Batterham et al. BMC Musculoskeletal Disorders 2011, 12:123 Page 2 of 13http://www.biomedcentral.com/1471-2474/12/123every year.  It has no cure. Regular moderate physi- Methodscal activity provides a wide range of health benefits Inclusion Criteriaand graded exercise programs are effective interven- Types of Studiestions for knee osteoarthritis . Both strength training Randomised controlled clinical trials were included. Theand aerobic exercise lead to significant improvements study must have been reported in English as translationin pain, physical function and general health although funding was not available. Studies must have reportedpatient adherence to long term exercise is poor . that one group performed aquatic exercise and the com- Geytenbeek (2002) found moderate quality evidence parison group participated in land based exercise; thissupporting aquatic exercise for pain, function, self effi- could have included any exercise training for strength,cacy, joint mobility, strength and balance outcomes for endurance, resistance or aerobic capacity whether gympeople with any disability . The effects of aquatic or home-based. To allow conclusions regarding the rela-exercise for people with arthritis were not investigated. tive effects of aquatic and land exercise, papers wereIn 2009, Bartels et al. reviewed the effectiveness of only included if they provided data that enabled out-aquatic exercise for the treatment of knee and hip comes following aquatic and land based exercise to beosteoarthritis compared to alternative strategies. The tested for significant differences.review included studies published till 2006 and con- Types of participantscluded that aquatic exercise improves function (SMD Participants had to be people with rheumatoid arthritis= 0.26, 95% CI 0.11 to 0.42) and quality of life (SMD = or osteoarthritis.0.32, 95% CI 0.03 to 0.61) compared to no exercise Types of Outcome measurescontrol outcomes . At that time only one study Trials must have reported function, mobility or patientcomparing aquatic to land exercise was available for satisfaction outcomes using any assessment instruments.review. Thomas et al. (2009) reviewed the treatment ofknee osteoarthritis and concluded that aquatic exercise Exclusion Criteriaresulted in strength benefits compared to control inter- Trials in which participants performed aquatic or landventions or land based exercise but did not quantify based exercise in conjunction with other interventionstreatment effects . Callahan (2009) evaluated all were excluded unless the effects of aquatic compared toexercise interventions for participants with chronic land based exercise could be partitioned from reportedarthritis and concluded that both aerobic and muscle data. Participants less than 18 years of age werestrengthening exercises are safe and moderately effec- excluded due to the additional management implicationstive for people with chronic arthritis . Aquatic associated with an immature musculoskeletal system.exercise appears to be a useful strategy for regaining Participants who exercised as part of rehabilitationmovement and function loss associated with arthritis, immediately following joint replacement surgery werebut it is more expensive and resource intensive than excluded as the review focus was effectiveness for peopleland based exercise. It would be advantageous for with joints affected by arthritis.those prescribing exercise to consider the nature andmagnitude of effects on function when aquatic pro- Search Strategygrams are compared to land based programs for this Medline, CINAHL, AMED and the Cochrane Centralpopulation. In addition, previous reviews have not Register of Controlled Clinical Trials were searchedsummarized the content of exercise programs, making from the commencement of each database to July 2010.program replication difficult for readers. A sensitive search was developed using the terms ‘aqua- tic physiotherapy’, ‘hydrotherapy’ or ‘water exercise’Objectives interventions for people with ‘arthritis’, ‘osteoarthritis’ orThis review explicitly assessed the relative advan- ‘rheumatoid arthritis’. No terms relating to the ‘compari-tages of aquatic exercise compared to land based son’ and ‘outcome’ of trials were searched to avoidexercise for people with arthritis on the outcomes of excessive exclusion of trials in an area where limitedfunction or mobility. In addition this review sought research has been conducted. The full electronic searchdata on participant perception of aquatic compared strategy is available from the first author on request.to land based exercise with respect to satisfaction,enjoyment and compliance. Data were extracted to Study Selectionidentify how function and mobility outcomes of Papers were initially screened and excluded based onexercise programs have been measured and to sum- title and abstract by two independent researchers. Fullmarise the components of reported land and aquatic text was obtained for the remaining papers and theseexercise programs. were assessed independently by both researchers against
Batterham et al. BMC Musculoskeletal Disorders 2011, 12:123 Page 3 of 13http://www.biomedcentral.com/1471-2474/12/123an inclusion and exclusion checklist. Disagreements through the extraction of data on walking ability andwere resolved through discussion; if this failed a third dynamic balance. If trials specified data collected underresearcher was consulted. a range of walking speeds, data for the fast pace was extracted. To assess patient perception of the programQuality Assessment any outcome that assessed patient enjoyment, satisfac-All included trials were critically appraised using the 11 tion or any other type of feedback of the exercise pro-item PEDro scale [12-14], 10 of which were scored grams was extracted.using explicit decision rules. All trials were indepen- To compare effectiveness of interventions for eachdently assessed by the first author. A search for included relevant outcome, point measures and measures ofpapers was then performed on PEDro and quality variability were extracted. Means and standard devia-assessment scores compared to those determined by two tions of outcomes measured immediately following theindependent PEDro assessors where these were available intervention were extracted and analysed. When neces-. If there was disagreement on an item’s assessment, sary, the standard deviation [sd] was approximated bythese were assessed independently by another dividing the inter-quartile range by 1.35. Medians wereresearcher. If no quality score was available in the used as best estimates of means. Standard error [SE]PEDro database, the paper was independently assessed was converted to sd using the formula SE = sd/(√n).by both reviewers. These data points were then used to calculate Hedges Item 4 (baseline comparability) was not fulfilled if  corrected standardised mean differences [SMD] andthere was a significant and important difference (95% 95% confidence intervals [CI] to assess interventionconfidence that SMD > 0.2) between groups at baseline effects. The SMD was the difference between two meansfor one measure of disease severity or one key outcome normalised using either pooled or control group stan-measure. If more than one outcome was measured by dard deviations (the former where no significant differ-trials, only one outcome had to achieve baseline similar- ence in control and intervention standard deviationsity to this fulfil criteria. Item 8 (key outcome measures was observed). This index is useful for comparing datawere obtained for more than 85% of participants who collected using different scales. A SMD <0.2 was consid-were assessed at baseline) was calculated using data for ered a small effect, 0.5 (>0.2, <0.8) a moderate effecteach group (rather than for the pooled intervention and and >0.8 a large effect . Data at baseline and imme-comparison group) when relevant data were reported. diately following the intervention were extracted. Long term effectiveness of interventions was not assessed as itData extraction was beyond the scope of the review. If trials did not useAll data extraction and calculations were performed Intention-To-Treat analysis [ITT], per-protocol dataindependently by two reviewers. Both sets of data were were extracted for analysis.then compared for discrepancies and these wereresolved through discussion. Meta analysis The following data were systematically extracted: Pooling of data across multiple studies can provide anstudy design details, participant characteristics and base- improved estimate of the effect of the intervention as aline demographics, affected joints, duration of arthritis, consequence of the larger number of total participantsgroup numbers, participant age and inclusion criteria, and reduction in random error due to samplingintervention and control group conditions including differences.pool temperature, group size, supervision of the exercise Meta-analysis was performed using Review Managerintervention, provision of a home exercise program, (RevMan5) software. Heterogeneity between trialscompliance of participants, number of drop outs, length was assessed using the I 2 statistic. Heterogeneity wasof interventions, duration and number of sessions, fea- considered substantial if I2 was greater than 50% and atures and components of aquatic and land-based exer- random effects model applied; otherwise a fixed effectscise including the provision of warm-up, stretching, cool model was used for the analysis . SMDs were useddown, balance, strengthening and functional exercises. where different scales were used to measure comparable Data assessing function, pooled indices and mobility outcomes across trials. Scale directions were aligned byoutcomes were also extracted. The World Health Orga- adding negative values where required.nization defined six domains for the assessment ofhealth . These include pain, self care, usual activities, Resultscognition, mobility and affect. Domains considered rele- Search yieldvant to function were usual activities and self care. Out- A total of 191 papers were identified from the search.comes that encompassed multiple domains were 173 papers were excluded based on title and abstract;classified as pooled indices. Mobility was assessed full text was obtained for the remaining 18 papers. Of
Batterham et al. BMC Musculoskeletal Disorders 2011, 12:123 Page 4 of 13http://www.biomedcentral.com/1471-2474/12/123these 8 papers were excluded as they did not meet allocated to groups. Data describing the interventioninclusion criteria and10 papers were included in the design is shown in Table 3.review. (Figure 1) Features and components of aquatic and land based exercise interventions are described in Table 4. Hall etQuality Assessment al. and Suomi & Collier did not provide any informationA summary of the quality assessment scores and the about the exercise interventions and are not included indecisions for each item are shown in Table 1 for all the table [21,22]. Suomi & Collier state that the pro-included trials. grams were based on People with Arthritis Can Exercise (PACE) and Arthritis Foundation Aquatic ProgramData Extraction (AFAP) protocols but these could not be found .Study design features are shown in Table 2. Participant Hall et al. reported that exercises were designed tonumbers reported in Table 2 are the numbers initially increase range of movement and muscle strength and Medline (Limited to English, Humans) 87 AMED (Limited to Humans) 65 CCRCT 69 CINAHL (Limited to English, Humans) 27 TOTAL 248 Duplicates removed (n = 57) Total search yield (n= 191) Excluded on title and abstract (n = 173) Language other than English n=1 No land based comparison n=38 Full text obtained (n=18) Complaint other than arthritis n =8 No exercise intervention n=60 No functional outcomes n = 11 Not CCT or RCT n = 52 Included Studies (n = 10) Following joint replacement surgery n=2 Gill (2009) Participants <18 yrs n=1 Lund (2008) Silvia (2008) Eversden (2007) Fransen (2007) Foley (2003) Suomi (2003) Excluded after reading full text (n = 8) Wyatt (2001) Inappropriate outcomes measures n=1 Smith (1998) Insufficient data n=1 Hall (1996) Land exercise combined with short wave diathermy n=1 Unable to access report n=1 No aquatic exercise n=1 Meta-analysis Function (n=8) No land based exercise group n=1 Pooled indices (n=5) Not RCT or CCT n=2 Walking ability (n=7) Dynamic balance (n=3) Figure 1 Search yield. CCT = Controlled Clinical Trial; RCT = Randomised Clinical Trial
Batterham et al. BMC Musculoskeletal Disorders 2011, 12:123 Page 5 of 13http://www.biomedcentral.com/1471-2474/12/123Table 1 Summary of Quality assessment scores Silva et Foley et Lund et Fransen Wyatt et Suomi & Eversden Gill et Hall et al., Smith et al., al., al., 2003 al., 2008 et al., al., 2001 Collier,2003 et al., al., 2009 1996  1998  2008    2007    2007   1. eligibility ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ criteria 2. random 1 1 1 opaque 1 1 1 randomly 1 flipping 1 random 1 random 1 random allocation drawing computer envelopes computer assigned virtual numbers numbers allocation of lots generated generated coin table table 3. allocation 1 likely 1 sealed 1 1 after 0 not 0 unlikely 1 sealed 1 sealed 1 1 concealed opaque baseline baseline described opaque envelopes independent independent envelopes, measures assessment envelopes coordinator allocator prior 4. baseline 1 VAS 1 Walk 1 VAS 1 WOMAC 0(1) no 1 ADLs & 1 VAS 1 1 Knee ROM, 1 Morning similarity (pain), speed, (pain), pain & outcomes Pain (pain), EQ- WOMAC AIMS2 stiffness, WOMAC ASE (pain) KOOS function comparable comparable SD pain & HAQ ADLs function 5. patient 0 0 0 0 0 0 0 0 0 0 blinding 6. therapist 0 0 0 0 0 0 0 0 0 0 blinding 7. assessor 1 1 1 1 1 0 1 1 1 1 blinding 8. adequate 0 81% 0(1) 80% 0(1) 96% 1 93% 1 91% 1 91% 0 81% 1 86% 1 94% overall 0 92% follow-up land aquatic, aquatic, aquatic, overall patients each aquatic, land 89% aquatic, 75% 74% land 80% land 89% Tai group 69% land aquatic land chi 9. ITT analysis 1 1 1 1 0 0 1 0 0 0 10. between 1 1 1 1 1 1 1 1 0 pre/post 1 group test comparisons reported 11. post 1 means 1 medians 1 means 1 means & 1 mean & 1 means & 1 medians 1 means 1 means & 1 means & intervention & SDs & IQR & SDs SDs SDs SDs & IQR & SDs SDs SDspoint & variability measures TOTAL 7/10* 7/10(8) 7/10(8) 8/10* 5/10(6) 5/10* 7/10* 7/10* 6/10* 6/10*Key:* accessed by PEDro with same score obtained✓ yes (not scored)(x) PEDro assessment by PEDro reviewers differs and is x1 yes (scored)0 nothat the type, duration and frequency of exercises were Intervention effectsstandardized in consultation with physiotherapists . Physical function There was considerable variability in the details pro- A number of outcomes were used to establish changesvided about the exercise interventions. The majority of in participant’s physical function (Additional File 1). Theexercise programs were not detailed enough to allow Western Ontario and McMaster Universities Osteoar-them to be reproduced with confidence (Table 5). thritis Index [WOMAC] has established reliability and Seven of the ten included trials presented information validity for this population . Function componentabout exercises in their programs (Table 6). Eversden et scores as reported by Fransen et al., Gill et al. and Foleyal., Suomi and Collier and Hall et al. did not provide et al. were included [1,7,25]. Silva et al. reported a totaldetails of either program [21-23]. Eversden et al. stated WOMAC score; this result was included with pooledthat exercises focussed on joint mobility, muscle indices . The Knee Injury and Osteoarthritis Out-strength and functional activities . Therefore none come Score [KOOS] is based on the WOMAC [26,27].of these trials have been included in Table 6. Fransen et The activities of daily life component score of theal. did not provide any details about the Tai Chi inter- KOOS was used to assess function. The Health Assess-vention . ment Questionnaire [HAQ] is a self reported disability
Batterham et al. BMC Musculoskeletal Disorders 2011, 12:123 Page 6 of 13http://www.biomedcentral.com/1471-2474/12/123Table 2 Study design Silva et Foley Lund et Fransen Wyatt Suomi & Eversden Gill et Hall et al., Smith al.,2008 et al., al.,2008 et al., et Collier,2003 et al., 2009 1996  et al.,  2003  2007  al.,2001  al.,2007  1998    Intervention PT PT PT Tai chi, PT PACE AFAP PT PT + OT, PT HEP Hydro education (ROM), HydroFollow-up data reported 3 24 3 months 8 weeks 3 months months weeksDiagnosis OA OA OA OA OA RA & OA RA OA & RA RA RA Hip ✗ ✓ ✗ ✓ ✗ ✓ Knee ✓ ✓ ✓ ✓ ✓ ✓ Multiple joints ✗ ✗ ✗ ✗ ✗ ✗ >6 ✓Duration of WB 8.5 (3.7)* ≥1 23.5 (8.8) 10(7)* 9.7 (7.7) 20.2arthritis years (12.6) LB 7.8 (7.9)* 20.8 (7.7) 8(8.5)* 11.9 (8.2) 11.6 (7.6)Number of WB (n) 32 35 27 55 46 11 57 44 35 12subjects LB (n) 32 35 25 56 11 58 42 34 12 Control (n) ✗ 35 27 41 ✗ 10 ✗ ✗ Immersion ✗ 35 Relaxation 35Age WB 59 (7.6) 73 (8.2) 65 (12.6) 70 (6.3) 45-70 yrs 68 (6.8) 55.2 (13.3) 69.2 55.8 (12.5) 61.9 (10.5) (11.6) LB 59 (6.1) 69.8 68 (9.5) 70.8 (6.3) 64.2 (3.3) 56.1 (11.9) 71.6 (8.9) 58.5 (11) 54.9 (9.2) (14.9)Participant Currently ✗ if ≥3 ✗ if in ✗ if >2 ✗ if classes in ✓ ✗inclusion (✓) undertaking sessions exercise sessions last 3/12and exclusion exercise per 1/52 classes per 1/52(✗) criteria for >1/12 Current PT ✗ ✗ ✗ ✗ ✗ Previous PT ✗ <6/12 ✗ <6/52 ✗ < 6/12 ? ✓ > 30/7 Previous JRS ✗ < 12/ ✗ ✗ <12/ ✗ ✗ <3/12 ✓ ✗ <6/12 12 12 Awaiting JRS ✗ <12/ ✗ ✓ 100% 52 Medications stable stable stable stable Corticosteroids ✗ <3/12 ✗<3/12 ✗ <4/52 Age (years) >50 59-85 45-70 60-79 ≥18Key:✗ included✓ participants (with this feature not included)* mean (sd) estimated from median (IQR)n number of participantssd standard deviation> more than< within (designated time period)/7 days/12 months/ 52 weeksAFAP Arthistis Foundation Aquatic Program. HEP home exercise program. JRS joint replacement surgery. LB land-based intervention. OA osteoarthritis. OToccupational therapy home visit. PACE People with Arthritis Can Exercise. PT physiotherapy. RA rheumatoid arthritis. ROM range of movement. WB aquaticintervention.All data presented as mean (sd) unless otherwise stated; missing data indicates that no relevant data were reported
Batterham et al. BMC Musculoskeletal Disorders 2011, 12:123 Page 7 of 13http://www.biomedcentral.com/1471-2474/12/123Table 3 Intervention Design Silva et Foley Lund et Fransen et al. Wyatt et Suomi & Eversdenet Gill et Hall et Smith et al. al. et al. al. 2007  al.2001 Collier 2003 al.2007  al. al. 1998  2008 2003 2008   2009 1996      WB LB WB LB WB LB WB LB WB LB WB LB WB LB WB LB WB LB WB LBExercise class size 5-8 Max 15 1-4 1-6 4-6 4-5 <5Supervision PT ✓ ✓ PT PT ✓ Tai ✓ ✓ ✓ ✓ ✓ ✓ PT PT PT PT PT HEP students chi I AFAP PACE I IHome program ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✓video ✗ ✗ ✗ ✗ ✓ ✓ ✓ ✓ ✗ ✗ ✗ ✓ onlyAdverse effects % 3 2 11 44 2 0 0Drop-outs 1 6 6 6 1 5 3 8 4 1 1 13 17 3 4 9 1 3Pool temperature °C 32 n/ n/ 33.5 n/ 34 n/a ~32.2 n/ 31.7 n/a 35 n/a n/ 36 n/ 36 n/a a a a a a a% Weight bearing/ 1.2 n/ n/ n/ ~50% n/a ~1.5 n/ 1.05 n/a n/a n/ n/ ~20% n/awater depth m a a a m a m a aCompliance% min. 80 84 75 92 85 81* 61* 79 90 82 88 89 requiredProgram time(weeks) 18 18 6 6 8 8 12 12 6 6 8 8 6 6 6 6 4 4 10 10Session time (min) 50 50 30 30 50 50 60 60 45 45 30 30 60 60 30 30 60 ?Sessions per week 3 3 3 3 2 2 2 2 3 3 2 2 1 1 2 2 2 2 3 x2-3/ dayTotal number 54 54 18 18 16 16 24 24 18 18 16 16 6 6 12 12 8 8 30 140-sessions 210Key:✓ included✗ not included in intervention* % of participants who attended greater than 50% of classesAFAP Arthritis Foundation Aquatic ProgramHEP home exercise program (3 recheck appointments with physiotherapist)I instructorLB land based interventionn/a not applicablePACE People with Arthritis Can ExercisePT PhysiotherapistWB aquatic interventionMissing data indicates that no relevant data were reportedmeasure related to activities of daily living . The MobilityArthritis Impact Measurement Scale 2 [AIMS2] assessed Walking ability was assessed by measuring walk speedhealth status, and physical function subscale data was (Additional File 3). All trials except Foley et al. reportedextracted . time taken to walk a specific distance . Foley et al.Pooled indices reported walk speed in ms-1 without specifying distanceIndices that incorporated multiple domains of health walked . The most common distance walked waswere included as pooled indices (Additional File 2). between 10 m and 15 m however participants in someWhere multiple pooled indices were measured in a sin- trials were assessed over 1609 m and 792 m. Dynamicgle trial, those measures that encompassed the greatest balance incorporated functional aspects of mobilitynumber of domains were pooled for meta-analysis. The including the 30 second chair stand and the Timed Upoutcomes that were included in the pooled indices & Go test. The Timed Up & Go test incorporates sit-to-assessment were the SF12, KOOS, Lequesne Index, stand, walking around a cone 3 m away and returningWOMAC and EQ5D. The SF-12 is a subset of the SF- to sitting [7,22]. The 30 second chair stand involves tim-36 health survey and can be split into two components, ing the number of sit-to-stand repetitions possible in 30a mental and physical component summary . Wyatt seconds . Lund et al. and Hall et al. did not reportet al.  did not measure a function or a pooled index relevant outcomes, and were not included in extractedand therefore was not included in extracted data. data [21,27].
Batterham et al. BMC Musculoskeletal Disorders 2011, 12:123 Page 8 of 13http://www.biomedcentral.com/1471-2474/12/123Table 4 Overview of exercise program components Silva et al. Foley et al. Lund et al. 2008 Fransen Wyatt et Smith et al. Eversden et Gill et al. 2008 2003 et al. al. 2001 1998  al. 2007 2009 2007   WB LB WB LB WB LB WB LB WB LB WB LB WB LB WB LB Warm-up ✗ ✗ ✓ ✓4 ✓10 min ✓ 10 min ✗ ✓ ✓ ✓ ✓ walking min running cycling stretches cycling with belt Stretches ✓20s ✓20s ✓LL ✓LL ✓30s LL ✓30s LL only ✗ ✓ ✓* ✓ ✓ ✓30s ✓30s 2 2 only only only 2 sets 2 sets reps reps LL LL Cool down ✗ ✗ ✗ ✗ ✓5 min ✓5 min ✗ ✓ ✗ ✓ ✓ ? ? Individually ✗ ✗ ✓intensity only ✗ ✗ ✗ ✓ ✓individuals ✓ ✓ tailored ability exercises Reps/Sets Isometric 7- 10reps 10 RM n of reps in 3.5 min for 10- 2 2 10 ✓ 2× strength 10reps, 6s ྡ3 × ྡ3× each exercise 20 sets sets reps 10reps exercises Isotonic 20- 15reps 15reps reps 40reps Balance ✗ ✗ ✗ ✗ ✓ ✓trampoline, ✓ ✗ ✗ ✗ ✗ ✗ ✗ balance board, & cushionStarting position ✓ ✓ ✗ ✗ ✓ ✓ ✓ ✗ ✗ ✗ ✗ ✗ ✗ ✗ ✓ ✓ specifiedAids Weights ✗ ✓1 ✓ ✓ ✓ ✓ ✗ ✗ ✗ kg Elastic ✗ ✓ ✗ ✓ ✗ ✗ ✗ bands Floats ✓ n/a n/a ✓ n/a ✓ n/ n/a n/a n/a ✓ n/a a Turbulence ✓ n/a ✓ n/a ✓ n/a ✓ n/ n/a ✗ n/a n/a ✓ n/a a Therapist ✗ ✗ ✗ ✗ ✓ ✗ ✗ ✗ ✓ ✓ ✗ ✗Key:✓ included✗ not included* 5 reps of 8-10 general ROM exercisesྡ progressed toLB land based interventionLL lower limbn/a not applicablen numberreps repetitionsRM repetition maximumWB aquatic interventionTable 5 Variation in detail provided for exercise interventions across included studies Silva et Foley et Lund et Fransen et Wyatt et Suomi & Eversden et Gill et Hall et Smith et al.2008 al.2003 al.2008 al.2007  al.2001 Collier2003 al.2007  al.2009 al.1996 al.1998        Aquatic exercise ✓ ✗ ✓ ✓ ✗ ✗✗ ✗✗ ✓ ✗✗ ✗interventionLand-based ✓ ✗ ✓ ✗✗ ✗ ✗✗ ✗✗ ✓ ✗✗ ✗exerciseinterventionKey:✗ Some exercises reported✗✗ No specific exercises reported✓Adequately reported
Batterham et al. BMC Musculoskeletal Disorders 2011, 12:123 Page 9 of 13http://www.biomedcentral.com/1471-2474/12/123Table 6 Exercise descriptions in included studies Silva et al. Foley et Lund et al. Fransen et al. Wyatt et al. 2001 Gill et al. 2009 Smith et 2008 al. 2003 2008 2007   al. 1998   WB LB WB LB WB LB WB LB WB LB WB LB WB LBAerobic Exercises Running ✓ ✓ Tai chi ✓ Jumping ✓ ✓ Cycling ✓ ✓ ✓ ✓ ✓ ✓ ✓20 min Walking mins ✓10 ✓10 ✓ ✓2 ✓245 m ✓245 m ✓20-30 ✓5-10Exercises for strength Hip flex. ✓ ✓ ✓ ✓ ✓ Hip ext. ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Hip add. ✓ ✓ ✓ ✓ ✓ ✓ ✓ Hip abd. ✓ ✓✓ ✓ ✓ ✓ ✓ ✓ ✓ Knee flex. ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Knee ext. ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓* SBP ✓ DLP ✓ ✓ Step-ups ✓ 20 cm ✓ stairs ✓ Sit/stand ✓ 42 cm ✓ SLR ✓ ✓ ✓ ✓ Squats ✓ ✓ ✓ ✓ Trunk flex. ✓ Dorsiflex. ✓ ✓ Plantar flex. ✓ ✓ Calf raises ✓ ✓ ✓ ✓Key:✓ included* isometric quadsabd. abductionadd. adductionDLP double leg pressext. extensionflex. flexionLB land based interventionm measured in meters not minutesSBP seated bench pressSLR straight leg raise (hip flex., maintain end range knee extension)WB aquatic interventionParticipants Perceptions 1.30) favouring land based exercise, meta-analysis wasHall et al. were the only authors to report measures of repeated excluding data from this study . Removingpatient perception of the program . No differences this data improved the statistical heterogeneity (I2 = 0%)were observed in enjoyment of water compared to land of included trials (n = 249 aquatic, 243 land based) andbased exercise programs. resulted in an overall non-significant SMD of 0.07 (95% CI = -0.26, 0.12) (Figure 2).Meta analysis For indices that encompassed multiple health domainsMeta-analysis was performed for function, mobility and higher scores indicated better health. As significant sta-pooled indices. Scale direction was adjusted as required tistical heterogeneity was detected (I2 = 58%) a randomusing negative values; for function outcomes higher effects model was used. No significant differencescore indicated better health. For function outcomes a between groups was observed (SMD 0.10, 95% CI =non significant SMD between groups of 0.13 (95% CI = -0.22, 0.42). A significant difference at baseline, SMD =-0.31, 0.04) in favour of land based exercise was found. -0.4 (95% CI = -0.03, 0.78) was detected for Fransen etAs there were significant baseline differences between al. As a result the analysis was repeated without thisgroups for Foley et al. SMD = 0.81 (95% CI = 0.33, data . Statistical heterogeneity was still significant (I2
Batterham et al. BMC Musculoskeletal Disorders 2011, 12:123 Page 10 of 13http://www.biomedcentral.com/1471-2474/12/123 Figure 2 Meta-analysis of function removing the data for Foley, et al.,showing a non significant difference between the two exercise strategies.= 57%) and no significant difference between interven- similarity between groups. Statistical heterogeneity wastions (n = 136 aquatic, 132 land based) was detected significant (I2 = 52%) and a random effects model was(SMD 0.19 (95% CI = -0.19, 0.56) (Figure 3). applied (Figure 6). No significant difference between Function outcomes and indices that encompassed groups (n = 97 aquatic, 100 land based) was detectedmultiple domains of health were pooled (Figure 4). Nine (SMD 0.16 (95% CI = -0.29, 0.62))trials (n = 281 aquatic and 275 land based) wereincluded. Statistical heterogeneity was not significant (I2 Discussion= 33%) and no significant difference between groups For all outcomes assessed in this review no statisticallywas observed (SMD 0.07 (95% CI = -0.24, 0.10)). significant differences were found for outcomes follow- For mobility outcomes a smaller scores indicated bet- ing water based compared to land based exercise. Thister health. The pooled SMD was 0.03 (95% CI = -0.16, finding was not affected by exclusion or inclusion of0.21) indicating no statistically significant difference trials with significant differences between groups priorbetween exercise strategies. Suomi and Collier and to the intervention.Wyatt et al. both reported data that indicated significant Although the majority of trials excluded participantsbetween group differences at baseline [22,30]. When with a history of surgery within the previous threedata were pooled without data from these trials hetero- months, some trials did not report against this charac-geneity improved (I 2 = 0%) but conclusions were teristic. The results should therefore be considered tounchanged (Figure 5). No significant difference between reflect outcomes for participants who were, in mostgroups (n = 198 aquatic, 197 land based) was found cases, participating in treatment for arthritis.(SMD = 0.04 (95% CI = -0.15, 0.24)). Trials assessed a variety of measures relating to func- Three trials assessed dynamic balance or mobility tion, pooled indices and mobility. While a wide variety[7,22,25] and all provided data that indicated baseline of functional outcomes were used, the WOMAC was Figure 3 Meta-analysis of outcomes that included multiple health domains removing the data for Fransen, et al. showing a non significant difference between the two rehabilitation strategies.
Batterham et al. BMC Musculoskeletal Disorders 2011, 12:123 Page 11 of 13http://www.biomedcentral.com/1471-2474/12/123 Figure 4 Meta-analysis of function and indices which included multiple health domains showing a non significant effect for differences between the two exercise strategies.the most common. The majority of trials assessed timed Analysis with and without trials with significant baselinewalks. Suomi and Collier and Wyatt et al. reported data differences did not change any review conclusions.for a 792 m and a 1609 m walk test respectively [22,30]. Only two trials, Foley et al. and Suomi and CollierThese longer distances require different training and found a statistically significant difference between landmay test walking endurance as well as speed. Both trials and aquatic exercise for any assessed outcome [1,22].had significant group differences at baseline confound- Foley et al. reported a significant difference betweening a view of the effectiveness of interventions for this groups for function and pooled indices . Significantoutcome. baseline differences for function (SMD =-0.81, 95% CI Significant baseline differences distort post-interven- -1.30, -0.33) favouring land based exercise) were foundtion SMDs and may hinder a true reflection of between and attrition rates of 26% for land based and 20% ofgroup differences. Significant baseline differences may aquatic study participants further confounded a view ofalso signal inadequate randomisation of participants. valid differences in intervention effects. Although Suomi Figure 5 Meta-analysis of walking ability without data for Suomi and Collier and Wyatt, et al., showing a non significant difference between the two rehabilitation strategies.
Batterham et al. BMC Musculoskeletal Disorders 2011, 12:123 Page 12 of 13http://www.biomedcentral.com/1471-2474/12/123 Figure 6 Meta-analysis of dynamic balance showing a non significant difference between the two rehabilitation strategies.and Collier found a significant intervention effect for the or land based exercise provide better function or mobi-792 m walk, assessment of the veracity of this result is lity outcomes. Variability in study parameters, studyconfounded . There were significant baseline differ- quality and exercise interventions may have contributedences and few participants (10 in each group). random error to outcomes, confounding the view of effects, however it is likely that both approaches yieldExercise Intervention comparable results. Most trials had design flaws, limitingWater and land both provide an environment for exer- confidence in observed effects. Three high quality trialscise. Regardless of the exercise medium, program goals (Silva et al., Smith et al. and Fransen et al.) each foundcan vary significantly. They may focus on improving no significant difference in outcomes for land comparedfunction, range of movement or strength. Differences to aquatic exercise [2,7,31].between land based programs are seen in descriptions of High quality trial design, with intention-to-analysis,Tai Chi, gym or home based exercise programs. Aquatic adequate follow-up and baseline similarity, wouldprograms also varied substantially (see Tables 4 &5). advance the quality of work in this field. Arguments for Justification for the content of exercise interventions choice of exercise components and rationale for exerciseor exercise selection was rarely provided and few trials choice and parameters would advance the science ofreported enough detail for both land and aquatic pro- exercise in water. There is a lack of information ongrams to be reproduced reliably. patient satisfaction or adherence to exercise interven- No rationale was provided for the water depth at tions despite the importance of patient engagement inwhich exercises were performed and no authors exercise programs.reported the use of shallow water to progressivelyincrease weight bearing and resistance. There was also Clinical Applicationsno explanation for the inclusion or exclusion of bal- Both aquatic and land based exercise programs appearance and trunk control exercises. No authors reported to result in comparable outcomes for function, mobilitythe use of high intensity exercise in the water, for or pooled indices. The prescription of aquatic exerciseexample with increased turbulence and speed. The for arthritic conditions may not be warranted due to theresistance used in water exercise was also highly vari- cost and limited availability of aquatic programs. For theable. Quantification of resistance applied in the aqua- blanket prescription of aquatic exercise for people withtic programs through turbulence, buoyancy, therapists arthritis, high quality trials showing clear benefits ofor elastic bands was not described in any of the trials. aquatic programs compared to land based programs areIn the aquatic programs a wide variety of equipment required. On the other hand aquatic exercise appearswas used to provide resistance including noodles, neither more nor less effective than land based exercise.rings, kickboards, gaiters, balls, floats and aqua belts, For people who have significant mobility or functionbut the reasons for these choices were not stated. limitations and are unable to exercise on land, aquaticDepth and temperature of water appeared similar exercise appears to be a legitimate alternative that mayacross trials. enable people to successfully participate in exercise. Clinical decision making regarding exercise choiceConclusion should consider patients’ specific requirements and dis-Overall aquatic and land based exercises appeared to abilities, patients’ preferences, therapist expertise andresult in comparable outcomes for participants. Meta- best available evidence as well as practical considera-analysis did not provide confidence that either aquatic tions such as availability and cost.
Batterham et al. BMC Musculoskeletal Disorders 2011, 12:123 Page 13 of 13http://www.biomedcentral.com/1471-2474/12/123Additional material 10. Thomas A, Eichenberger G, Kempton C, Pape D, York S, Decker AM, Kohia M: Recommendations for the treatment of knee osteoarthritis, using various therapy techniques, based on categorizations of a Additional File 1: Effects of intervention on function. literature review. Journal of Geriatric Physical Therapy 2009, 32:33-38. Additional File 2: Effects of intervention on outcomes that 11. Callahan LF: Physical activity programs for chronic arthritis. Current encompass multiply health domains. Opinion in Rheumatology 2009, 21:177-182. 12. de Morton NA: The PEDro scale is a valid measure of the methodological Additional File 3: Effects of interventions on mobility. quality of clinical trials: a demographic study. Australian Journal of Physiotherapy 2009, 55:129-133. 13. Macedo LG, Elkins MR, Maher CG, Moseley AM, Herbert RD, Sherrington C: There was evidence of convergent and construct validity ofAbbreviations Physiotherapy Evidence Database quality scale for physiotherapy trials.ADL: Activities of Daily Life; AIMS2: Arthritis Impact Measurement Scale 2; Journal of Clinical Epidemiology 2010, 63:920-925.ASE: Arthritis Self-Efficacy score; CI: Confidence Interval; HAQ: Health 14. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M: Reliability ofAssessment Questionnaire; IQR: Inter-quartile range; KOOS: Knee Injury and the PEDro scale for rating quality of randomized controlled trials.Osteoarthritis Outcome Score; MCS: Mental component Summary Scale; Physical Therapy 2003, 83:713-721.PCS: Physical Component Summary Scale; QoL: Quality of Life; ROM: Range 15. PEDro: Physiotherapy Evidence Database. [http://www.pedro.org.au/].of Movement; SMD: Standardised Mean Difference; VAS: Visual Analogue 16. Sadana R, Tandon A, Serdobova I, Cao Y, Xie WJ, Chatterji S, Ustün BL:Scale; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Describing Population Health in six Domains: comparable results from 66Index; 50FWT: 50 Foot Walk Test. household surveys. Geneva, Switzerland: World Health Organization; 2002. 17. Hedges LV, Olkin I: Statistical Methods for Meta-Analysis Orlando: AcademicAuthor details Press, Inc; 1985.1 Department of Physiotherapy, Monash University Peninsula campus, 18. Cohen J: Statistical power analysis for the behavioral health sciences. 2McMahons Rd, Frankston, Australia. 2The Melbourne Sports Medicine Centre, edition. Hillsdale, New Jersey: Lawrence Erlbaum Associates, Inc; 1988.4/250 Collins St, Melbourne, Australia. 19. The Cochrane Collaboration: Review Manager (RevMan). Copenhagen: The Nordic Cochrane Centre;, 5.0 2008.Authors’ contributions 20. Higgins J, Thompson S, Deeks J, Altman D: Measuring inconsistency inAll authors participated in the design of the review and read and approved the meta-analyses. BMJ 2003, 327:557-560.final manuscript. SH repeated the selection of studies for inclusion in the review, 21. Hall J, Skevington SM, Maddison PJ, Chapman K: A randomized anddata extraction and analysis. JK supervised the overall development of the review, controlled trial of hydrotherapy in rheumatoid arthritis. Arthritis Care &clarified statistical analysis methods, assisted in the interpretation of results and Research 1996, 9:206-215.writing of the manuscript and provided a third independent assessment where 22. Suomi R, Collier D: Effects of arthritis exercise programs on functionalnecessary. SB developed inclusion/exclusion criteria, performed the searches on fitness and perceived activities of daily living measures in older adultsthe databases, designed tables for data extraction, performed data extraction and with arthritis. Archives of physical medicine and rehabilitation 2003,meta-analysis. Both authors wrote the text of the review. 84:1589-1594. 23. Eversden L, Maggs F, Nightingale P, Jobanputra P: A pragmaticCompeting interests randomised controlled trial of hydrotherapy and land exercises onThere are no financial or non-financial competing interests for any authors. overall well being and quality of life in rheumatoid arthritis. BMCThe systematic review was completed as partial fulfilment of the Bachelor of Musculoskeletal Disorders 2007, 8.Physiotherapy with Honours degree (Monash University). 24. 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Fransen M, Nairn L, Winstanley J, Lam P, Edmonds J: Physical activity for The pre-publication history for this paper can be accessed here: osteoarthritis management: a randomized controlled clinical trial http://www.biomedcentral.com/1471-2474/12/123/prepub evaluating hydrotherapy or Tai Chi classes. Arthritis & Rheumatism: Arthritis Care & Research 2007, 57:407-414. doi:10.1186/1471-2474-12-1238. Geytenbeek J: Evidence for effective hydrotherapy. Physiotherapy 2002, 88:514-529. Cite this article as: Batterham et al.: Systematic review and meta- analysis comparing land and aquatic exercise for people with hip or9. Bartels EM, Lund H, Hagen KB, Dagfinrud H, Christensen R, Danneskiold- knee arthritis on function, mobility and other health outcomes. BMC Samsoe B: Aquatic exercise for the treatment of knee and hip Musculoskeletal Disorders 2011 12:123. osteoarthritis. Cochrane Database of Systematic Reviews 2009.