Hydrotherapy in Knee Osteoarthritis – Evidence Based

Approach

By : Dr. Rajal Sukhiyaji

• Background

• objective • Method• Results• Discussion• Conclusion• Take home

message • References

Background

Modalities are also used.

Complementary therapies include :

• Acupuncture• Aromatherapy• Hydrotherapy• Tai chi• Alexander technique• Chiropractic• Massage• Reflexology

Hydrotherapy ????

To see the effectiveness and safety of Hydrotherapy in the treatment of knee osteoarthritis when it is compared with other interventions or no intervention.

Inclusion criteria :

• Studies published in last twenty years in English language with free full text .

• Study design - RCT, Meta-analysis, Systematic review, case series and pilot study.

• Study done on patient with knee OA.

• Outcome measure : Pain, Knee muscle strength, Physical function, Balance, Gait, Quality of life.

Exclusion criteria:

• Studies regarding assessment or biomechanical changes or pathology of knee OA.

Literature search :

• Literature search was done in February 2015.

• The following databases were searched:Pubmed, Biomed, Cochrane, and TRIP.

• Key words : Hydrotherapy, Aquatic therapy, Knee Osteoarthritis, Hydrotherapy and Knee OA, Aquatic therapy and Knee OA

Search ResultsDatabase Number of

ResultsArticles identified aspotentially relevantfrom reading title

Number ofarticles analyzed

Pubmed 112 11 6Biomed 152 4 3

Cochrane 164 1 1TRIP 61 7Total 10

Selection of relevant articles

• Results from each database search were assessed for all potentially relevant articles by reading the titles.

• Abstracts were then studied to ensure the article met the inclusion criteria.

• All articles that were relevant were obtained in full to be critically analyzed.

Primary search finding n= 489 Pubmed n= 112 Biomed n=152

Cochrane n=164 TRIP n=61

Included n = 10

Potentially relevant n = 23

Excluded n = 13

Exclusion reasons: Duplicates, free full text not available, other language, or study is included in

any systematic review.

Design Number

RCTs 6

Review 2

Case series 1

Pilot study 1

Title Method Outcome measure

Result

Hydrotherapy Versus ConventionalLand-Based Exercise for theManagement of Patients WithOsteoarthritis of the Knee:A Randomized Clinical Trial

American Physical TherapyAssociation (2008)

64 subjects with OA of the knee were randomly assigned to 1 of 2 groups thatperformed exercises for 18 weeks: a water-based exercise group and a land-basedexercise group

Measurements were recordedby a blinded investigator at baseline and at 9 and 18 weeks after initiating theintervention.

Visual analog scale (VAS) for painin the previous week,

The Western Ontario and McMaster Universities OsteoarthritisIndex (WOMAC),

Pain during gait assessed by a VAS at rest and immediately followinga 50-foot (15.24-m) walk test (50FWT), and

The Lequesne Index.

Reductions inpain and improvements in WOMAC and Lequesne index scores were similar between groups. Pain before and after the 50FWT decreased significantly over time in both groups. The water-based exercise group experienced a significantly greaterdecrease in pain than the land-based exercise group before and after the 50FWT at the week-18 follow-up.

Title Method Outcome measure

Result

A randomized controlled trial of aquatic and land-basedexercise in patients with knee osteoarthritis.

J Rehabil Med (2008)

79 patients(62 women), with a mean age of 68 years (age range40–89 years) were randomized to aquatic exercise (n = 27),land-based exercise (n = 25) or control (n = 27).

The intervention programme: 8 weeks with 2 sessions per week with 3 months follow up period.

Pain assessment scale (VAS)

Knee Injury and Osteoarthritis Outcome Score questionnaire (KOOS)

Standing balance. Balance was evaluated using a Balance MasterPro®(Version 6.0, NeuroCom® International Clackamas, OR, USA)

Knee muscle strength by isokineticdynamometry at 30 deg/s, 60 deg/s and 90 deg/s

Only land-based exercise showed some improvementin pain and muscle strength compared with thecontrol group, while no clinical benefits were detectable afteraquatic exercise compared with the control group.

Aquatic exercise has significantly less adverse effects comparedwith a land-based programme

Title Method Outcome measure

Result

A comparison of Kneipp hydrotherapy with conventionalphysiotherapy in the treatment of osteoarthritis of the hip or knee:protocol of a prospective randomised controlled clinical trial

BMC Musculoskeletal Disorders (2009)

180 patients diagnosed with osteoarthritis of hip or knee will be randomlyassigned to one of three intervention groups: hydrotherapy, physiotherapy, and both physiotherapyand hydrotherapy of the affected joint.

Assessmentswill be made at baseline, after two weeks of inpatient treatment, and finally after a further tenweeks of follow-up

Patient questionnaire: SF-36, AIMS2-SF, Lequesne knee and hip questionnaire, EQ5D

Physician documentation: Timed up and go, VAS, Range-of-motion affected joint.

Hydrotherapy for OA of the hip or knee joint using serial cold and warm water stimulation improves the range of movementin the affected joint, provides significantpain relief and increases quality of life .

Title Method Outcome measure

Result

Physical Activity for Osteoarthritis Management:A Randomized Controlled Clinical TrialEvaluating Hydrotherapy or Tai Chi Classes

Arthritis & Rheumatism(2007)

152 older persons with chronic symptomatic hip or knee OA

hydrotherapy classes (n = 55), Tai Chi classes (n = 56) control group (n = 41)

Outcomes were assessed at baseline , 12 weeks and 24 weeks follow up after randomization.

Pain andphysical function (Western Ontario and McMaster Universities Osteoarthritis Index),

General health status (MedicalOutcomes Study Short Form 12 Health Survey [SF-12], version 2), Psychological well-being (DASS21),

Physical performance(timed 50 –foot walk test, stair climb test and up & go test)

Both types of classes resulted in large improvements in self-reportedphysical function, greater than improvements demonstratedfor traditional land-based exercise.

Hydrotherapy classes appeared to be more acceptable (higher attendance), appeared to provide greater relief of joint pain, and resulted in larger improvements inobjective measures of physical performance.

Title Method Outcome measures

Results

Does hydrotherapy improve strength and physical functionin patients with osteoarthritis—a randomised controlled trialcomparing a gym based and a hydrotherapy basedstrengthening programme.

Ann Rheum Dis (2003)

105 community living participants aged 50 years and over with clinical OA of the hip or knee.

Participants were randomised into three groups: hydrotherapy (n = 35), gym (n = 35), orcontrol (n = 35).

The two exercising groups had three exercise sessions a week for six weeks.

Muscle strength dynamometry,Six minute walk test, WOMAC OA Index, Total drugs, SF-12 quality of life,Adelaide Activities Profile, andThe Arthritis Self-Efficacy Scale.

Both the gym andhydrotherapy interventions produce positive functional outcomesfor patients with OA.

Hydrotherapy may be more suitable for aerobic based exerciseprogrammes and the gym based exercise more suitable forstrengthening programmes.

Title Method Outcome measure ResultThe PICO project: aquatic exercise for kneeosteoarthritis in overweight and obese individuals

BMC Musculoskeletal Disorders (2013)

PICO is a single-blinded, randomized controlled trial involves 50 overweightand obese adults with3 months duration.

Participants will be randomly assignedto one of two groups: Aquatic exercise (AE) and Controlgroup (CG).

The main outcomes will be KOA symptoms (pain andstiffness) and quality of life, physical function (aerobic capacity, strength, and flexibility) and gait (kinetics andkinematics).

The secondary outcomes are body composition,morphology, physical activity level, and inflammatorybiomarkers.

The PICO program shall provide insight into the effectiveness of an aquatic exercise program in thecontrol of KOA symptoms and in the improvement of the quality of life.

Title Method Outcome measure

Results

Effect of watergym in knee osteoarthritis

(2011)

Level of evidence IV, Case series.

42 volunteers, 38 women and 4men with OA, practicing watergym , divided into the followinggroups: beginners, intermediate, advanced, and advanced levelwith other physical activities in addition to watergym .

Individuals were assessed at times zero, 8 and12 weeks, with classes lasting 45 minutes, twice a week

Functionwas assessed by the Aggregate Locomotor Function (ALF)score, and

Pain and other symptoms by the visual analogical scale (VAS) and by the Western Ontario and McMaster UniversitiesOsteoarthritis Index (WOMAC) questionnaire

None of thetests showed a significant improvement of pain or locomotion.

Watergym was not effective in improving symptomsand did not affect the locomotor capacity of individuals withknee OA.

Title Method Outcome measure

Result

Systematic review and meta-analysis comparingland and aquatic exercise for people with hip orknee arthritis on function, mobility and otherhealth outcomes

BMC Musculoskeletal Disorders (2011)

Medline, CINAHL, AMED and the Cochrane Central Register of Controlled Clinical Trials were searched up to July 2010. Ten randomised, controlled clinical trials that compared land to aquatic exercise for adults with arthritis were included.Meta-analyses were performed for function, mobility and indices that pooled healthoutcomes across multiple domains.

Western Ontario and McMaster Universities OsteoarthritisIndex [WOMAC]

The Knee Injury and Osteoarthritis OutcomeScore [KOOS]

The Health AssessmentQuestionnaire [HAQ]

Arthritis Impact Measurement Scale 2 [AIMS2]

Walking ability was assessed by measuring walk speed

Both aquatic and land based exercise programs appearto result in comparable outcomes for function, mobilityor pooled indices. Meta analysis did not provide confidence that either aquatic or land based exercise provide better function or mobilityoutcomes.No research was found that examined participant preferences for aquatic compared to land based exercise, identifying this as an area forfurther research.

Title Method Outcome measures

Results

Aquatic exercise for the treatment of knee and hiposteoarthritis (Review)

The Cochrane Collaboration (2009)

Searched MEDLINE from 1949, EMBASE from 1980, CENTRAL (Issue 2, 2006), CINAHL from 1982, Web of Science from1945, all up to May 2006. There was no language restriction.

Randomised controlled trials or quasi-randomised clinical trials.

Pain : WOMAC,VAS, HAQ, SF-36 (Short Form), SF-12,AIMS.Function : WOMAC, HAQ, DRI , SF-36 , ASEQ , FAP-Score, SPF Scale, AAP.Walking ability: 6MW, 8 feet walk time, one mile walk time.Stiffness measures: WOMAC, ROM.Quality of life : SF-12, AIMS-2-Affect, PQOL , QWB, GSI, EQ-VAS.Mental health: SF-36, SF-12, AIMS-2-Satisfaction, ASEQ-Mental, Satisfaction, QWB, PsychologicalDistress.

Small-to-moderate effect on function and on quality of life. Minor reduction in pain. No effect on walking ability or stiffness immediately after end of treatment.No evidence of effect on pain, function or quality of life wereobserved on the one trial including participants with hip osteoarthritis alone.Immediately after treatment, there was a large effect on pain, but no evidence of effect on stiffness or walking ability for knee OA.

Title Method Outcome measures

Results

Physiotherapist-designed aquatic exerciseprogramme for community-dwelling elderswith osteoarthritis of the knee: a Hong Kongpilot study

(2014)

Subjects were recruited by convenience sampling ofthe elders aged 65 years and above.

The PDAE consisted of individual and groupexercises , and was delivered twice a weekfor 10 weeks in a public indoor swimming pool byregistered physiotherapists of the EHS.

Chinese Arthritis Impact Measurement Scales 2 (CAIMS 2).

Functional exercise capacity : the 6-minute walk test.

Lower limb strength and function: using the dynamometer test of the Nicholas Manual Muscle Tester (NMMT) andthe 30-second repeated sit-to stand test.

Standing balance : the functionalreach test (FRT)

ROM of the knee joints : goniometer.

There was an improvement in the range of knee flexion, the strength of the quadriceps, score of functional reach test and the repeated sit-to-stand test increased.

Improvement in the mobility level ,walking and bending ability of the trunk,levels of pain and mood , and thetotal score (P<0.01) in the Chinese Arthritis ImpactMeasurement Scales 2.

• According to available resources and literature, both negative and positive results have been gained.

• Studies present in meta-analysis and systematic review showed that no research was found that examined participant preferences for hydrotherapy compared to land based exercise.

• Meta analysis did not provide confidence that either aquatic or land based exercise provide better function or mobility outcomes.

• Some RCT results showed reduction in pain and improvement in functional activities whereas some showed there was no beneficial effects of hydrotherapy.

• One study show that land based exercises are more beneficial than hydrotherapy but hydrotherapy has less side effect as compared to land based exercises.

• One study showed that hydrotherapy for osteoarthritis of the hip or knee joint using serial cold and warm water stimulation not only improves the range of movement in the affected joint but also provides significant pain relief and increases quality of life over a period of up to three months .

• There is only scattered evidence from RCTs or meta-analyses which investigate the use of hydrotherapy for osteoarthritis with respect to its long-term and sustained effects .

• Based on the number of literatures which have been analyzed so far, it is difficult to say on confirmatory bases that hydrotherapy is useful in treatment of knee OA.

• Overall aquatic and land based exercises appeared to result in comparable outcomes for participants for function, mobility or pooled indices.

• The prescription of aquatic exercise for arthritic conditions may not be warranted due to the cost and limited availability of aquatic programs.

• For people who have significant mobility or function limitations and are unable to exercise on land, aquatic exercise appears to be a legitimate alternative that may enable people to successfully participate in exercise.

• Hydrotherapy as a noninvasive, non-interventional, reasonably priced, therapeutic option with few side effects, in the concomitant treatment of osteoarthritis of the hip or knee.

TAKE HOME MESSAGE

• Silva LE et al, Hydrotherapy Versus Conventional Land-Based Exercise for the Management of Patients With Osteoarthritis of the Knee: A Randomized Clinical Trial, PHYS THER. 2008; 88:12-21

• Hans lund et al, A randomized controlled trial of aquatic and land-based exercise in patients with knee osteoarthritis, j rehabil med, 2008; 40: 137–144

• Martin Schencking et al, A comparison of Kneipp hydrotherapy with conventional physiotherapy in the treatment of osteoarthritis of the hip or knee: protocol of a prospective randomised controlled clinical trial, BMC Musculoskeletal Disorders 2009, 10:104 doi:10.1186/1471-2474-10-104

• Fransen et al, Physical Activity for Osteoarthritis Management: A Randomized Controlled Clinical Trial Evaluating Hydrotherapy or Tai Chi Classes, Arthritis & Rheumatism, Vol. 57, No. 3, April 15, 2007, pp 407–414

• Foley et al, 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, Ann Rheum Dis 2003;62:1162–1167

• Yázigi et al, The PICO project: aquatic exercise for knee osteoarthritis in overweight and obese individuals, BMC Musculoskeletal Disorders 2013, 14:320

• Guerreiro JPF et al, Effect of watergym in knee osteoarthritis, Acta Ortop Bras, 2014;22(1):25-8

• Batterham et al, Systematic review and meta-analysis comparing land and aquatic exercise for people with hip or knee arthritis on function, mobility and other health outcomes, BMC Musculoskeletal Disorders 2011, 12:123

• Bartels EM et al,Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database of Systematic Reviews 2007, Issue 4.

• Mary CK Lau et al, Physiotherapist-designed aquatic exercise programme for community-dwelling elders with osteoarthritis of the knee: a Hong Kong pilot study Hong Kong Med J 2014;20:16–23.

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