Aquatic exercise for the treatment of knee and hip osteoarthritis (Review

Aquatic exercise for the treatment of knee and hip

osteoarthritis (Review)

Bartels EM, Lund H, Hagen KB, Dagfinrud H, Christensen R, Danneskiold-Samsøe B

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2009, Issue 1

http://www.thecochranelibrary.com

Aquatic exercise for the treatment of knee and hip osteoarthritis (Review)

Copyright © 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 Aquatic exercise versus control after treatment - knee&hip mixed, Outcome 1 Pain. . . 21

Analysis 1.2. Comparison 1 Aquatic exercise versus control after treatment - knee&hip mixed, Outcome 2 Function. 22

Analysis 1.3. Comparison 1 Aquatic exercise versus control after treatment - knee&hip mixed, Outcome 3 Walking

ability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Analysis 1.4. Comparison 1 Aquatic exercise versus control after treatment - knee&hip mixed, Outcome 4 Stiffness. . 24

Analysis 1.5. Comparison 1 Aquatic exercise versus control after treatment - knee&hip mixed, Outcome 5 Quality of life. 25

Analysis 1.6. Comparison 1 Aquatic exercise versus control after treatment - knee&hip mixed, Outcome 6 Mental health. 26

Analysis 2.1. Comparison 2 Aquatic exercise versus control after treatment -hip, Outcome 1 Function. . . . . . 27

Analysis 2.2. Comparison 2 Aquatic exercise versus control after treatment -hip, Outcome 2 Quality of life. . . . 27

Analysis 3.1. Comparison 3 Aquatic exercise versus land after treatment - knee, Outcome 1 Pain. . . . . . . . 28

Analysis 3.2. Comparison 3 Aquatic exercise versus land after treatment - knee, Outcome 2 Walking ability. . . . 28

Analysis 3.3. Comparison 3 Aquatic exercise versus land after treatment - knee, Outcome 3 Stiffness. . . . . . . 29

Analysis 4.1. Comparison 4 Aquatic exercise versus control at follow up - knee&hip mixed, Outcome 1 Pain. . . . 29

Analysis 4.2. Comparison 4 Aquatic exercise versus control at follow up - knee&hip mixed, Outcome 2 Function. . 30

Analysis 4.3. Comparison 4 Aquatic exercise versus control at follow up - knee&hip mixed, Outcome 3 Stiffness. . . 30

Analysis 4.4. Comparison 4 Aquatic exercise versus control at follow up - knee&hip mixed, Outcome 4 Mental health. 31

Analysis 5.1. Comparison 5 Aquatic exercise versus control at follow up - hip, Outcome 1 Pain. . . . . . . . . 31

Analysis 5.2. Comparison 5 Aquatic exercise versus control at follow up - hip, Outcome 2 Function. . . . . . . 32

Analysis 5.3. Comparison 5 Aquatic exercise versus control at follow up - hip, Outcome 3 Quality of life. . . . . 32

32ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

36INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iAquatic exercise for the treatment of knee and hip osteoarthritis (Review)


[Intervention Review]

Aquatic exercise for the treatment of knee and hiposteoarthritis

Else Marie Bartels2, Hans Lund3, Kåre Birger Hagen4, Hanne Dagfinrud5 , Robin Christensen6, Bente Danneskiold-Samsøe1

1The Parker Institute, Frederiksberg Hospital, Frederiksberg, Denmark. 2The Danish National Library of Science and Medicine, Fred-

eriksberg, Denmark. 3Parker Instituttet, Frederiksberg Hospital, Frederiksberg, Denmark. 4National Resource Centre for Rehabilita-

tion in Rheumatology, Diakonhjemmet Hospital, 0319 Oslo, Norway. 5Section for Health Science, University of Oslo, Oslo, Norway.6Parker Institute: Musculoskeletal Statistics Unit, Frederiksberg Hospital, Frederiksberg, Denmark

Contact address: Bente Danneskiold-Samsøe, The Parker Institute, Frederiksberg Hospital, Frederiksberg, DK-2000, Denmark.

[email protected].

Editorial group: Cochrane Musculoskeletal Group.

Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009.

Review content assessed as up-to-date: 14 August 2007.

Citation: Bartels EM, Lund H, Hagen KB, Dagfinrud H, Christensen R, Danneskiold-Samsøe B. Aquatic exercise for the

treatment of knee and hip osteoarthritis. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD005523. DOI:

10.1002/14651858.CD005523.pub2.


A B S T R A C T

Background

Clinical experience indicates that aquatic exercise may have advantages for osteoarthritis patients.

Objectives

To compare the effectiveness and safety of aquatic-exercise interventions in the treatment of knee and hip osteoarthritis.

Search methods

We searched MEDLINE from 1949, EMBASE from 1980, CENTRAL (Issue 2, 2006), CINAHL from 1982, Web of Science from

1945, all up to May 2006. There was no language restriction.

Selection criteria

Randomised controlled trials or quasi-randomised clinical trials.

Data collection and analysis

Two review authors independently selected trials for inclusion, assessed the internal validity of included trials and extracted data. Pooled

results were analyzed using standardized mean differences (SMD).

Main results

Thre is a lack of high-quality studies in this area. In total, six trials (800 participants) were included. At the end of treatment for

combined knee and hip osteoarthritis, there was a small-to-moderate effect on function (SMD 0.26, 95% confidence interval (CI)

0.11 to 0.42) and a small-to-moderate effect on quality of life (SMD 0.32, 95% CI 0.03 to 0.61). A minor effect of a 3% absolute

reduction (0.6 fewer points on a 0 to 20 scale) and 6.6% relative reduction from baseline was found for pain. There was no evidence of

effect on walking ability or stiffness immediately after end of treatment. No evidence of effect on pain, function or quality of life were

observed on the one trial including participants with hip osteoarthritis alone. Only one trial was identified including knee osteoarthritis

1Aquatic exercise for the treatment of knee and hip osteoarthritis (Review)


mailto:[email protected]

alone, comparing aquatic exercise with land-based exercise. Immediately after treatment, there was a large effect on pain (SMD 0.86,

95%CI 0.25 to 1.47; 22% relative percent improvement), but no evidence of effect on stiffness or walking ability. Only two studies

reported adverse effects, that is, the interventions did not increase self-reported pain or symptom scores. No radiographic evaluation

was performed in any of the included studies.

Authors’ conclusions

Aquatic exercise appears to have some beneficial short-term effects for patients with hip and/or knee OA while no long-term effects

have been documented. Based on this, one may consider using aquatic exercise as the first part of a longer exercise programme for

osteoarthritis patients. The controlled and randomised studies in this area are still too few to give further recommendations on how

to apply the therapy, and studies of clearly defined patient groups with long-term outcomes are needed to decide on the further use of

this therapy in the treatment of osteoarthritis.

P L A I N L A N G U A G E S U M M A R Y

Aquatic exercise for osteoarthritis

This summary of a Cochrane review presents what we know from research about the effect of aquatic exercise for osteoarthritis of the

hip or knee. The review shows that:

There is gold level evidence that for osteoarthritis of the hip or knee, aquatic exercise probably slightly reduces pain and slightly improves

function over 3 months.

The progression of damage in osteoarthritis as seen on x-rays was not measured. Therefore, it is not known whether aquatic exercise

improves the progression of osteoarthritis.

Aquatic exercise may not cause harm. But there is not enough evidence to be certain.

More research is needed to determine long term effects and to understand which type of aquatic exercise, how often and for how long,

might be beneficial.

What is osteoarthritis and what is aquatic exercise?

Osteoarthritis (OA) is the most common form of arthritis that affects the hips and knees. In OA, the cartilage that protects the ends

of the bones breaks down and causes pain and swelling. Aquatic exercise is sometimes known as ’pool therapy’ or ’hydrotherapy’. It

involves exercises in water that is heated to about 32 to 36 degrees Celsius. Exercises may include aerobic activities, stretching and

strengthening, and range of motion.

What are the effects of aquatic exercise?

In the studies, some people did aquatic exercises for different lengths of time and number of sessions per week, while other people did

no exercise or exercises on land. The effects were mainly measured at 3 months.

In people with osteoarthritis of the hip or knee,

- pain may decrease by 1 more point on a scale of 0 to 20 with aquatic exercise

- function may improve by 3 more points on a scale of 0 to 68 with aquatic exercise

- progress of damage of osteoarthritis as seen on x-rays was not measured

- there may be little or no difference in harms such as pain or other symptoms with aquatic exercises than with no exercise



B A C K G R O U N D

Osteoarthritis (OA) is a chronic disease ’characterized by joint

pain, tenderness, limitation of movement, crepitus, occasional ef-

fusion, and variable degrees of local inflammation, but without sys-

temic effects’ (Brandt 1986). ’The disease process not only affects

the articular cartilage, but involves the entire joint, including the

subchondral bone, ligaments, capsule, synovial membrane, and

periarticular muscles’ (Flores 2003). OA occurs most frequently

in knees hands, hips, back and neck (Felson 2003). The character-

istics of the disease are thickening of the joint capsule, progressive

cartilage loss, and osteophyte formation, leading to functional im-

pairments (Oliveria 1995; Sowers 2000). Epidemiological studies

show that osteoarthritis accounts for more trouble in walking and

climbing stairs than any other musculoskeletal disease (Guccione

1994). At present, only treatment of the symptoms and treatment

to prevent further development of the disease are possible. Knee

and hip osteoarthritis are widespread diseases, seen in up to 6% of

the population (Felson 1998). OA is hardly ever seen in children

or adults younger than 40 years of age (Oliveria 1995; Sowers

2000). However, the prevalence increases with age, and, due to the

growing group of elderly people, a higher prevalence will probably

be seen in the future. This review is limited to osteoarthritis of the

knee and hip joint.

The aim of physical therapy treatment for osteoarthritis patients

is to improve pain control and improve physical capacity. This

might be achieved by the following changes: increased muscle

strength, improved balance and coordination of movements, and

better joint mobility (Hurley 2003). Improved muscle strength in

osteoarthritis patients is correlated to the patient’s functional level

(Gur 2002). However, due to pain or very low functional levels, it

is often difficult to apply an adequate strength-exercise program.

In addition, with increasing joint damage, it may not be possible

to carry out a whole range of exercises, normally possible on land,

with an osteoarthritis patient.

Over the years, aquatic exercise has been known as pool therapy,

hydrotherapy, and sometimes in earlier literature even balneother-

apy. The treatment has to take part in water and involve exercises.

The water is most often heated to 32º to 36º Celsius. Today, bal-

neotherapy covers use of hot-water treatment known to ease pain,

decrease stiffness and cause muscle relaxation, and this has been

further developed with various forms of salt and/or sulphur treat-

ment, mud packs, and jet streams (spa-therapy)(Verhagen 2000).

Since the main aim of physical therapy for osteoarthritis patients is

to improve their physical ability, the present review will only look

at studies where aquatic exercise in some form has been applied.

Aquatic exercise may be advantageous for osteoarthritis patients.

When the hot-water element is included, it is thought that it gives

the arthritis patients decreased pain sensation, decreases stiffness

of the muscular-skeletal system, and causes muscle relaxation (

Elkayam 1991). Aquatic exercise may therefore be a better base

on which to start training of osteoarthritis patients than a similar

training on land.

O B J E C T I V E S

To compare the effectiveness and safety of aquatic-exercise inter-

ventions in the treatment of knee and hip osteoarthritis when these

are compared to other interventions or no intervention.

M E T H O D S

Criteria for considering studies for this review

Types of studies

Studies were eligible if they were randomised controlled trials or

quasi-randomised clinical trials.

Types of participants

Patients with osteoarthritis (OA) in either one or both knee(s) or

one or both hip(s), as defined by the American Rheumatology

Association (ARA) criteria (Altman 1986) who did not suffer from

any other arthritic conditions or any other disease which may

affect the joints. All degrees of, and both primary and secondary

OA, were eligible. Studies including a mixture of patients with

hip or knee OA, were examined in order to evaluate whether it

was possible to distinguish between knee and hip OA. Studies

including a mixture of different rheumatic patients were included

only if it was possible to extract the data from the OA patients. If

possible, the level of disability was described, and possible gender

difference were considered.

Types of interventions

Studies included one treatment group in which aquatic exercise

was applied. All types of exercises developed in the therapeutic/

heated indoor pool (ROM, dynamics, aerobics etc.) were per-

mitted. The use of medication, alternative therapies or lifestyle

changes were described, and must have been comparable in the

groups studied. When comparing different programs, types of ex-

ercise, depth of water, and temperature will be considered.

Types of outcome measures

The primary outcome for measurement of effectiveness was the

benefit or harm of aquatic exercise therapy. Beneficial outcome

measures recommended by OMERACT III (Bellamy 1997) in-

cluded the following:

Primary outcomes



Pain

Functional status (for example, measured by the Activities of Daily

Living Scale, patient global assessment)

Radiographs (studies > one year)(Bellamy 1997)

Adverse effectsTotal number withdrawals

Number withdrawals due to adverse events

Total adverse events

Secondary outcomesConsumption of medicine, home care consumption, surgery, re-

turn to work, psychological well being, coping skills, measures such

as ambulatory function, walking speed, endurance in the form of

a standardized walk test (e.g. 6 minute walk), use of gait aids.

Search methods for identification of studies

1) Bibliographic databases

We searched the following databases: CENTRAL (The CochraneLibrary Issue 2, 2006), MEDLINE from 1949, EMBASE from

1980, CINAHL from 1982, Web of Science from 1945, all up to

May 2006.

The search strategies contained the following elements:

Osteoarthritis/osteoarthrosis, and if possible osteoarthritis of the

knee or of the hip, and all reasonable expressions for aquatic ther-

apy. There was no restriction on language.

Specified search strategiesWe used broad search strategies which created a high proportion of

non-relevant references, but since a wide range of terms have been

used for aquatic exercise over the years, this did, on the other hand,

ensure that relevant references were retrieved. We searched for both

osteoarthritis and the more specific ’knee’ or ’hip’ osteoarthritis.

This is important to prevent missing out on important references

using more specific terminology. Aquatic exercise is not clearly

indexed in the bibliographic databases, but the aforementioned

considerations ought to have lead to a fairly complete retrieval.

Search strategies:Cochrane Central Register of Controlled Trials (CENTRAL):This database was searched following the strategy for search in

MEDLINE and EMBASE (see below).

MEDLINE via PubMed(osteoarthritis OR knee osteoarthritis OR hip osteoarthritis OR

osteoarthros?s) AND (balneotherapy OR hydrotherapy OR swim-

ming OR pool therapy OR aquatic exercises OR water exercises

OR water)

EMBASEI

osteoarthritis (keyword exploded) OR knee osteoarthritis (key-

word exploded) OR hip osteoarthritis OR osteoarthros?s

AND

balneotherapy (keyword exploded) OR swimming (keyword ex-

ploded) OR hydrotherapy OR aquatic exercise* OR aquatic sport*

OR pool therapy OR water aerobics OR water exercise* OR water

run* OR water training OR water gymnastics

II

osteoarthritis (keyword exploded) OR knee osteoarthritis (key-

word exploded) OR hip osteoarthritis OR osteoarthros?s

AND

physiotherapy (keyword exploded) OR sport (keyword exploded)

AND

water OR aquatic OR pool

The end result is:

I OR II

CINAHLI

osteoarthritis (keyword exploded) OR osteoarthros?s

AND

balneotherapy (keyword exploded) OR swimming (keyword ex-

ploded) OR hydrotherapy (keyword exploded) OR aquatic exer-

cises (keyword exploded) OR aquatic sports (keyword exploded)

OR pool therapy OR water aerobics OR water run* OR water

training OR water gymnastics

II

osteoarthritis (keyword exploded) OR osteoarthros?s

AND

physical therapy (keyword exploded)

AND


The end result is:

I OR II

Web of scienceI

osteoarthritis OR knee osteoarthritis OR hip osteoarthritis OR

osteoarthros?s

AND

balneotherapy OR swimming OR hydrotherapy OR aquatic ex-

ercise* OR aquatic sport* OR pool therapy OR water aerobics

OR water exercise* OR water run* OR water training OR water

gymnastics

II

osteoarthritis OR knee osteoarthritis OR hip osteoarthritis OR

osteoarthros?s

AND

physiotherapy OR physical therapy OR sport *

AND


The end result is:

I OR II

PEDro (Physiotherapy Evidence Database):

Therapy: Hydrotherapy, Balneotherapy.

The Danish National Library of Science and Medicine’s catalogue

in the systematic group covering pool therapy was searched to

make sure that there would not be any older studies published as

monographs.



2) Reference checking

We checked the references of included studies for further relevant

literature.

3) Handsearching

We handsearched abstracts published in Physical Therapy from

the APTA Annual Conference 2002 to 2006, in Rheumatology

Supplement from BSR Annual Meeting 2002 to 2006, and from

the Scandinavian Journal of Rheumatology from the Scandinavian

Congress of Rheumatology 2002 to 2006.

4) Other

In addition, we contacted institutions, societies, specialists known

to have expertise in aquatic therapy and authors of included studies

to identify any additional published or unpublished data.

Data collection and analysis

Selection of trials

Two review authors (EMB, HL) independently screened abstracts,

keywords and publication type of all publications obtained from

the described searches. Uncertainty or disagreements were resolved

by discussion with BDS, HD and KBH. Where the method of

randomization or data (standard deviation or error) was not clearly

described, or where data were missing, the authors of the study

in question were contacted to clarify the issues. All studies which

might be eligible RCT’s, or quasi-RCT’s, were obtained in full and

assessed, based on the inclusion and exclusion criteria. Trials which

were excluded were identified and are presented with reasons for

exclusion.

Quality assessment of included studies

In order to ensure that variation was not caused by systematic errors

in the study design or execution, two review authors (EMB, HL)

independently assigned each selected study to quality categories

described in the Cochrane Handbook for Systematic Reviews of

Interventions (Higgins 2005). Uncertainty or disagreements were

resolved by discussion with BDS, HD and KBH. Where further

information about the studies was needed, the authors of these

studies were contacted for clarification. The following five criteria

were used:

a) Blinding of provider or patient

MET: The patient or the provider was blinded for the interven-

tion.

UNCLEAR: Blinding not reported

NOT MET: The patient and the provider were not blinded for

the intervention.

(a) is an impossible criteria to set for aquatic exercise since both

patient and provider clearly is aware of the treatment).

b) Concealment of allocation

ADEQUATE: (A) indicates adequate concealment of the alloca-

tion (for example, by telephone randomisation, or use of consec-

utively numbered, sealed, opaque envelopes).

UNCLEAR: (B) indicates uncertainty about whether the alloca-

tion was adequately concealed (for example, where the method of

concealment is not known).

INADEQUATE: (C) indicates that the allocation was definitely

not adequately concealed (for example, open random number lists

or quasi-randomisation such as alternate days, odd/even date of

birth, or hospital number).

c) Outcome assessment

MET: assessor unaware of the assigned treatment when collecting

outcome measures.

UNCLEAR: blinding of assessor not reported and cannot be ver-

ified by contacting investigators.

NOT MET: assessor aware of the assigned treatment when col-

lecting outcome measures.

d) Co-intervention

MET: interventions other than exercise avoided, controlled or used

similarly across comparison groups.

UNCLEAR: use of interventions other than exercise not reported

and cannot be verified by contacting the investigators.

NOT MET: dissimilar use of interventions other than exercise

across comparison groups, i.e. differences in the care provided to

the participants in the comparison groups other than the inter-

vention under investigation.

e) Losses to follow-up

MET: losses to follow up less than 20% and equally distributed

between comparison groups.

UNCLEAR: losses to follow up not reported.

NOT MET: losses to follow up greater than 20%.

f) Intention-to-treat

MET: intention to treat analysis performed or possible with data

provided.

UNCLEAR: intention to treat not reported, and cannot be verified

by contacting the investigators.

NOT MET: intention to treat analyses not done and not possible

for reviewers to calculate independently.

Studies were allocated to the following groups: a) low risk of bias

(all criteria MET), b) moderate risk of bias (three to four criteria

MET), and c) high risk of bias (less than three criteria MET). The

studies’ possible conflict of interest was considered as part of the

quality assessment procedure. Other methodological issues such

as baseline comparability, sample size etc. is documented in the

table ’Characteristics of included studies’.

Analyses and Presentation

The studies were stratified in sub-categories according to:

- Length of follow-up (e.g. at the end of treatment and three, six

and twelve months after treatment).

- Type of intervention (e.g. range of motion (ROM) exercise, aer-

obic exercise, group exercise, individual exercise).

- Primary outcomes, as pain and physical function.

The results were allocated into comparable groups. The three pa-

tient groups considered were 1) a mixed group suffering from



hip and/or knee osteoarthritis, 2) a group suffering from hip os-

teoarthritis alone, and finally 3) a group suffering from knee os-

teoarthritis alone.

In each group, the analysis was divided into aquatic exercise versus

control, or aquatic exercise versus another type of exercise.

The meta-analysis focused on outcomes concerning improvement

in the following categories:

• pain

• function

• walking ability

• stiffness

• quality of Life

• mental health

Data extraction

Two review authors (EMB, HL) independently extracted the re-

sults for statistical analysis. Uncertainty or disagreement were re-

solved by discussion with RC, HD, KBH, and BDS.

When choosing the outcome measure for analysis, it is always the

primary outcome decided by the authors. Otherwise we decided

on the following priority list, if more than one measured parameter

for a category was present in the study.

The list for pain measures (in descending order): WOMAC-Pain

(Western Ontario and McMaster Universities Osteoarthritis In-

dex), VAS-Pain (Visual Analogue Scale), HAQ-Pain (Health As-

sessment Questionnaire), SF-36-Pain (Short Form), SF-12-Pain,

AIMS-Pain (Arthritis Impact Measurement Scale).

The list for function measures (in descending order): WOMAC-

Function, HAQ-Function, DRI (Disability Rating Index), SF-

36-Function, ASEQ-Function (Arthritis Self-Efficacy Question-

naire), FAP-Score (Functional Ambulation Performance), SPF-

Scale (Summary Physical Function), AAP (Adelaide Activities’

Profile).

The list for walking ability (in descending order): 6MW (Six Min-

utes Walk), 8 feet walk time, one mile walk time.

The list for stiffness measures (in descending order): WOMAC-

Stiffness, Range of Motion (ROM).

The list for quality of life measures (in descending order): SF-

12-Quality of Life, AIMS-2-Affect, PQOL (Perceived Quality Of

Life Scale), QWB (Quality of Well-Being Scale), GSI (Global

Self-Rating Index), EQ-VAS (European Quality of Life Visual

Analogue Scale).

The list for mental health measures (in descending order): SF-36-

Mental, SF-12-Mental, AIMS-2-Satisfaction, ASEQ-Mental, Sat-

isfaction (Satisfaction with Aquatic Therapy Scale), QWB, Psy-

chological Distress.

Comparisons

Comparisons were made according to type of control group (no

treatment, other treatment). Pooling of trials was only attempted

if at least two trials of comparable aquatic-therapy protocols with

the same conditions, and comparable outcome measurements, ex-

isted.

Statistical analysis was performed using RevMan 4.2 software.

Continuous Outcomes

Since similar, but not identical, instruments were used to measure

pain or functional status etc., we calculated standardized mean

differences (SMD). Heterogeneity was tested by applying a chi-

squared test. If the P-value of this test was lower than 0.25, an I2 test was performed. If the I2 test showed a value greater than

50%, we considered this to indicate substantial heterogeneity, and

a random effects model was used.

Grading of evidence

The grading system used (Tugwell 2004) is recommended by the

Cochrane Musculoskeletal Review Group:

Platinum: A published systematic review that has at least two in-

dividual controlled trials each satisfying the following:

·Sample sizes of at least 50 per group - if these do not find a

statistically significant difference, they are adequately powered for

a 20% relative difference in the relevant outcome.

·Blinding of patients and assessors for outcomes.

·Handling of withdrawals: >80% follow up (imputations based on

methods such as Last Observation Carried Forward (LOCF) are

acceptable).

·Concealment of treatment allocation.

Gold: At least one randomised clinical trial meeting all of the fol-

lowing criteria for the major outcome(s) as reported:

·Sample sizes of at least 50 per group - if these do not find a

statistically significant difference, they are adequately powered for

a 20% relative difference in the relevant outcome.

·Blinding of patients and assessors for outcomes.

·Handling of withdrawals > 80% follow up (imputations based on

methods such as LOCF are acceptable).

·Concealment of treatment allocation.

Silver: Randomised trials that does not meet the above criteria. Sil-

ver ranking would also include evidence from at least one study of

non-randomised cohorts that did and did not receive the therapy,

or evidence from at least one high quality case-control study. A ran-

domised trial with a ’head-to-head’ comparison of agents would

be considered silver-level ranking, unless a reference was provided

for comparison of one of the agents to placebo, and showing at

least a 20% relative difference.

Bronze: The bronze ranking is given to evidence if at least one high

quality case series without controls (including simple before/after

studies in which patients act as their own control) or if the conclu-

sion is derived from expert opinion based on clinical experience

without reference to any of the foregoing (for example, argument

from physiology, bench research or first principles).

Clinical relevance tables

Clinical relevance tables are compiled under additional tables to

improve the readability of the review. Continuous outcome tables

are also presented under ’Additional tables’. Absolute benefit was

calculated as the improvement in the intervention group minus

the improvement in the control group, in original units. Relative

difference in change from baseline was calculated as the absolute



benefit divided by the baseline mean of the control group.

R E S U L T S

Description of studies

See: Characteristics of included studies; Characteristics of excluded

studies.

Results of the search

The literature search identified 30 potential studies.

Included studies

Out of these, six RCTs were included in the systematic review

(Cochrane 2005; n=310), (Foley 2003; n=70), (Patrick 2001; n=

246), (Wyatt 2001; n=46), (Stener-Victorin 2004; n=28), (Wang

2004; n=43). Of the included studies, four studies recruited pa-

tients with both knee or hip osteoarthritis or both (Cochrane 2005;

Foley 2003; Patrick 2001; Wang 2004); one study recruited pa-

tients with hip OA alone (Stener-Victorin 2004), and one study

recruited only patients with knee OA (Wyatt 2001).

Excluded studies

Twenty-four studies were excluded (see table ’Characteristics of ex-cluded studies’ for further information).

Risk of bias in included studies

Hip and knee osteoarthritis mixed

Two of the studies had a sample size higher than 50 in each group

(Cochrane 2005; Patrick 2001). One study recruited 35 in each

group (Foley 2003) and one study recruited 22 in each group

(Wang 2004). Two of the studies performed a blind assessment of

the outcome (Cochrane 2005; Foley 2003), while it was unclear

in the two other studies (Patrick 2001; Wang 2004). Three studies

fulfilled the demand of less than 20% withdrawal (Foley 2003;

Patrick 2001; Wang 2004), but in one other study withdrawal was

not exceeding 28% (Cochrane 2005). Finally, three of the studies

fulfilled the demand of concealment of allocation (Cochrane 2005;

Foley 2003; Wang 2004), while one study did not (Patrick 2001).

In conclusion, the evidence presented in this review is based upon

a GOLD level of evidence.

Hip alone

Only one study was included (Stener-Victorin 2004). The evi-

dence for hip alone was graded as SILVER, since concealment of

allocation was unclear, attempt to avoid co-intervention was not

mentioned, losses to follow up was greater than 20%, and the as-

sessor was not blinded.

Knee alone

Only one study was included (Wyatt 2001). The evidence for

knee alone was graded as SILVER, since concealment of allocation

was unclear, attempt to avoid co-intervention was not mentioned,

losses to follow up were not reported, and no intention-to-treat

analysis was presented

Effects of interventions

Aquatic exercise versus control - measured immediately after the

exercise period

Hip and knee mixed

There was a small but statistically significant effect on function

(SMD: 0.26, 95% confidence interval (CI) 0.11 to 0.42), quality

of life (SMD: 0.32, 95% CI 0.03 to 0.61), and mental health

(SMD: 0.16 95% CI 0.01 to 0.32) in favour of aquatic exercises.

A minor effect of a 3% absolute reduction (0.6 fewer points on

a 0 to 20 scale) and 6.6% relative reduction was found for pain

(SMD: 0.19, 95% CI 0.04 to 0.35). No statistically significant

differences were found for walking ability or stiffness (Cochrane

2005; Foley 2003; Patrick 2001; Wang 2004).

Hip alone

No evidence of effect on function or quality of life was found in

this study (Stener-Victorin 2004).

Knee alone

No study met the inclusion criteria for patients with only knee

OA, and comparing aquatic exercise with a non-exercising control

group.

Aquatic exercise versus control - follow-up measurements

Hip and knee mixed

Only one study reported a six month follow-up (Cochrane 2005).

No difference was found six months after completion of treatment

on pain, function, stiffness or mental health (Cochrane 2005).

Hip alone

No statistically significant difference in function or quality of life

was found in this study (Stener-Victorin 2004).

Knee alone


OA, and comparing aquatic exercise with a non-exercising control

group.

Aquatic exercise versus exercise on land - measured immediately

after the exercise period

Hip and knee mixed

No study met the inclusion criteria for patients with hip and knee

OA, and comparing aquatic exercise with a land-based exercise

group.

Hip alone

No study met the inclusion criteria for patients with only hip OA,

and comparing aquatic exercise with a land-based exercise group.

Knee alone

A large effect was found for pain (SMD: 0.86, 95% CI 0.25 to

1.47) in favour of aquatic exercises, while no evidence of effect

was seen on stiffness or walking ability (Wyatt 2001).

Aquatic exercise versus exercise on land - follow-up measurements

Hip and knee mixed



No study met the inclusion criteria for patients with hip and knee


group.

Hip alone

No study met the inclusion criteria for patients with only hip OA,

and comparing aquatic exercise with a land-based exercise group.

Knee alone



group at follow-up.

Clinical relevance tables are available for knee and hip mixed (Table

1), hip alone (Table 2), and knee alone (Table 3).

Adverse effects

Two studies reported that neither aquatic nor land-based exercise

increase self-reported pain or other symptoms (Foley 2003; Wang

2004). Foley also reported that no difference in drug consump-

tion was observed between the groups (Foley 2003). One study

concluded that none of the drop outs was due to the exercise inter-

ventions (Cochrane 2005). The remaining three studies did not

report anything about adverse effects (Wyatt 2001; Patrick 2001;

Stener-Victorin 2004).

Radiographic evaluation

No radiographic evaluation was performed in any of the included

studies. However, since all studies lasted shorter than one year, this

outcome was not relevant (Bellamy 1997).

D I S C U S S I O N

This review is concerned about the use of aquatic therapy in the

treatment of osteoarthritis of the lower extremities. The condition

is common and affects in particular, older people. There is no cure,

and it is therefore important to look into both prevention and

treatment. The economical consequences of this disease when it

develops into disability are serious (Rothfuss 1997). A treatment of

osteoarthritis which can stop or slow down the disabling process is

therefore of great importance, both when looking at the economy,

and when looking at the quality of life for the patient.

The lower extremities include two joints, the hip and knee. These

joints are very different both in type and loading. The treatment

having an effect on the knee may therefore not have any effect on

the hip joint. In an ideal world, studies would have been designed

to look at aquatic therapy on only one of these joints. In the real

world, it seems that it has been difficult to define patient groups

which were only suffering from osteoarthritis of one of the joints.

Furthermore, the described exercises in the included studies are

not specific to the knee of hip, but both joints. We have therefore

generally carried out analyses on mixed joint studies.

To carry out a meta-analysis, a grading of retrieved studies into

the categories of platinum, gold, silver and bronze is problematic

when looking at aquatic or other exercise therapy. It is obvious

that patient and provider cannot be blinded to the treatment. The

criteria of blinding must in this case be considered irrelevant, and

the overall analysis for the mixed group of patients with hip and

knee OA is acceptable as gold standard. The awareness of being

treated may, on the other hand, still provide a bias when compared

to a control group not exposed to treatment. In the cases where

aquatic exercise is compared to exercises on land, one must assume

that there is no such effect, since both groups receive treatment and

attention from providing staff. For all other studies, bias cannot

be ignored completely.

We found very few studies of a quality acceptable for a meta-

analysis. As our end result, only four studies fulfilled all the set

criteria in the group with a mixture hip and knee OA, and only one

study was acceptable for analysis in each of the groups knee OA

alone and hip OA alone. A separation on joint or exercises aimed

specifically on one of the two joints in question was not possible

in any of the mixed group studies. In this group, two studies had

less than 20% drop-out while the other two studies in this group

had less than 28% drop-out. This is very good for a therapy which

demands out of house treatment several times a week, although

the ideal drop-out ought to be less than 20%.

At the end of the treatment, improvement was seen in physical

function, pain, mental health and quality of life, when compared

to a control group. These effects did not last up to a six month

follow-up in the only study reporting on this (Cochrane 2005), It

may be asked if aquatic exercise has to be maintained at some level

to preserve the improvements seen at the end of the treatment or if

other therapies, like exercise on land, should be applied following

the aquatic exercise. If the patients’ physical ability has improved,

exercises on land become more feasible, especially in the more

disabled patients. Furthermore, exercise on land may more easily

be arranged and at a lower cost.

Exercise may not in all cases be beneficial for patients with knee

or hip OA. One earlier study indicates that strengthening exercise

may increase the OA progression if the patient has a varus malalign-

ment higher than five degrees (Sharma 2003), and another study

of land-based exercise for patients with knee OA indicates an in-

crease in knee oedema following exercise (Rogind 1998). Report

of adverse events of a treatment is important for any treatment.

In the present review, only two studies reported that the inter-

ventions did not increase self-reported pain or symptom scores

(Foley 2003; Wang 2004). No comments on adverse effects were

present in the other included studies. In future studies of effects of

aquatic exercise it is therefore vital to report on adverse as well as

on beneficial effects of the treatment, and it is recommended that

the reporting of adverse effects is presented in accordance to the

Ioannidis and Lau classification (Ioannidis 2001; Ethgen 2005).

Since only one study (Stener-Victorin 2004) compared aquatic

exercise to control in hip OA patients, this is still an area in need

of further study. From this one trial, no positive or negative ef-



fects of aquatic exercise were seen just after or at the three month

follow-up. Based on this study, we can only conclude that aquatic

exercise as applied here has no effect on hip OA alone. An anal-

ysis of the exercises in the programme which had no effect, and

a consideration of what type of training may improve a hip joint

without creating damage, would be the basis on which further

studies ought to be designed, before discarding aquatic exercise as

a possible treatment of hip osteoarthritis.

One study comparing land exercise with aquatic exercise which

concerned only knee OA qualified for inclusion and this study was

of poor quality (Wyatt 2001). A large positive effect on pain at

the end of treatment was found, and no adverse effects were seen.

Unfortunately, no follow-up was carried out. An effect on pain

though is a very important finding, since it suggests that at least

part of the treatment involving training and strengthening of the

muscles around the knee should take part as aquatic exercise, until

the patient’s condition has improved. Pain is often the limiting

factor when using exercise as part of a treatment programme.

The lack of a long-term effect of aquatic exercise found when

analysing the group of mixed hip and knee osteoarthritis patients

may be due to the lack of effect on the hip osteoarthritis which

could hide an effect on the knee osteoarthritis. Since there is no

way of separating the two types of patients in the existing studies,

one can only recommend future studies to be joint specific and to

design an exercise programme which is aimed at the specific joint.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

Aquatic exercise has some short-term beneficial effects on the con-

dition of OA patients with hip or knee OA or both. The controlled

and randomised studies in this area are still too few to give further

recommendations on how to use this therapy. There is a positive

effect on both mixed knee and hip OA and on knee OA alone

at the end of an aquatic training programme. This is not seen in

the only study applying this treatment on hip OA alone. No long-

term effects have been found. Aquatic exercise may therefore be

considered as the first part of an exercise therapy programme to

get particularly disabled patients introduced to training. Further

physical therapy interventions may then continue on land, but

the balance between the two types is still not clear based on the

available studies. Based upon clinical experience, experts consider

it to be a useful intervention thus more research is needed to see if

the indications of a positive effect of aquatic exercise can be sup-

ported by appropriately designed studies with medium and long-

term term follow up.

Implications for research

There are very few randomised controlled trials which consider the

effects of aquatic exercise on knee or hip osteoarthritis. Further-

more, neither type of exercise nor dose (intensity, frequency and

duration) are clearly described in these studies. The physiologi-

cal knowledge of osteoarthritis is still limited. Analyses of earlier

studies concerning biomechanics and neuromuscular function of

the lower extremities may assist in deciding the correct treatment,

and new research concerning the function of the lower extremities

and the effect of different physical interventions is much needed.

Based on these aforementioned studies, a documented hypothesis

for the treatment can be expressed, and a randomised controlled

trial based on the hypothesis could be designed. Future studies of

this type are needed if the optimal use of aquatic exercise in the

treatment of knee and hip osteoarthritis is to be determined.

A C K N O W L E D G E M E N T S

We thank the staff at Interlibrary Loan Department, Copenhagen

University Library North, for finding even the most obscure ref-

erences.

R E F E R E N C E S

References to studies included in this review

Cochrane 2005 {published data only}

Cochrane T, Davey RC, Matthes Edwards SM. Randomised

controlled trial of the cost-effectiveness of water-based

therapy for lower limb osteoarthritis. Health Technology

Assessment 2005;9(31):iii-xi, 1.

Foley 2003 {published data only}

Foley A, Halbert J, Hewitt T, Crotty M. Does hydrotherapy

improve strength and physical function in patients with

osteoarthritis--a randomised controlled trial comparing

a gym based and a hydrotherapy based strengthening

programme. Annals of the Rheumatic Diseases 2003;62(12):

1162–7.

Patrick 2001 {published data only}

Patrick DL, Ramsey SD, Spencer AC, Kinne S, Belza B,

Topolski TD. Economic evaluation of aquatic exercise

for persons with osteoarthritis. Medical Care 2001;39(5):

413–24.

Stener-Victorin 2004 {published data only}

Stener-Victorin E, Kruse-Smidje C, Jung K. Comparison

between electro-acupuncture and hydrotherapy, both in

combination with patient education and patient education



alone, on the symptomatic treatment of osteoarthritis of the

hip. Clinical Journal of Pain 2004;20(3):179–85.

Wang 2004 {published data only}

Wang TT. Aquatic exercise improves flexibility, strength,

and walk time in osteoarthritis. PhD Thesis 2004.

Wyatt 2001 {published data only}

Wyatt FB, Milam S, Manske RC, Deere R. The effects of

aquatic and traditional exercise programs on persons with

knee osteoarthritis. Journal of Strength and Conditioning

Research 2001;15(3):337–40.

References to studies excluded from this review

Ahern 1995 {published data only}

Ahern M, Nicholls E, Simionato E, Clark M, Bond M.

Clinical and psychological effects of hydrotherapy in

rheumatic diseases. Clinical Rehabilitation 1995;9:204–12.

Alexander 2001 {published data only}

Alexander MJL, Butcher JE, MacDonald PB. Effects of a

water exercise program on walking gait, flexibility, strength,

self-reported disability and other psycho-social measures of

older individuals with arthritis. Physiotherapy Canada 2001;

203-11.

Belza 2002 {published data only}

Belza B, Topolski T, Kinne S, Patrick DL, Ramsey SD. Does

adherence make a difference? Results from a community-

based aquatic exercise program. Nursing Research 2002;51

(5):285–91.

Borchers 2003 {published data only}

Borchers M, Schwarzkopf S, Stucki G. A multidisciplinary,

multimodal daycare concept for patients with osteoarthritis

- First results [Tageskliniken für funktionsstörungen bei

muskuloskelettalen erkrankungen – pilotergebnisse aus dem

schwerpunkt osteoarthrose (OA)]. Aktuelle Rheumatologie2003;28:43–8.

Cusack 2003 {published data only}

Cusack T. Abstracts from the Irish Society of Chartered

Physiotherapists Annual Conference held in Dublin on 31st

October and 1st November 2003. Physiotherapy-Ireland(PHYSIOTHER-IRELAND) 2003;24(2):37–50.

D’Lima 1996 {published data only}

D’Lima DD, Colwell CW, Jr, Morris BA, Hardwick ME,

Kozin F. The effect of preoperative exercise on total knee

replacement outcomes. Clinical Orthopaedics 1996, (326):

174–82.

Elkayam 1991 {published data only}

Elkayam O, Wigler I, Tishler M, Rosenblum I, Caspi D,

Segal R, et al.Effect of spa therapy in Tiberias on patients

with rheumatoid arthritis and osteoarthritis [see comments].

Journal of Rheumatology 1991;18(12):1799–803.

Green 1993 {published data only}

Green J, McKenna F, Redfern EJ, Chamberlain MA. Home

exercises are as effective as outpatient hydrotherapy for

osteoarthritis of the hip. British Journal of Rheumatology

1993;32(9):812–5.

Guillemin 2001 {published data only}

Guillemin F, Virion JM, Escudier P, De Talance N, Weryha

G. Effect on osteoarthritis of spa therapy at Bourbonne-les-

Bains. Joint, bone, spine : revue du rhumatisme. 2001;68(6):

499–503.

Gyurcsik 2003 {published data only}

Gyurcsik NC, Estabrooks PA, Frahm-Templar MJ. Exercise-

related goals and self-efficacy as correlates of aquatic exercise

in individuals with arthritis. Arthritis and Rheumatism

2003;49(3):306–13.

Hill 1999 {published data only}

Hill S, Eckett MJH, Paterson C, Harkness EF. A pilot study

to evaluate the effects of floatation spa treatment on patients

with osteoarthritis. Complementary Therapies in Medicine1999;7:235–8.

Kostopoulos 2000 {published data only}

Kostopoulos D. Comparative effects of aquatic recreational

and aquatic exercise programs on mobility, pain perception

and treatment satisfaction among elderly persons with

osteoarthritis of the knee. PhD Thesis 2000.

Kovacs 2002 {published data only}

Kovacs I, Bender T. The therapeutic effects of Cserkeszolo

thermal water in osteoarthritis of the knee: a double blind,

controlled, follow-up study. Rheumatology International

2002;21(6):218–21.

Lin 2004 {published data only}

Lin SY, Davey RC, Cochrane T. Community rehabilitation

for older adults with osteoarthritis of the lower limb: a

controlled clinical trial. Clinical Rehabilitation 2004;18(1):

92–101.

Minor 1989 {published data only}

Minor MA, Hewett JE, Webel RR, Anderson SK, Kay

DR. Efficacy of physical conditioning exercise in patients

with rheumatoid arthritis and osteoarthritis. Arthritis and

Rheumatism 1989;32(11):1396–405.

Nguyen 1997 {published data only}

Nguyen M, Revel M, Dougados M. Prolonged effects of 3

week therapy in a spa resort on lumbar spine, knee and hip

osteoarthritis: follow-up after 6 months. A randomized

controlled trial. British Journal of Rheumatology 1997;36(1):

77–81.

Norton 1999 {published data only}

Norton CO, Hoobler K, Welding AB, Jensen GM.

Effectiveness of aquatic exercise in the treatment of women

with osteoarthritis. The Journal of Aquatic Physical Therapy1999;5(3):8–15.

Silva 2005 {published data only}

Silva LE, Pessanha AC, Oliveira LM, Myamoto S, Valim V,

Jones A, et al.Efficacy of water exercise in the treatment of

patients with knee osteoarthritis: A randomized, single-

blind, controlled clinical trial. Annals of the RheumaticDiseases 2005;64:556.

Suomi 1997 {published data only}

Suomi R, Lindauer S. Effectiveness of arthritis foundation

aquatic program on strength and range of motion in women



with arthritis. Journal of Aging & Physical Activity 1997;5:

341–51.


Suomi R, Koceja DM. Postural sway characteristics in

women with lower extremity arthritis before and after an

aquatic exercise intervention. Archives of Physical Medicineand Rehabilitation 2000;81(6):780–5.


Suomi R, Collier D. Effects of arthritis exercise programs

on functional fitness and perceived activities of daily living

measures in older adults with arthritis. Archives of Physical

Medicine and Rehabilitation 2003;84(11):1589–94.

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Tishler M, Rosenberg O, Levy O, Elias I, Amit-Vazina

M. The effect of balneotherapy on osteoarthritis. Is an

intermittent regimen effective?. European Journal of InternalMedicine 2004;15(2):93–6.

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C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Cochrane 2005

Methods Intention to treat

Blinded assessor

Losses to follow up 25-27%

Concealment of allocation

Participants 312 volunteers randomised into Aquatic: 153, Control: 159

63% female

Mean age 70

All with pain and stiffness in the knee or hip were included, the ACR criteria was not followed

Interventions Aquatic exercise: stretching, strengthening and aerobic exercises, primarily low to moderate intensity.

3 months supervised, 9 months unsupervised. Sessions of 1 hour, twice a week. Total: 84 sessions.

Control:

Telephone interview quarterly monitoring changes in exercise behaviour and other treatment

Outcomes Pain (WOMAC), stiffness (WOMAC) and function (WOMAC).

Quality of life (SF-36 & EuroQol).

Walk ability (8 foot walk)

Notes GOLD

Risk of bias

Item Authors’ judgement Description

Allocation concealment? Yes A - Adequate

Foley 2003


Blinded assessor

Losses to follow up 20% (aquatic) 26% (land-based)


Participants 105 volunteers randomised into

Aquatic: 35

Land-based: 35

Control: 35

Mean age 71

49.5 % female

Radiological diagnosis of hip or knee OA



Foley 2003 (Continued)

Interventions Aquatic exercise:

Stretching and strengthening exercise.

Land-based:

Strengthening exercise

Both exercise groups: 30 min each session, 3 times per week for 6 weeks.

Control:

3 telephone calls to record any changes in condition and treatment

Outcomes Pain (WOMAC), stiffness (WOMAC), function (WOMAC), Quality of life (SF-12)

Notes GOLD

Risk of bias



Patrick 2001


Blinding of assessor unclear

Losses to follow up 19%

Concealment of allocation unclear


Aquatic: 125

Control: 124

Mean age 66

86 % female

Clinically confirmed diagnosis of OA

Interventions Aquatic:

Joint range-of-motion, maintenance of muscle strength

Control:

Follow used activities, abstain from new exercise programs

Outcomes Pain (HAQ), function (HAQ), quality of life (QOL), quality of well being (QWB)

Notes GOLD

Risk of bias


Allocation concealment? Unclear B - Unclear



Stener-Victorin 2004


Patient, therapist and assessor was not blinded

Losses to follow up 31%

Unclear concealment of allocation


Electro-acupuncture: 15

Aquatic: 15

Patient education: 15

Interventions Patient education + electro-acupuncture

Patient education + hydrotherapy

Patient education alone

Outcomes Disability rating index (DRI)

Global self rating index (GSI)

Notes SILVER

Risk of bias


Allocation concealment? Unclear B - Unclear

Wang 2004

Methods Intention to Treat

Patient, therapist and assessor was not blinded

Losses to follow up 18.3 %


Participants 43 volunteers randomised into aquatic exercise: 21

control: 22

Interventions Aquatic exercise with focus on strengthening exercise

Outcomes Pain in joint

Six-minute walk

Functional status

Psychological distress

Notes GOLD

Risk of bias




Wang 2004 (Continued)


Wyatt 2001

Methods No intention to treat analysis

Blinded assessor

Losses to follow up not reported

Unclear concealment of allocation

Participants 46 volunteers randomised into a land-based and aquatic exercise program. Number of participants in each

group not reported

Interventions Aquatic and

Land-based exercise was the same: resistance exercise over knee, straight leg raises, mini-squat and walking

Outcomes VAS pain

1 mile walk time

Stiffness

Notes SILVER

Risk of bias


Allocation concealment? Unclear D - Not used

See grading system in text for definition of Gold and Silver.

ACR criteria for the hip joint: age greater than 40 years, weight-bearing pain, pain relieved by sitting, antalgic gait, decreased painful

range of motion, a normal erythrocyte sedimentation rate (ESR) and a negative rheumatoid factor test.

ACR criteria for the knee joint: age greater than 50 years, knee pain, stiffness < 30 min, crepitus, bony tenderness, bony enlargement,

no palpable warmth, a normal erythrocyte sedimentation rate (ESR) and a negative rheumatoid factor test.

EUROQOL: The EuroQol is a multidimensional health profile developed by the EuroQol Group in 1990 and revised in 1993.

HAQ: Health Assessment Questionnaire.

PQOL: The Perceived Quality of Life Scale is a generic instrument for assessing perceived quality of life among adults.

VAS: Visual analogue scale

WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index



Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Ahern 1995 Poor randomization procedure. No follow up. But the immediate effect is described for pain, stiffness, depression,

self-efficacy

Alexander 2001 Not randomized. Mix of different patient categories (OA, 27; RA 3; FMS 1; Psoriasis 1)

Belza 2002 OA in different joints not hip and/or knee alone.

Borchers 2003 No aquatic exercise, not possible to assess the effect of water treatment alone,

Cusack 2003 Abstract only

D’Lima 1996 Aquatic exercise is combined with land exercise. Mix of both OA and RA

Elkayam 1991 No exercise, only water immersion.

Green 1993 Only data on surrogate outcomes

Guillemin 2001 No exercise (only SPA therapy). No randomization.

Gyurcsik 2003 Not possible to evaluate the effect on KNEE OA (Mix of OA, RA and FMS). No randomization

Hill 1999 No exercise, only water immersion.

Kostopoulos 2000 Only comparing two different types of aquatic exercises

Kovacs 2002 No exercise, only immersion.

Lin 2004 Not randomised

Minor 1989 When it is possible to distinguish between OA and RA, it is not possible to distinguish between aquatic and

non-aquatic exercise / control

Nguyen 1997 Mix of hip, knee and lumbar OA. No exercise, a mixed modality of spa and balneotherapy

Norton 1999 Only effect sizes reported, and no SD was given, thus it was impossible to include the results in the meta-analysis

Silva 2005 No exercise

Suomi 1997 Mix of RA and OA.





(Continued)

Tishler 2004 No exercise, only water immersion.

OA: Osteoarthritis

RA: Rheumatoid arthritis

FMS: Fibromyalgia syndrome

SPA therapy: treatment including water, but not including exercise

SD: Standard deviation



D A T A A N D A N A L Y S E S

Comparison 1. Aquatic exercise versus control after treatment - knee&hip mixed

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Pain 4 638 Std. Mean Difference (IV, Random, 95% CI) 0.19 [0.04, 0.35]

1.1 WOMAC pain 2 380 Std. Mean Difference (IV, Random, 95% CI) 0.20 [-0.00, 0.40]

1.2 Visual Analogue Pain 1 43 Std. Mean Difference (IV, Random, 95% CI) 0.50 [-0.10, 1.11]

1.3 HAQ pain 1 215 Std. Mean Difference (IV, Random, 95% CI) 0.12 [-0.15, 0.39]

2 Function 4 648 Std. Mean Difference (IV, Random, 95% CI) 0.26 [0.11, 0.42]

2.1 WOMAC function 2 375 Std. Mean Difference (IV, Random, 95% CI) 0.23 [0.03, 0.44]

2.2 HAQ function 2 273 Std. Mean Difference (IV, Random, 95% CI) 0.31 [0.07, 0.55]

3 Walking ability 2 355 Std. Mean Difference (IV, Random, 95% CI) 0.18 [-0.03, 0.39]

3.1 Six-minute walk 1 43 Std. Mean Difference (IV, Random, 95% CI) -0.03 [-0.63, 0.57]

3.2 8-foot walk time 1 312 Std. Mean Difference (IV, Random, 95% CI) 0.21 [-0.01, 0.43]

4 Stiffness 2 380 Std. Mean Difference (IV, Random, 95% CI) 0.14 [-0.06, 0.34]

4.1 WOMAC stiffness 2 380 Std. Mean Difference (IV, Random, 95% CI) 0.14 [-0.06, 0.34]

5 Quality of life 3 599 Std. Mean Difference (IV, Random, 95% CI) 0.32 [0.03, 0.61]

5.1 SF-12 physical 1 70 Std. Mean Difference (IV, Random, 95% CI) 0.69 [0.21, 1.17]

5.2 PQOL - perceived quality

of life

1 222 Std. Mean Difference (IV, Random, 95% CI) 0.35 [0.09, 0.62]

5.3 EURO-QOL 1 307 Std. Mean Difference (IV, Random, 95% CI) 0.10 [-0.12, 0.33]

6 Mental health 4 642 Std. Mean Difference (IV, Random, 95% CI) 0.16 [0.01, 0.32]

6.1 SF-36 mental 1 307 Std. Mean Difference (IV, Random, 95% CI) 0.15 [-0.08, 0.37]


6.3 Psychological Distress 1 43 Std. Mean Difference (IV, Random, 95% CI) 0.37 [-0.24, 0.97]

6.4 QWB - quality of well

being

1 222 Std. Mean Difference (IV, Random, 95% CI) 0.13 [-0.13, 0.40]

Comparison 2. Aquatic exercise versus control after treatment -hip


studies

No. of


1 Function 1 28 Std. Mean Difference (IV, Random, 95% CI) 0.76 [-0.02, 1.53]

1.1 DRI-disability rating

index


2 Quality of life 1 28 Std. Mean Difference (IV, Random, 95% CI) 0.76 [-0.02, 1.53]

2.1 GSI - global self rating

index




Comparison 3. Aquatic exercise versus land after treatment - knee


studies

No. of


1 Pain 1 46 Std. Mean Difference (IV, Random, 95% CI) 0.86 [0.25, 1.47]

1.1 VAS pain 1 46 Std. Mean Difference (IV, Random, 95% CI) 0.86 [0.25, 1.47]

2 Walking ability 1 46 Std. Mean Difference (IV, Random, 95% CI) 0.43 [-0.16, 1.01]

2.1 1 MILE walk time 1 46 Std. Mean Difference (IV, Random, 95% CI) 0.43 [-0.16, 1.01]

3 Stiffness 1 46 Std. Mean Difference (IV, Random, 95% CI) -0.26 [-0.84, 0.32]

Comparison 4. Aquatic exercise versus control at follow up - knee&hip mixed


studies

No. of


1 Pain 1 310 Std. Mean Difference (IV, Random, 95% CI) 0.11 [-0.12, 0.33]

1.1 WOMAC pain 1 310 Std. Mean Difference (IV, Random, 95% CI) 0.11 [-0.12, 0.33]


2.1 WOMAC function 1 306 Std. Mean Difference (IV, Random, 95% CI) 0.10 [-0.12, 0.33]

3 Stiffness 1 310 Std. Mean Difference (IV, Random, 95% CI) 0.13 [-0.09, 0.36]

3.1 WOMAC stiffness 1 310 Std. Mean Difference (IV, Random, 95% CI) 0.13 [-0.09, 0.36]

4 Mental health 1 309 Std. Mean Difference (IV, Random, 95% CI) 0.05 [-0.17, 0.27]


Comparison 5. Aquatic exercise versus control at follow up - hip


studies

No. of


1 Pain 1 17 Std. Mean Difference (IV, Random, 95% CI) 1.00 [-0.04, 2.04]

1.1 VAS pain 1 17 Std. Mean Difference (IV, Random, 95% CI) 1.00 [-0.04, 2.04]


2.1 DRI-disability rating

index


3 Quality of life 1 17 Std. Mean Difference (IV, Random, 95% CI) 1.00 [-0.04, 2.04]

3.1 GSI - global self rating

index




Analysis 1.1. Comparison 1 Aquatic exercise versus control after treatment - knee&hip mixed, Outcome 1

Pain.

Review: Aquatic exercise for the treatment of knee and hip osteoarthritis

Comparison: 1 Aquatic exercise versus control after treatment - knee%hip mixed

Outcome: 1 Pain

Study or subgroup Exercise Control

Std.Mean

Difference Weight

Std.Mean

Difference

N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

1 WOMAC pain

Cochrane 2005 152 -8.46 (3.74) 158 -9.35 (3.54) 48.7 % 0.24 [ 0.02, 0.47 ]

Foley 2003 35 -10 (4) 35 -10 (4) 11.1 % 0.0 [ -0.47, 0.47 ]

Subtotal (95% CI) 187 193 59.7 % 0.20 [ 0.00, 0.40 ]

Heterogeneity: Tau2 = 0.0; Chi2 = 0.85, df = 1 (P = 0.36); I2 =0.0%

Test for overall effect: Z = 1.93 (P = 0.054)

2 Visual Analogue Pain

Wang 2004 21 -43.5 (18.6) 22 -54.9 (25.2) 6.6 % 0.50 [ -0.10, 1.11 ]

Subtotal (95% CI) 21 22 6.6 % 0.50 [ -0.10, 1.11 ]

Heterogeneity: not applicable


3 HAQ pain

Patrick 2001 98 -1.38 (0.73) 117 -1.46 (0.62) 33.7 % 0.12 [ -0.15, 0.39 ]

Subtotal (95% CI) 98 117 33.7 % 0.12 [ -0.15, 0.39 ]



Total (95% CI) 306 332 100.0 % 0.19 [ 0.04, 0.35 ]



-4 -2 0 2 4

Favours control Favours aquatic exer




Function.



Outcome: 2 Function


Std.Mean

Difference Weight

Std.Mean

Difference


1 WOMAC function

Cochrane 2005 149 -29.26 (14.48) 156 -32.42 (13.25) 47.2 % 0.23 [ 0.00, 0.45 ]

Foley 2003 35 -33 (17) 35 -37 (13) 10.8 % 0.26 [ -0.21, 0.73 ]

Subtotal (95% CI) 184 191 58.0 % 0.23 [ 0.03, 0.44 ]



2 HAQ function

Patrick 2001 109 -0.93 (0.55) 121 -1.13 (0.67) 35.3 % 0.32 [ 0.06, 0.58 ]

Wang 2004 21 -0.9 (0.4) 22 -1 (0.5) 6.7 % 0.22 [ -0.38, 0.82 ]

Subtotal (95% CI) 130 143 42.0 % 0.31 [ 0.07, 0.55 ]



Total (95% CI) 314 334 100.0 % 0.26 [ 0.11, 0.42 ]



-4 -2 0 2 4

Favours control Favours aquatic exer




Walking ability.



Outcome: 3 Walking ability


Std.Mean

Difference Weight

Std.Mean

Difference


1 Six-minute walk

Wang 2004 21 1274.1 (263.3) 22 1281.8 (290.5) 12.2 % -0.03 [ -0.63, 0.57 ]

Subtotal (95% CI) 21 22 12.2 % -0.03 [ -0.63, 0.57 ]



2 8-foot walk time

Cochrane 2005 153 -3.1 (1.27) 159 -3.43 (1.78) 87.8 % 0.21 [ -0.01, 0.43 ]

Subtotal (95% CI) 153 159 87.8 % 0.21 [ -0.01, 0.43 ]



Total (95% CI) 174 181 100.0 % 0.18 [ -0.03, 0.39 ]



-4 -2 0 2 4

Favours control Favours aquatic ex




Stiffness.



Outcome: 4 Stiffness


Std.Mean

Difference Weight

Std.Mean

Difference


1 WOMAC stiffness

Cochrane 2005 152 -3.88 (1.67) 158 -4.15 (1.48) 81.5 % 0.17 [ -0.05, 0.39 ]

Foley 2003 35 -4 (3) 35 -4 (3) 18.5 % 0.0 [ -0.47, 0.47 ]

Total (95% CI) 187 193 100.0 % 0.14 [ -0.06, 0.34 ]



-4 -2 0 2 4





Quality of life.



Outcome: 5 Quality of life


Std.Mean

Difference Weight

Std.Mean

Difference


1 SF-12 physical

Foley 2003 35 37.1 (12.7) 35 28.8 (11) 21.6 % 0.69 [ 0.21, 1.17 ]

Subtotal (95% CI) 35 35 21.6 % 0.69 [ 0.21, 1.17 ]



2 PQOL - perceived quality of life

Patrick 2001 101 6.4 (1.7) 121 5.79 (1.75) 37.3 % 0.35 [ 0.09, 0.62 ]

Subtotal (95% CI) 101 121 37.3 % 0.35 [ 0.09, 0.62 ]



3 EURO-QOL

Cochrane 2005 150 62.55 (18.61) 157 60.68 (17.39) 41.1 % 0.10 [ -0.12, 0.33 ]

Subtotal (95% CI) 150 157 41.1 % 0.10 [ -0.12, 0.33 ]



Total (95% CI) 286 313 100.0 % 0.32 [ 0.03, 0.61 ]

Heterogeneity: Tau2 = 0.04; Chi2 = 5.39, df = 2 (P = 0.07); I2 =63%


-4 -2 0 2 4





Mental health.



Outcome: 6 Mental health


Std.Mean

Difference Weight

Std.Mean

Difference


1 SF-36 mental

Cochrane 2005 149 51.23 (46.1) 158 44.51 (45.24) 48.0 % 0.15 [ -0.08, 0.37 ]

Subtotal (95% CI) 149 158 48.0 % 0.15 [ -0.08, 0.37 ]



2 SF-12 mental

Foley 2003 35 53.3 (15.5) 35 50.5 (14) 10.9 % 0.19 [ -0.28, 0.66 ]

Subtotal (95% CI) 35 35 10.9 % 0.19 [ -0.28, 0.66 ]



3 Psychological Distress

Wang 2004 21 -37.9 (20.6) 22 -45.2 (18.5) 6.6 % 0.37 [ -0.24, 0.97 ]

Subtotal (95% CI) 21 22 6.6 % 0.37 [ -0.24, 0.97 ]



4 QWB - quality of well being

Patrick 2001 101 0.61 (0.07) 121 0.6 (0.08) 34.5 % 0.13 [ -0.13, 0.40 ]

Subtotal (95% CI) 101 121 34.5 % 0.13 [ -0.13, 0.40 ]



Total (95% CI) 306 336 100.0 % 0.16 [ 0.01, 0.32 ]



-4 -2 0 2 4




Analysis 2.1. Comparison 2 Aquatic exercise versus control after treatment -hip, Outcome 1 Function.


Comparison: 2 Aquatic exercise versus control after treatment -hip

Outcome: 1 Function


Std.Mean

Difference Weight

Std.Mean

Difference


1 DRI-disability rating index

Stener-Victorin 2004 13 -31 (15.4) 15 -43 (15.4) 100.0 % 0.76 [ -0.02, 1.53 ]

Total (95% CI) 13 15 100.0 % 0.76 [ -0.02, 1.53 ]



-4 -2 0 2 4

Favours control Favours aquat exerci

Analysis 2.2. Comparison 2 Aquatic exercise versus control after treatment -hip, Outcome 2 Quality of life.


Comparison: 2 Aquatic exercise versus control after treatment -hip



Std.Mean

Difference Weight

Std.Mean

Difference


1 GSI - global self rating index

Stener-Victorin 2004 13 -0.25 (4.5) 15 -3.75 (4.5) 100.0 % 0.76 [ -0.02, 1.53 ]

Total (95% CI) 13 15 100.0 % 0.76 [ -0.02, 1.53 ]



-4 -2 0 2 4




Analysis 3.1. Comparison 3 Aquatic exercise versus land after treatment - knee, Outcome 1 Pain.


Comparison: 3 Aquatic exercise versus land after treatment - knee

Outcome: 1 Pain


Std.Mean

Difference Weight

Std.Mean

Difference


1 VAS pain

Wyatt 2001 23 -2.4 (1.6) 23 -3.8 (1.6) 100.0 % 0.86 [ 0.25, 1.47 ]

Total (95% CI) 23 23 100.0 % 0.86 [ 0.25, 1.47 ]



-4 -2 0 2 4

Favours land Favours aquatic exer

Analysis 3.2. Comparison 3 Aquatic exercise versus land after treatment - knee, Outcome 2 Walking ability.



Outcome: 2 Walking ability

Study or subgroup Aquatic Exercise Land exercise

Std.Mean

Difference Weight

Std.Mean

Difference


1 1 MILE walk time

Wyatt 2001 23 -18.9 (1.4) 23 -19.7 (2.2) 100.0 % 0.43 [ -0.16, 1.01 ]

Total (95% CI) 23 23 100.0 % 0.43 [ -0.16, 1.01 ]



-4 -2 0 2 4

Favours land Favours aquat exerci



Analysis 3.3. Comparison 3 Aquatic exercise versus land after treatment - knee, Outcome 3 Stiffness.





Std.Mean

Difference Weight

Std.Mean

Difference


Wyatt 2001 23 117.3 (14.2) 23 120.8 (12) 100.0 % -0.26 [ -0.84, 0.32 ]

Total (95% CI) 23 23 100.0 % -0.26 [ -0.84, 0.32 ]



-4 -2 0 2 4

Favours land Favours aquat exerci

Analysis 4.1. Comparison 4 Aquatic exercise versus control at follow up - knee&hip mixed, Outcome 1 Pain.


Comparison: 4 Aquatic exercise versus control at follow up - knee%hip mixed

Outcome: 1 Pain

Study or subgroup Aquatic Exercise Control

Std.Mean

Difference Weight

Std.Mean

Difference


1 WOMAC pain

Cochrane 2005 152 -8.49 (3.94) 158 -8.88 (3.45) 100.0 % 0.11 [ -0.12, 0.33 ]

Total (95% CI) 152 158 100.0 % 0.11 [ -0.12, 0.33 ]



-4 -2 0 2 4




Analysis 4.2. Comparison 4 Aquatic exercise versus control at follow up - knee&hip mixed, Outcome 2

Function.



Outcome: 2 Function


Std.Mean

Difference Weight

Std.Mean

Difference


1 WOMAC function

Cochrane 2005 150 -29.73 (14.62) 156 -31.15 (12.73) 100.0 % 0.10 [ -0.12, 0.33 ]

Total (95% CI) 150 156 100.0 % 0.10 [ -0.12, 0.33 ]



-4 -2 0 2 4



Stiffness.





Std.Mean

Difference Weight

Std.Mean

Difference


1 WOMAC stiffness

Cochrane 2005 152 -3.77 (1.62) 158 -3.98 (1.5) 100.0 % 0.13 [ -0.09, 0.36 ]

Total (95% CI) 152 158 100.0 % 0.13 [ -0.09, 0.36 ]



-4 -2 0 2 4





Mental health.



Outcome: 4 Mental health


Std.Mean

Difference Weight

Std.Mean

Difference


1 SF-36 mental

Cochrane 2005 150 69.36 (18.59) 159 68.43 (17.69) 100.0 % 0.05 [ -0.17, 0.27 ]

Total (95% CI) 150 159 100.0 % 0.05 [ -0.17, 0.27 ]



-4 -2 0 2 4


Analysis 5.1. Comparison 5 Aquatic exercise versus control at follow up - hip, Outcome 1 Pain.


Comparison: 5 Aquatic exercise versus control at follow up - hip

Outcome: 1 Pain


Std.Mean

Difference Weight

Std.Mean

Difference


1 VAS pain

Stener-Victorin 2004 10 -25.5 (21.89) 7 -48.5 (21.89) 100.0 % 1.00 [ -0.04, 2.04 ]

Total (95% CI) 10 7 100.0 % 1.00 [ -0.04, 2.04 ]



-4 -2 0 2 4




Analysis 5.2. Comparison 5 Aquatic exercise versus control at follow up - hip, Outcome 2 Function.



Outcome: 2 Function


Std.Mean

Difference Weight

Std.Mean

Difference


1 DRI-disability rating index

Stener-Victorin 2004 10 -26.5 (23.8) 7 -51.5 (23.8) 100.0 % 1.00 [ -0.04, 2.04 ]

Total (95% CI) 10 7 100.0 % 1.00 [ -0.04, 2.04 ]



-4 -2 0 2 4


Analysis 5.3. Comparison 5 Aquatic exercise versus control at follow up - hip, Outcome 3 Quality of life.





Std.Mean

Difference Weight

Std.Mean

Difference


1 GSI - global self rating index

Stener-Victorin 2004 10 -1 (1.9) 7 -3 (1.9) 100.0 % 1.00 [ -0.04, 2.04 ]

Total (95% CI) 10 7 100.0 % 1.00 [ -0.04, 2.04 ]



-4 -2 0 2 4




A D D I T I O N A L T A B L E S

Table 1. Clinical relevance table - Knee and hip mixed OA

Study Outcome

(scale)

# patients (#

trials

Ctl baseline

mean,SD

Wt absolute

change

Relative %

change

Statistical

Sig.

Quality of ev-

idence

Cochrane

(2005) ; Foley

(2003)

WOMAC

(Western On-

tario

McMaster Os-

teoarthritis In-

dex) (pain) (0-

20)

380 (2) 9.10 (3.14) 3.0% (0.

6 fewer points

on a scale 0 to

20 scale)

6.6% (I) statis-

tically signifi-

cant but not

clinically sig-

nificant

GOLD

Wang (2004) VAS (Vi-

sual Analogue

Scale) pain (0-

100)

43 (1) 55.3 (24.6) 12% (12.

3 fewer points

on a 0-100

scale)

0.2% (I) not significant GOLD

Patrick (2001) HAQ (Health

Assessment

Question-

naire) pain (0-

3)

249 (1) 1.05 (0.61) 2% (0.07

fewer points

on a 0-3 scale)

7% (I) not significant GOLD

Cochrane

(2005); Foley

(2003)

WOMAC

function (0-

68)

380 (2) 31.05 (11.24) 4.3% (2.9

points on scale

of 0 to 68)

9.4% (1) statis-

tically signifi-

cant but not

clinically sig-

nificant

GOLD

Patrick (2001)

; Wang (2004)

HAQ

function (0-3)

292 (2) 0.95 (0.5) 5.2% (0.16

fewer points

on a 0-3 scale)

16.3% (I) statistically

significant

GOLD

Cochrane

(2005)

WOMAC

pain (0-20)

310 (1) 9.10 (3.14) 0.3% (0.35

points

fewer on a 0-

20 scale)

4% (I) not significant GOLD

Cochrane

(2005)

WOMAC

function (0-

68)

310 (1) 31.05 (11.24) 0.1% (0.11

fewer

points on a 0-

68 scale)

0.4% (I) not significant GOLD

Legend: ctl=

control group;

SD=standard

deviation; wt=

weighted; I=

improve-



Table 1. Clinical relevance table - Knee and hip mixed OA (Continued)

ment; sig=sig-

nificance;

Table 2. Clinical relevance table - Hip OA

Study Outcome

(scale)

#patients #

(trials)

Ctl baseline

mean,SD

Absolute

change

Relative %

change

Statistical sig. Quality of ev-

idence

Stener-Vic-

torin (2004)

VAS (Visual

Analog Scale)

pain (0-100)

28 (1) 56.0 (21.89) 22% (21.

9 fewer points

on a 0-100

scale)

40% (I) not statis-

tically signifi-

cant

SILVER

Legend: ctl=

control group,

SD=

standard devi-

ation, sig=sig-

nificance, I=

improvement

Table 3. Clinical relevance table - Knee OA

Study Outcome

(scale)

#patients (#

trials)

Ctl baseline

mean,SD

Absolute

change

Relative %

change

Statisitical

sig.

Quality of ev-

idence

Wyatt (2001) VAS (Visual

Analog Scale)

pain (0-10)

46 (1) 5.6 (1.4) 12% (1.2

fewer

points on a 0-

10 scale)

22% (I) statistically

significant

SILVER

Legend: ctl=

control group;

sig=signif-

icance; I=im-

provement



W H A T ’ S N E W

Last assessed as up-to-date: 14 August 2007.

Date Event Description

19 September 2008 Amended Converted to new review format. C006-R

H I S T O R Y

Protocol first published: Issue 4, 2005

Review first published: Issue 4, 2007

C O N T R I B U T I O N S O F A U T H O R S

Content:

Bartels EM, Lund H, Hagen KB, Dagfinrud H, Danneskiold-Samsøe B

Methodology:

KB Hagen, EM Bartels, H Lund, H Dagfinrud, Christensen R,

Statistics:

R Christensen, KB Hagen

D E C L A R A T I O N S O F I N T E R E S T

None known

S O U R C E S O F S U P P O R T

Internal sources

• OAK foundation, Denmark.

• Copenhagen University Library, Denmark.



External sources

• No sources of support supplied

I N D E X T E R M S

Medical Subject Headings (MeSH)

∗Water; Balneology; Chronic Disease; Exercise; Exercise Therapy [∗methods]; Hydrotherapy [methods]; Osteoarthritis, Hip [∗therapy];

Osteoarthritis, Knee [∗therapy]; Randomized Controlled Trials as Topic; Swimming

MeSH check words

Humans



Aquatic exercise for the treatment of knee and hip osteoarthritis (Review

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