDELINES
CONCLUSION
1. Aquatic therapy does not improve function more than land- based exercises do:
 2 studies that compared aquatic therapy vs land- based exercises showed that
function had improved significantly however the difference between them was
not statistical significant.
 3 studies that explored the pain intensity using VAS showed that aquatic therapy
had statistically significant and clinically relevant improvement in pain compared
to land- based exercises because the improvement was greater than the SEM and
the MCID of VAS.
2. Aquatic therapy which consists of strengthening, stretching exercises of lower
extremities muscles (quadriceps, hamstrings, gastrocnemius) and gait training for 3
sessions weekly may show promising results on the pain management of people
suffering from knee OA.
3. Further research is required with:
 Larger sample sizes and normally distributed to allow generalizations
 Specific stages regarding the severity of OA, duration, sets and repetitions of each
exercise
 Focus on the long term effects of aquatic therapy in knee OA
CURRENT PRACTICE
Authors &
Type of study
No
Participant
With Knee
OA
Methodology Outcome
Measures
Results Advantages Limitations
RCT by
Wyatt et al
(2001)
N=46 • 2 groups LBG + AQG
• 3/7 sessions, 6 weeks
• Strengthening and
stretching exercises, gait
training
• Pool: 32 °C, 1.4m depth
1. VAS AQG showed
statistical significant
difference in pain
VAS (p≤ .05).
• Randomisation
• Same exercises 2
groups
performance bias
• Small sample size
• Single blinded (assessor)
• Duration of each sessions
• No ITT
• No baseline
characteristics
Equal ? Representative?
RCT by
Silva et al
(2008)
N=64 • 2 groups LBEG+ WBEG
• 3/7 sessions, 50 mins
program, 18 weeks
• Warm up, stretching
and strengthening
exercises, gait training
• Pool: 32 °C, 1.2m
depth
1. WOMAC
2. VAS
AQG Statistical
significant
differences in pain
before (p=.009) and
after (p<.000)
50FWT.
NO significant
difference in
WOMAC b/w
groups.
• Randomisation
• Baseline
characteristics
• ITT
• Same exercises 2
groups
performance bias
• Sample size
calculation VAS
• Single blinded (assessor)
• NO information about
aquatic education
background of physios
• Small sample size
RCT by
Lim, Tchai and
Jang (2010)
N=75 • 3 groups, AQG, LBG, CG
• 3/7 sessions, 40 mins
program, 8 weeks
• Warm up,
strengthening, and
stretching exercises,
gait training (fast
walking), bicycle
• Pool: 34°C , 1.15m
depth
1. WOMAC NO significant
difference in
function between
AQG + LBG.
• Baseline
characteristics
• Randomization
• ITT Drop outs
• Small sample size
• Single blinded
• No information about
education background of
physios and control
group intervention
RCT by
Yennan,
Suputtitada and
Yuktanandana
(2010)
N=50 • 2 groups, AQG, LBG
• 3/7 sessions, 65 mins
program, 6 weeks
• Strengthening and
stretching exercises,
gait training, bicycle
• Pool: ambient °C, waist
depth
1. VAS AQG showed
statistical
significant ↓ in
pain compared to
LBG p=.007.
• Same exercises 2
groups
• Baseline
Characteristics
equal groups
• No drop outs
• Small sample size
• No information about
who did the
interventions
Quasi-
expiramental
study by
Sekome and
Maddocks
(2019)
N=18 • Single group, pre-test &
post-test
• 2/7 sessions 60 mins
program, 4 weeks
• Strengthening and
stretching exercises,
gait training
• Pool: 34 °C, waist
depth.
1. VAS
2. WOMAC
Statistically
significant ↓ VAS
and ↑ WOMAC
p≤.05 and large
effect sizes
VAS=.71,
WOMAC=.79
• Blinding assessor
• Inclusion criteria
• Physio with
experience to
aquatic therapy
• Small sample size
• No control group -
>affects internal validity
• Convenience sample->
representative to OA
population??
Psychometric
properties
for
knee OA
WOMAC VAS
Type Disease specific, patient- reported, 3
subscales: pain, stiffness, and function
Generic, patient- reported
ICF Body function, activities and participation Body function
Reliability
I.C.C
1. Excellent test retest reliability (Williams,
Piva, Irrgang, Crossley and Fitzgerald, 2012):
• 2m=.90 ,6m=.88, 12m=81
• Range: .90- .81
2. Excellent test retest reliability (Basaran,
Guzel, Seydaoglu and Guler-Uysal, 2010):
• Range: .80–.98
Excellent test retest reliability
(Alghadir, Anwer, Iqbal & Iqbal,
2018): 0.97
Internal
Consistency
Cronbach’s A
Ranges from Acceptable - excellent internal
consistency (Williams, Piva, Irrgang, Crossley
and Fitzgerald, 2012):
• Pain: .78
• Stiffness: .81
• Function: .94
• Total: .95
N/A: 1 item only
Construct validity Moderate correlation (Basaran, Guzel,
Seydaoglu and Guler-Uysal, 2010):
• Convergent with Lequesnce Index
Total:.60
• Convergent with SF-36
Total: .57
Excellent correletion
Convergent with (Alghadir, Anwer,
and Iqbal, 2018):
• VAS-NRS r=0.941
• VAS-VRS r=0.878
Clinical validity No No
Criterion validity No Gold Standard No Gold Standard
Content validity Some items are unclear
i.e. getting on/out of the car
(Williams, Piva, Irrgang, Crossley and
Fitzgerald, 2012)
N/A: 1 item only
Responsiveness Effect size=.63 (12 weeks)
(Brooks, Rolfe, Cheras and Myers, 2004)
Standardized Response (Kersten,
White and Tennant, 2014):
Mean= .62
SEM
MCID
MDC
2m= 5.1, 6m= 5.4, 12m= 6.7
2m= 4.0
6m= 6.6
12m= 1.6
2m= 14.1, 6m= 15, 12m= 18.5
(Williams, Piva, Irrgang, Crossley & Fitzgerald,
2012)
• 0.03 (Alghadir, Anwer and Iqbal,
2018)
• 1.75 (Alghadir, Anwer and Iqbal,
2018)
• 0.08 (Bennell, 2005)
I.C.C=Intra Class Correlation Coefficient ,SEM=Standard Error of Measurement, MCID=Minimal Clinically Important Change , SF-36=The Short Form (36)
Health Survey, NRS=Numeric rating scale, VRS=Verbal Rating Scale, MDC=Minimum Detectable Change, VAS=Visual analogue Scale, WOMAC=Western
Ontario and McMaster Universities Arthritis Index
REFERENCES
Dong, R., Wu, Y., Xu, S., Zhang, L., Ying, J., & Jin, H. et al. (2018). Is aquatic exercise more effective than land-based exercise for knee osteoarthritis?. Medicine, 97(52), e13823. doi: 10.1097/md.0000000000013823
Sekome, K., & Maddocks, S. (2019). The short-term effects of hydrotherapy on pain and self-perceived functional status in individuals living with osteoarthritis of the knee joint. South African Journal Of Physiotherapy, 75(1).
doi: 10.4102/sajp.v75i1.476
Silva, L., Valim, V., Pessanha, A., Oliveira, L., Myamoto, S., Jones, A., & Natour, J. (2008). Hydrotherapy Versus Conventional Land-Based Exercise for the Management of Patients With Osteoarthritis of the Knee: A
Randomized Clinical Trial. Physical Therapy, 88(1), 12-21. doi: 10.2522/ptj.20060040
Wyatt, F., Milam, S., Manske, R., & Deere, R. (2001). The Effects of Aquatic and Traditional Exercise Programs on Persons With Knee Osteoarthritis. The Journal Of Strength And Conditioning Research, 15(3), 337. doi:
10.1519/1533-4287(2001)015<0337:teoaat>2.0.co;2
Yennan, P., Suputtitada, A., & Yuktanandana, P. (2010). Effects of aquatic exercise and land-based exercise on postural sway in elderly with knee osteoarthritis. Asian Biomedicine, 4(5), 739-745. doi: 10.2478/abm-2010-0096
Alghamdi, Olney and Costigan, 2004; Becker and Cole, 2004; Munukka et al, 2016
Buoyancy Hydrostatic
Pressure
Warmth of
water
Drag Force In general,
exercising in
water or dry
land:
1. Reverses
cartilage atrophy
and slowdown
progression of
OA

↑cartilage
nutrition
3. ↑
intra-articular
nutrient diffusion
4. ↑ synovial
blood flow
1. ↓weight
bearing 
↓joint
Compression
2. ↑freedom of
movement
↑ ROM
=
PAIN RELIEF
1. ↑blood
circulation and
venous
return
↓ of oedema
 Freedom of
movement
2. ↑ constant
resistance to
the chest
wall
strengthening
inspiratory
muscles
↑ respiratory
function
=
↑FUNCTION
1. Sensory
overflow
2.Suppression
sympathetic
nervous system
3. ↓ pain
=
PAIN RELIEF
1. Soft tissue
resistance
training
2. ↑muscle
Activity
3. ↑muscle
stretching
=
↑FUNCTION

2. Reference list
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Osteoarthritis and cartilage, 27(11), 1578-1589.
Basaran, S., Guzel, R., Seydaoglu, G., & Guler-Uysal, F. (2010). Validity, reliability, and comparison of the WOMAC osteoarthritis index and Lequesne algofunctional index in Turkish patients with hip or knee osteoarthritis.
Clinical Rheumatology, 29(7), 749-756. doi: 10.1007/s10067-010-1398-2.
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75(1). doi: 10.4102/sajp.v75i1.476
Silva, L., Valim, V., Pessanha, A., Oliveira, L., Myamoto, S., Jones, A., & Natour, J. (2008). Hydrotherapy Versus Conventional Land-Based Exercise for the Management of Patients With Osteoarthritis of the Knee: A
Randomized Clinical Trial. Physical Therapy, 88(1), 12-21. doi: 10.2522/ptj.20060040.
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Williams, V., Piva, S., Irrgang, J., Crossley, C., & Fitzgerald, G. (2012). Comparison of Reliability and Responsiveness of Patient-Reported Clinical Outcome Measures in Knee Osteoarthritis Rehabilitation. Journal Of
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Wyatt, F., Milam, S., Manske, R., & Deere, R. (2001). The Effects of Aquatic and Traditional Exercise Programs on Persons With Knee Osteoarthritis. The Journal Of Strength And Conditioning Research, 15(3), 337. doi:
10.1519/1533-4287(2001)015<0337:teoaat>2.0.co;2.
Yennan, P., Suputtitada, A., & Yuktanandana, P. (2010). Effects of aquatic exercise and land-based exercise on postural sway in elderly with knee osteoarthritis. Asian Biomedicine, 4(5), 739-745. doi: 10.2478/abm-2010-
0096.