Research Articles

EVIDENCE-BASED RESEARCH

There is extensive evidence supporting the use of aquatic physiotherapy (hydrotherapy) exercise in the treatment of many conditions. Here is a summary of some of this research.


Use of hydrotherapy / aquatic physiotherapy pre-operatively for hips and knees

For many people, participating in aquatic physiotherapy prior to surgery for my hip/knee replacement is helpful to their condition, with pain reduction more likely than with land exercise only.A study by Gill and McBurney (2009) showed benefit from both land and aquatic physiotherapy prior to surgery. Walking and sit to stand (a measure of function) improved in land and aquatic groups, however immediate pain relief after the class was better in the aquatic group.This is great news for prospective patients who have trouble walking or exercising on land as the aquatic option appears to offer as many benefits as the land program, plus the added benefit of pain relief.There are other studies showing a benefit to pre-operative exercise.  A study by Wallis and Taylor (2011) looking at 23 studies with 1461 participants waiting for hip or knee replacement surgery demonstrated that pre-operative exercise does reduce pain prior to having joint replacement surgery. The inclusion of some educational sessions to the exercise programs may also improve activity after surgery.Some studies show no benefit to the long term result after surgery, but a factor not considered is that many prospective surgical patients spend the 3-6months period leading up to their surgery on a walking stick and minimizing their exercise due to stiffness and pain. They lose fitness and some gain weight.

All canadians should get a minimum of ½ hour of reasonable exercise a day for heart, brain and other health. Attending aquatic therapy prior to surgery may help you to maintain general health and wellbeing while you are unable to perform your normal exercise. Being sedentary while waiting for surgery is likely to result in a larger health and fitness deterioration than remaining active by attending hydrotherapy.

For more information, please see:

  • Gill SD, McBurney H, Schulz DL (2009): ‘Land-based versus pool-based exercise for people awaiting joint replacement surgery of the hip or knee: results of a randomized controlled trial’. Archives of Physical Medicine and Rehabilitation. 90(3): 388-394
  • Wallis J and Taylor N (2011): ‘Pre-operative interventions (non-surgical and non-pharmacological) for patients with hip or knee osteoarthritis awaiting joint replacement surgery–a systematic review and meta-analysis’. Osteoarthritis Cartilage 19(12): 1381-95

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Hydrotherapy after surgery – wound management

A recent systematic review by Villalta et al. (2013) of eight studies with 287 participants showed that “after orthopaedic surgery aquatic physical therapy improves function and does not increase the risk of wound-related adverse events and is as effective as land-based therapy in terms of pain, edema, strength, and range of motion in the early postoperative period”.This evidence should provide assurances for doctors and physios that sending patients to aquatic physiotherapy post-surgery is a definite possibility in the early rehabilitation process.Our practice was responsible for the aquatic physiotherapy treatment provided in one of the studies in this systematic review (Rahmann et al 2009). Our management of total hips and knees is based on this and other studies ensuring best outcomes and safe, hygienic practice. Therefore patients to Brisbane Hydrotherapy can rest assured that they are receiving the very best practice in care.

For more information, please see:

  • Rahmann AE, Brauer SG, Nitz JC (2009): ‘A specific inpatient aquatic physiotherapy program improves strength after total hip or knee replacement surgery: a randomized controlled trial’. Arch Phys Med Rehabil. 90(5):745-55. doi: 10.1016/j.apmr.2008.12.011.
  • Villalta, EM, Peiris, CL (2013): ‘Early aquatic physical therapy improves function and does not increase risk of wound-related adverse events for adults after orthopedic surgery: a systematic review and meta-analysis’. Arch Phys Med Rehabil. 94(1):138-48

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Osteoarthritis and Aquatic Physiotherapy can improve stiffness, pain, physical function, well-being and mood

Ostearthritis of the hip and knee are common conditions that effect a large percentage of the population. A study by Hinman et al. (2007) showed improvement in pain, stiffness, hip strength and quality of life in osteoarthritis patients after they participated in a six-week program of aquatic physical therapy. The program was carried out in a 34XX heated indoor pool with an experienced aquatic physical therapist. Patients were encouraged to continue with their program after the six-week intervention was completed.

A study by Belza et al. (2002) looked at the effect of regular attendance at aquatic exercise for people with osteoarthritis. The results showed that “consistent participation in exercise programs results in better outcomes”. The study showed improved quality of well-being, physical function and change in arthritis quality of life in the treatment group compared to controls (who did no water exercise). When comparing treatment-group adherers to treatment-group non-adherers (irregular attenders), quality of well-being and depressed mood improved for adherers, but not for non-adherers. So… the more regular your attendance the better you feel.

For more information, please see:

  • Hinman RS, Heywood SE, Day AR (2007): ‘Aquatic physical therapy for hip and knee osteoarthritis: results of a single-blind randomized controlled trial’. Phys Ther. 87(1):32-43.
  • Belza, B, Topolski, T, Kinne, S, Patrick, DL, Ramsey, SD (2002): ‘Does Adherence Make a Difference?: Results From a Community-Based Aquatic Exercise Program’. Nursing Research 51(5):285-91.

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Hydrotherapy in the treatment of cerebral palsy

There is a recognised lack of research related to cerebral palsy and aquatic physiotherapy. Yet children and adults with cerebral palsy and their parents/carers/support workers seek out hydrotherapy as a way of managing tone and spasticity, improving function and strength, promoting health and well-being, decreasing pain, providing aerobic exercise and as a recreational/relaxation pursuit.

A 2011 systematic review by Blohm looked at 8 studies, including three randomised controlled trials. “All eight studies reported that aquatic interventions, either as a major component or as a stand-alone intervention, were beneficial for children and adolescents with cerebral palsy.” Benefits reported in the studies included:

  • improvement in gross motor skills, and maintaining improvements for 3 – 6 months after the intervention
  • improvement in function including walking efficiency, lower limb muscle strength, balance, respiratory function and reduced spasticity (tone)
  • positive results for passive range of motion
  • increased swimming skills (in some studies)
  • performance, satisfaction, social functioning and self-perception.

Another study by Gorter and Currie (2011) looked at articles published since 2005 and found the majority were done on higher functioning children with cerebral palsy, in particular ambulatory adolescent children with spastic CP (diplegia and hemiplegia; GMFCS levels I, II, and III). In that time there was only one study on a child with GMFCS level IV and no studies which included children with GMFCS level IV. Participants in this study showed improvements in various areas including muscle strength, energy expenditure, gross motor function scores and mobility performance in home, and community environments.

A third paper, another systematic review by Jorgić and  Dimitrijević et al (2012) also reported aquatic intervention having a positive effect on improving physical fitness and social behaviour in children and adults with cerebral palsy. Another 2013 systematic review, by Franzen and Tryniszewski (2013) also concludes that aquatic therapy programs caused statistically significant improvements in the GMFM and gait parameters, gait velocity and stride length. Overall, aquatic therapy was shown to be effective in improving motor function in children ages 6 months-21 years, with various diagnoses involving neuromotor impairments (including cerebral palsy, rett syndrome and autism). The review also showed that aquatic therapy as an intervention had a very low risk of adverse events/harm to patients.

For more information, please see:

  • Blohm D (2012): ‘Effectiveness of aquatic interventions for children with cerebral palsy: systematic review of the current literature’. Phys Ther. 19(1):19-29.
  • Jorgić B & Dimitrijević K et al. (2012): ‘Effects of aquatic programs in children and adolescents with cerebral palsy: systematic review’. Sports Science 5(2):49-56.
  • Franzen  K & Tryniszewski P (2013): ‘Effectiveness of Aquatic Therapy for Children with Neurodevelopmental Disorders: A Systematic Review of Current Literature’.
  • Gorter J & Currie S (2011). ‘Aquatic Exercise Programs for Children and Adolescents with Cerebral Palsy: What Do We Know and Where Do We Go?’ Int J Pediatr. doi: 10.1155/2011/712165.

Hydrotherapy for fibromyalgia syndrome (FMS)

A 2009 systematic review (Perraton and Matochka 2009) concluded that there is strong evidence for the use of hydrotherapy in the management of FMS.

Many of the studies in this review used physiotherapy supervision of the hydrotherapy program as opposed (for example) to self- lead or volunteer-lead programs. Professional supervision may be an important component of hydrotherapy programs for FMS. This may possibly be due to the fact that a progressive exercise program is usually what is required and in most cases volunteers and even allied heath assistants are unable to progress or change exercises.

Of the 11 studies that were reviewed, aerobic exercise featured in all studies and strengthening and flexibility exercises were included in a majority of the programs.

Improved anxiety and depression-related outcomes were reported immediately following intervention periods and after follow up periods in a number of trials. The exercise component of the studies (as opposed to the relaxation or passive components) may be more important in changing depression-related outcomes in the FMS patient.

Another 2008 systematic review by  McVeigh and McGaughey reported positive outcomes for pain, health-status and tender point count. There is strong evidence for the use of hydrotherapy in the management of FMS.

The European League Against Rheumatism (ELAR) published guidelines for the management of FMS in 2007 (Carville and Arendt-Nielsen). They list nine recommendations including hydrotherapy and Individually tailored exercise programmes including aerobic exercise and strength training for the management of FMS.

For more information, please see:

Häuser W, Thieme K & Turk DC (2010): ‘Guidelines on the management of fibromyalgia syndrome – a systematic review’.  J Pain. 14(1):5-10.

McVeigh JG, McGaughey H, Hall M & Kane P (2008): ‘The effectiveness of hydrotherapy in the management of fibromyalgia syndrome: a systematic review’. Rheumatology International. 29(2):119-130

Perraton L, Machotka Z & Kumar S (2009): ‘Components of effective randomized controlled trials of hydrotherapy programs for fibromyalgia syndrome: a systematic review’. Journal of Pain Research. 2:165-173.

Effect of Therapeutic Aquatic Exercise on Symptoms and Function Associated With Lower Limb Osteoarthritis: Systematic Review With Meta-Analysis

  1. B. Waller, PT, MSc, Department of Health Sciences, University of Jyvaskyla, PO Box 35, FI-40014, Jyvaskyla, Finland.,A. Ogonowska-Slodownik, MSc, Faculty of Rehabilitation, Jozef Pilsudski University of Physical Education, Warsaw, Poland., M. Vitor, MSc, Faculty of Sport, University of Porto, Porto, Portugal., J. Lambeck, PT, BHS, KU Leuven, Faculty of Kinesiology and Rehabilitation Sciences, Leuven, Belgium.,D. Daly, PhD, KU Leuven, Faculty of Kinesiology and Rehabilitation Sciences., U.M. Kujala, MD, PhD, Department of Health Sciences, University of Jyvaskyla., A. Heinonen, PhD, Department of Health Sciences, University of Jyvaskyla. Address all correspondence to Mr Waller at: ben.waller@jyu.fi.

Abstract

Background Current management of osteoarthritis (OA) focuses on pain control and maintaining physical function through pharmacological, nonpharmacological, and surgical treatments. Exercise, including therapeutic aquatic exercise (TAE), is considered one of the most important management options. Nevertheless, there is no up-to-date systematic review describing the effect of TAE on symptoms and function associated with lower limb OA.

Purpose The purpose of this study was to conduct a systematic review with meta-analysis to determine the effect of TAE on symptoms and function associated with lower limb OA.

Data Sources The data sources used in this study were: MEDLINE, PubMed, EMBASE, CINAHL, PEDro, and SPORTDiscus.

Study Selection All studies selected for review were randomized controlled trials with an aquatic exercise group and a nontreatment control group. In total, 11 studies fulfilled the inclusion criteria and were included in the synthesis and meta-analysis.

Data Extraction Data were extracted and checked for accuracy by 3 independent reviewers.

Data Synthesis Standardized mean difference (SMD) with 95% confidence interval (95% CI) was calculated for all outcomes. The meta-analysis showed a significant TAE effect on pain (SMD=0.26 [95% CI=0.11, 0.41]), self-reported function (SMD=0.30 [95% CI=0.18, 0.43]), and physical functioning (SMD=0.22 [95% CI=0.07, 0.38]). Additionally, a significant effect was seen on stiffness (SMD=0.20 [95% CI=0.03, 0.36]) and quality of life (SMD=0.24 [95% CI=0.04, 0.45]).

Limitations Heterogeneity of outcome measures and small sample sizes for many of the included trials imply that conclusions based on these results should be made with caution.

Conclusions The results indicate that TAE is effective in managing symptoms associated with lower limb OA.

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