Effectiveness of Aquatic Therapy on Reducing Pain and Increasing Physical Function in Adult Patients with Hip and/or Knee Osteoarthritis

Osteoarthritis (OA) is the most common type of arthritis with knee being the most affected joint. Most common symptoms of OA are pain, reduced balance, muscle weakness, decreased Range of Motion, and joint instability Beissner et al. [1]. All these affect performances of activities of daily living (ADL) Kwon et al. [2]. There are many ways to treat OA Lin et al. [3]. One of the methods is aquatic therapy. The beneficial effect of aquatic therapy is reduction of pain by using warm water, buoyancy of water, turbulence or depth of immersion, and facilitating closed-chain exercises Lund et al. [4]. However, there are limitations to this method, which are high cost for setting and lack of studies in community-based settings in OA. The purpose of this study was to examine the evidence of the effectiveness of aquatic therapy in patients with hip and/or knee OA on reducing pain and improving physical function. For this study, we created a clinical/research PICO question (Population, Intervention, Comparison, and Outcome), a key to evidence-based decision Richardson et al. [5]. The PICO formed for our study is as follows:

P: For patients with hip and/or knee OA

I: Does aquatic therapy

C: Compared to other therapy or control conditions

O: Reduce pain and/or increase physical function?

Review of literature and search strategy: A research has been made in the following databases: Ovid, MEDLINE, Global Health, and CINAHL. Keywords and Search items used to search articles for our study were Aquatic therapy, Osteoarthritis, function, activities of daily living, occupational therapy. We used PICO method to search for the relevant articles that have the evidence. We then selected the strongest study based on a variety of factors, such as relevance, study design, sample size, outcomes, significance, year of publication, and intensity of the intervention (frequency and duration).

Our review revealed three articles that focus most relevantly on the purpose of this study. Evidence study design and study level were determined based on the hierarchy of levels of evidence in evidence-based practice Hughes [6]. The first study Wang et al. [7] was level II evidence with a randomized controlled trial design. The participants were 38 subjects with OA of hip and/or knee. Also, they were directed to do 50 minutes aquatic exercise, 3 random days per week for 12 weeks. The exercise was composed of warm up, flexibility, strength training, and cool down. The temperature of pool was about 30 degree Celsius. The results were significant improvements on 3 out of 4 physical functions measurement and no significant change on pain measurement. The second study Hinman et al. [8] was level II evidence with a single blinded randomized controlled trial design. In this study, the participants were 71 subjects with OA. They were directed to do 45 to 60 minutes of aquatic exercise, twice weekly for 6 weeks. The exercises were functional weight-bearing and progressive exercise. The temperature of pool was 34 degrees. The results were significant improvements on both pain and physical functions. The third study Silva et al. [9] was level II evidence with randomized controlled trial design with blinded investigator. In this study, the participants were 64 subjects with OA divided into groups of 5 to 8 participants. They were directed to do 50 minutes aquatic training session, 3 times a week for 18 weeks. The exercise composed of static stretching, isometric and isotonic strengthening of major muscle group of the lower extremities, and gait training. All adapted land-based exercises with floaters and increased speed. The pool was 32 degrees. The results were divided into 2 groups which are intergroup and intragroup. The intergroup comparison showed significant improvement on pain. The intragroup comparison showed significant improvement on pain but not as much improvement on physical functions.

We chose the strongest study by considering different factors, such as year of publication, intensity of intervention, and detailed explanation of intervention. Silva study had the most recent publication year. Also, its experiment had the longest duration. Furthermore, it had the most detailed explanation of treatment plan. Therefore, Silva study was selected as the strongest evidence in our review and showed that aquatic therapy reduces pain in OA condition and leads to improvements in physical function. So, depending on Silva et al. [9], we created clinical guidelines and recommendations to follow aquatic therapy protocol in clinics. Our study protocol can be applied in case of all individuals with OA of hip and/or knee joint. Thus, clinical guidelines, recommendations, a plan and audit tool have been developed in our study to implement aquatic therapy in clinical settings (Table 1).

Table 1:A summary of recommendations, plan, and audit tool.

Our review suggests that aquatic therapy exercises are effective and helpful in reducing pain and improving physical function in patients with hip and/or knee OA. Thus, clinical guidelines, recommendations, a plan and audit tool have been created in our study to implement aquatic therapy in clinics. The clinical guidelines for recommended intervention, the plan, and the audit tool recommend therapists to apply aquatic therapy with patients with hip and/or knee OA.

1. Beissner KL, Collins JE, Holmes H (2000) Muscle force and range of motion as predictors of function in older adults. Physical Therapy 80(6): 556-563.
2. Kwon IS, Oldaker S, Schrager M, Talbot LA, Fozard JL, et al. (2001) Relationship between muscle strength and the time taken to complete a standardized walk-turn-walk test. Journal of Gerontology Series A 56(9): B398-B404.
3. Lin SY, Davey RC, Cochrane T (2004) Community rehabilitation for older adults with osteoarthritis of the lower limb: A controlled clinical trial. Clinical Rehabilitation 18(1): 92-101.
4. Lund H, Weile U, Christensen R, Rostock B, Downey A, et al. (2008) A randomized controlled trial of aquatic and land-based exercise in patients with knee osteoarthritis. Journal of Rehabilitation Medicine 40(2): 137- 144.
5. Richardson WS, Wilson MC, Nishikawa J, Hayward RS (1995) The wellbuilt clinical question: A key to evidence-based decision. ACP Journal Club 123(3): A12-A13.
6. Hughes I (2006) Action research in healthcare: what is the evidence? ALAR Journal 11(1): 29-39.
7. Wang TJ, Belza B, Thompson FE, Whitney JD, Bennett K (2007) Effects of aquatic exercise on flexibility, strength and aerobic fitness in adults with osteoarthritis of the hip or knee. Journal of Advanced Nursing 57(2): 141-152.
8. Hinman RS, Heywood SE, Day AR (2007) Aquatic physical therapy for hip and knee osteoarthritis: Results of a single-blind randomized controlled trial. Physical Therapy, 87(1): 32-43.
9. Silva LE, Valim V, Pessanha AC, Oliveira LM, Myamoto S, et al. (2008). Hydrotherapy versus conventional land-based exercise for the management of patients with osteoarthritis of the knee: A randomized clinical trial. Physical Therapy 88(1): 12-21.