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Research Report

Hydrotherapy Versus Conventional


Land-Based Exercise for the
Management of Patients With
Osteoarthritis of the Knee:
LE Silva, is Physiotherapist, Rheu-
matology Rehabilitation Section,
Division of Rheumatology, Federal
A Randomized Clinical Trial
University of São Paulo, São Paulo, Luciana E Silva, Valeria Valim, Ana Paula C Pessanha, Leda M Oliveira,
Brazil.
Samira Myamoto, Anamaria Jones, Jamil Natour
V Valim, MD, PhD, Division of
Rheumatology, Federal University
of Espı́rito Santo, Espı́rito Santo, Background and Purpose
Brazil.
This study was designed to evaluate the effectiveness of hydrotherapy in subjects
APC Pessanha, is Physiotherapist, with osteoarthritis (OA) of the knee compared with subjects with OA of the knee
Rheumatology Rehabilitation Sec- who performed land-based exercises.
tion, Division of Rheumatology,
Federal University of São Paulo.
Subjects and Methods
LM Oliveira, is Physiotherapist,
Rheumatology Rehabilitation Sec-
Sixty-four subjects with OA of the knee were randomly assigned to 1 of 2 groups that
tion, Division of Rheumatology, performed exercises for 18 weeks: a water-based exercise group and a land-based
Federal University of São Paulo. exercise group. The outcome measures included a visual analog scale (VAS) for pain
S Myamoto, is Physiotherapist,
in the previous week, the Western Ontario and McMaster Universities Osteoarthritis
Rheumatology Rehabilitation Sec- Index (WOMAC), pain during gait assessed by a VAS at rest and immediately following
tion, Division of Rheumatology, a 50-foot (15.24-m) walk test (50FWT), walking time measured at fast and comfort-
Federal University of São Paulo. able paces during the 50FWT, and the Lequesne Index. Measurements were recorded
A Jones, is Physiotherapist, Rheu- by a blinded investigator at baseline and at 9 and 18 weeks after initiating the
matology Rehabilitation Section, intervention.
Division of Rheumatology, Federal
University of São Paulo. Results
J Natour, MD, PhD, is Professor The 2 groups were homogenous regarding all parameters at baseline. Reductions in
of Rheumatology, Rheumatology pain and improvements in WOMAC and Lequesne index scores were similar between
Rehabilitation Section, Division
of Rheumatology, Federal Uni-
groups. Pain before and after the 50FWT decreased significantly over time in both
versity of São Paulo, São Paulo, groups. However, the water-based exercise group experienced a significantly greater
Brazil. Postal address: Disciplina decrease in pain than the land-based exercise group before and after the 50FWT at
de Reumatologia, Universidade the week-18 follow-up.
Federal de São Paulo, Rua Botu-
catu 740, 04023900 São Paulo,
Brazil. Address all correspondence
Discussion and Conclusion
to Dr Natour at: jnatour@reumato. Both water-based and land-based exercises reduced knee pain and increased knee
epm.br. function in participants with OA of the knee. Hydrotherapy was superior to land-
[Silva LE, Valim V, Pessanha APC, based exercise in relieving pain before and after walking during the last follow-up.
et al. Hydrotherapy versus con- Water-based exercises are a suitable and effective alternative for the management of
ventional land-based exercise for OA of the knee.
the management of patients with
osteoarthritis of the knee: a ran-
domized clinical trial. Phys Ther.
2008;88:12–21.]

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12 f Physical Therapy Volume 88 Number 1 January 2008


Hydrotherapy Versus Conventional Land-Based Exercise

O
steoarthritis (OA) is a chronic enhancing functional capacity. The au- Method
disease characterized mainly thors recommended considering the Subjects
by complex, multifactorial hydrodynamic forces that influence Patients with OA of the knee were
joint degeneration. The prevalence the exercising limb in order to ensure selected from the Rheumatology
of OA increases with age and even- adequate progression through the ex- Outpatient Clinics at São Paulo Hos-
tually leads to joint stiffness, progres- ercises. However, as the exercises in pital (Universidade Federal de São
sive deformity, and functional im- the study were performed in only a Paulo/Escola Paulista de Medicina
pairment, which, in turn, negatively sitting position, the results should be [UNIFESP/EPM]) and were invited to
affect the individual’s quality of life.1 generalized cautiously. participate in this study. Inclusion
In recent years, the increase in the criteria included clinical and radio-
elderly population has been accom- In another study investigating the graphic diagnosis of OA of the knee
panied by a proportional increase in effects of a progressive 10-week according to the American College
the number of people with OA.2– 4 aquatic resistance training program of Rheumatology criteria20 and knee
in women who were healthy, Tapani pain ranging from 30 to 90 mm on a
There is evidence indicating that et al15 observed improvement in the visual analog scale (VAS). The mini-
land-based exercises can be benefi- static and dynamic torque of the mum and maximum inclusion values
cial for people with OA of the knee knee extensors and flexors as well for pain (30 and 90 mm) were cho-
by reducing pain and improving as an increase in muscle activity and sen to detect clinically relevant im-
global function. These exercises have a gain in the lean muscle mass of provements and avoid regression to
been recommended in 2 guidelines.5,6 the quadriceps femoris and ham- the mean. All of the participants gave
A systematic literature review7 has string muscles. The authors sug- written informed consent prior to
shown that regular physical exercise is gested aquatic resistance training as being enrolled in the study.
associated with significant improve- an appropriate option for individuals
ment in the functional capacity of peo- with a limited capacity for exercising Patients were excluded if they had
ple with OA of the knee. Measure- on dry land. neurological diseases of the lower
ments of chondroitin sulfate in the limbs, symptomatic heart disease,
synovial fluid have indicated that exer- To our knowledge, only one study16 symptomatic disease affecting the
cise causes no significant harm to peo- has evaluated the effectiveness of extremities other than OA of the
ple with OA of the knee.8 In another hydrotherapy exercise for the man- knee, symptomatic lung disease, se-
systematic review of randomized con- agement of OA of the knee in com- vere systemic disease that could in-
trolled trials, the authors9 suggested parison with land-based exercises. terfere with the assessments, psychi-
that aerobic and strengthening exer- The authors demonstrated that both atric disorder, epilepsy, skin disease,
cises are effective in reducing pain and exercise modalities were equally ef- or an inability to walk. Patients who
disability in such patients. fective in improving strength (force- received intra-articular injections of
generating capacity) and physical steroids in the preceding 3 months
Aquatic exercises have been widely function. However, the sample was and those who had physical therapy
used in physical therapy programs, composed of patients with knee or intervention for their knee in the
especially when exercising under hip OA, which impedes the deter- preceding 6 months or practiced reg-
normal conditions of gravity is diffi- mination of the effects on patients ular physical activity (3 times a week
cult and painful.10,11 Water buoyancy with only OA of the knee. Moreover, or more) for more than 1 month also
reduces the weight that joints, bones, the study used a 6-week exercise were excluded.
and muscles have to bear. The warmth program, which may not have al-
and pressure of the water also reduce lowed sufficient time to produce Randomized allocation into either a
swelling and increase blood circula- changes in strength or physical func- land-based exercise group or a
tion.12 Consequently, an underwater tion. There have been few nonran- water-based exercise group was
environment allows early active mobi- domized studies on the use of hydro- done by drawing lots. The partici-
lization and dynamic strengthening.12–14 therapy for the management of OA pants were evaluated before inter-
of the knee.17–19 Thus, the aim of the vention (baseline or T0), at 9 weeks
In a study comparing the benefits of present study was to investigate the after initiating the intervention (T9),
therapeutic knee exercise underwa- therapeutic effectiveness of hydro- and at 18 weeks after initiating the
ter and on dry land in people who therapy in subjects with OA of the intervention (the end of the protocol
were healthy, Tapani et al11 con- knee and compare the outcome with or T18). A single, blinded investi-
cluded that drag underwater pro- that obtained using conventional gator performed all pain, function,
vided specific stimulation, thereby land-based exercises. and gait evaluations. Participants

January 2008 Volume 88 Number 1 Physical Therapy f 13


Hydrotherapy Versus Conventional Land-Based Exercise

with poor adherence to the program 5. The number of nonsteroidal anti- 20 to 40 repetitions, and load was
(defined as missing more than 2 con- inflammatory drugs (NSAIDs) applied as follows. In the first week
secutive sessions or more than 20% used. The NSAID used during the of adaptation to the program, the
of all sessions) were excluded from study was sodium diclofenac participants performed 20 repeti-
the exercise program, but their data (50-mg tablets). Participants were tions without extra resistance. In the
were used in the statistical analysis. asked to keep a daily record of second and third weeks, they per-
their NSAID use. The mean num- formed 20 repetitions, with extra re-
Measurements ber of sodium diclofenac tablets sistance provided by elastic bands or
The primary outcome measure was used monthly then was calculated by 1-kg ankle weights in the land-
pain in the previous week, assessed for each group. based exercise group and by floaters
using a 100-mm VAS for pain. This is and increased speed in the water-
a valid, reliable, and responsive tech- Intervention based exercise group. After four
nique for assessing pain in people The water-based and land-based ex- weeks, resistance was maintained and
with OA.21 ercises were performed in groups of the number of repetitions was in-
5 to 8 participants. The groups creased to 40. This number of exer-
The secondary outcome measures were instructed by 2 trained physical cise repetitions was chosen based on a
included: therapists who were randomly as- study by Deyle et al25 in which each
signed to the groups. Physical thera- set of exercises was done in 30 sec-
1. The Lequesne Index for OA of pist crossover between groups oc- onds, corresponding to the time that
the knee, which evaluates pain or curred every week to ensure that the participants in the present study
discomfort, maximum distance both physical therapists instructed usually took to do each of the 40 rep-
walked, and activities of daily liv- the 2 groups throughout the proto- etitions. Gait was trained in 10-minute
ing. Scores range from 0 to 24, col. Participants were instructed to sessions. Table 1 summarizes the ex-
with higher scores indicating take 50-mg sodium diclofenac tablets ercise protocol for each group.
greater disease severity. The Le- as needed, not surpassing a maxi-
quesne Index questionnaire is mum dose of 150 mg per day. Data Analysis
well recognized for its adequate Sample size was calculated using a
validity, reliability, and respon- The water-based exercise group un- VAS for pain as the main parameter.
siveness for individuals with OA derwent supervised water exercise With 64 participants, our study had
of the knee.22 sessions in a heated (32°C) pool an 80% power to detect a change in
(120-cm deep), and the land-based pain of 17.5 mm between the water-
2. The Western Ontario and McMas- exercise group underwent super- based and land-based groups. The
ter Universities Osteoarthritis In- vised land-based exercise sessions significance level was set at .05, with
dex (WOMAC), which consists of in a room with mats and a walkway. ␤⫽20%.
3 subscales: pain, stiffness, and The same types of exercise were
physical function. Scores range used for both groups. Land-based Categorical baseline variables were
from 0 to 96, with higher scores exercises were adapted to be per- analyzed using the chi-square test,
indicating greater disease sever- formed underwater in order to ex- and continuous baseline variables
ity. The WOMAC questionnaire is ercise the same muscles. The exer- were analyzed using an independent-
well recognized for its adequate cises used for both groups included sample t test or the Mann-Whitney
validity, reliability, and respon- stretching and strengthening of the U test in the case of data with a
siveness for individuals with OA major muscle groups of the lower skewed distribution. The outcomes
of the knee.23 extremities, along with gait training. were analyzed according to the
Both groups had 50-minute training intention-to-treat principle. We used
3. Pain during gait, assessed by a sessions 3 times a week for 18 weeks. a 2-way, repeated-measures multiple
100-mm VAS at rest and immedi- regression analysis of variance
ately following a 50-foot (15.24-m) Two repetitions of each static (ANOVA) with Tukey post hoc test,
walk test (50FWT).24 stretching exercise were performed with intervention (water-based exer-
per muscle group, with each repeti- cise versus land-based exercise) as
4. The walking time measured at fast tion lasting 20 seconds. Isometric the between-subject variable and
and comfortable paces during the strengthening involved 7 to 10 repe- time (T0, T9, and T18) as the within-
50FWT. titions, with contraction maintained subject variable. The dependent vari-
for 6 seconds. Isotonic strengthen- ables analyzed were pain in the pre-
ing exercises were performed with vious week, Lequesne Index and

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Hydrotherapy Versus Conventional Land-Based Exercise

Table 1.
Description of Exercises Performed During the Intervention Period21–23

Land-Based Exercises Water-Based Exercises


Stretching: Stretching:
In a sitting position, cross one leg over the other and place one In a sitting position, with your back against the side of the pool,
hand on top of the foot to grasp the toes; pull and hold for cross one leg over the other and place one hand on top of the
20 s foot to grasp the toes; pull and hold for 20 s
In a supine position, with the knees flexed so that the feet are In a sitting position, with your back against the side of the pool,
resting comfortably in a flat position, raise the exercise limb straighten one knee using a band to raise the foot in
with the knee in full extension using a band around the foot dorsiflexion and hold for 20 s
to maintain dorsiflexion; hold the stretch for 20 s
In a standing position, holding onto the edge of the pool, bend
Lying on your side with the exercise limb on top, keep both one knee (heel up toward buttocks), hold the raised foot with
knees together and the lower leg straight; bend the top knee one hand, and gradually push the pelvis forward, holding for 20 s
by grasping the foot with the hand; bring the heel as close to
the buttocks as possible; hold the stretch for 20 s In a sitting position, with your back against the side of the pool,
straighten one knee using a band to raise the foot in dorsiflexion
and slowly move the foot outward to the side, holding for 20 s

Isometric strengthening: Isometric strengthening:


In a supine position, with the knees straight, perform In a supine position, with cervical and pelvic floaters, perform
dorsiflexion and hold for 6 s dorsiflexion and hold for 6 s
In a supine position, with the knees straight, perform plantar In a supine position, with cervical and pelvic floaters, perform
flexion and hold for 6 s plantar flexion and hold for 6 s
Isotonic strengthening: Isotonic strengthening:
In a supine position, with the knees flexed so that the feet are In a standing position in front of the wall, hold the wall with
resting comfortably in a flat position and with the hands your hands, lift the leg backward to a comfortable height;
resting by your sides, raise the midsection to make a straight return and repeat with the other leg; extra resistance provided
line through your knees, hips, and shoulder (bridge); extra by floaters and increased speed
resistance provided by 1-kg ankle weights
In a standing position, with your back against the side of the
In a supine position, with both legs resting on a triangular pool, slowly lift the leg straight forward to a comfortable
support and the knees flexed at a 30° angle, straighten one height; return and repeat with the other leg; extra resistance
leg; return and repeat with the other leg; extra resistance provided by floaters and increased speed
provided by 1-kg angle weights
In a supine position, with certival and pelvic floaters, bend and
In a supine position and the contralateral limb knee flexed so straighten the knees with sustained dorsiflexion; extra
that the foot is resting comfortably in a flat position, raise the resistance provided by floaters and increased speed
exercise limb with the knee in full extension to the height of
the contralateral flexed knee, then lower the limb back to the In a supine position, with cervical and pelvic floaters, perform
initial position; extra resistance provided by 1-kg ankel weights abduction and adduction of the thighs with sustained
dorsiflexion; extra resistance provided by floaters and
Lying flat on your back with both legs straight, place an elastic increased speed
band around the thighs just above the knees and perform thigh
abductions; extra resistance provided by eleastic bands In a sitting position, with floaters under the arms, straighten the
knee with the foot in dorsiflexio and bend the knees with the
Lying flat on your back with both legs straight, place a ball between foot in plantar flexion while moving forward in the pool; extra
the knees and perform thigh adductions; extra resistance resistance provided by floaters and increased speed
provided by 1-kg ankle weights
In a sitting position, with floaters under the arms, straighten the
Lying sideways, bend the knee and hip of the lower leg and raise knee with the foot in plantar flexion and bend the knees with
the upper leg, keeping it straight; extra resistance provided by the foot in dorsiflexion while moving backward in the pool;
1-kg ankle weights extra resistance provided by floaters and increased speed

In a supine position, with the knees flexed so that the feet are In a standing position, rise up on your toes and return; extra
resting comfortably in a flat position and with hands on your resistance provided by the increased speed
thighs, slowly slide the hands along your leg up toward your
knees and bring your shoulders and head up; extra resistance
provided by 1-kg angle weights
(Continued)

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Hydrotherapy Versus Conventional Land-Based Exercise

Table 1.
Continued

Land-Based Exercises Water-Based Exercises


In a prone position, slowly pull one heel toward the buttocks; Gait training:
return and repeat with the other leg; extra resistance provided Forward walking with alternated movement of the upper and
by 1-kg ankle weights lower extremities
In a standing position, rise up on your toes and return; extra Walk raising the knee
resistance provided by 1-kg ankle weights Lateral walking
Backward walking
Gait training:
Forward walking with alternated movement of the upper and
lower extremities
Walk raising the knee
Lateral walking
Backward walking

WOMAC scores, time to complete (30 female, 2 male) were randomly ercise group, 31 of the 32 partici-
the 50FWT at a fast pace, time to assigned to the water-based exercise pants (96%) concluded the protocol.
complete the 50FWT at a comfort- group, and 32 participants (29 fe- The only dropout in this group was
able pace, pain before the 50FWT, male, 3 male) were randomly as- due to work-related problems. In the
pain after the 50FWT, and NSAID signed to the land-based exercise land-based exercise group, 26 of the
use. When significant intergroup dif- group. Table 2 displays the charac- 32 participants (81%) concluded the
ferences were detected by the teristics of both groups. The 2 study, with 6 dropouts. Three partic-
ANOVA, a paired t test was used to groups did not differ significantly at ipants discontinued the protocol in
assess intragroup differences at T0, baseline regarding demographic the 1st week because they did not
T9, and T18. characteristics and disease-related like being randomly allocated to the
parameters. land-based exercise group; another
Results participant also dropped out in the
Sixty-four participants were included A total of 57 participants concluded 1st week because of transportation
in the study. Thirty-two participants the protocol. In the water-based ex- problems that impeded adherence to

Table 2.
Baseline Demographic Characteristics and Disease-Related Parameters in Participants With Osteoarthritis of the Kneea

Parameter Water-Based Exercise Land-Based Exercise P


Group (nⴝ32) Group (nⴝ32)
Age (y) 59 (7.60) 59 (6.08) .80
Height (cm) 153 (4.36) 153 (6.97) .90
Body weight (kg) 75 (11.87) 76 (12.89) .60
VAS for pain (mm) 61.9 (15.7) 68.2 (15.5) .25
Sodium diclofenac (50-mg tablets/mo) 31.63 (19.79) 31.11 (19.78) .98
Lequesne Index 11.96 (3.82) 12.24 (3.78) .64
WOMAC 32.86 (13.99) 34.92 (12.62) .45
50FWT, comfortable pace (s) 12.94 (15.12) 13.19 (15.57) .67
50FWT, fast pace (s) 8.71 (10.33) 8.58 (10.34) .98
VAS for pain before the 50FWT (mm) 39.6 (23.4) 53.0 (24.4) .12
VAS for pain after the 50FWT (mm) 48.2 (25.6) 61.1 (19.6) .12
a
Results expressed as the mean with standard deviation in parentheses. VAS⫽visual analog scale, 50FWT⫽50-ft (15.24-m) walk test, WOMAC⫽Western
Ontario and McMaster Universities Osteoarthritis Index.

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Hydrotherapy Versus Conventional Land-Based Exercise

Table 3.
Visual Analog Scale (VAS) Scores for Pain in Previous Week, Lequesne Index Scores, and Western Ontario and McMaster
Universities Osteoarthritis Index (WOMAC) Scores for Participants With Osteoarthritis of the Knee at 0 Weeks (T0), 9 Weeks (T9)
and 18 Weeks (T18) After Intervention

Water-Based Exercise Group Land-Based Exercise Group P (Intergroup)


(nⴝ32) (nⴝ32)
MeanⴞSD (95% CIa) MeanⴞSD (95% CI)
VAS (mm)
T0 61.9⫾15.7 (56.2–67.5) 68.2⫾15.5 (62.1–74.4) .198
T9 37.0⫾18.1 (28.8–45.3) 38.4⫾27.5 (29.4–47.4)
T18 26.7⫾23.1 (17.7–38.5) 37.3⫾27.5 (27.3–47.2)
P (intragroup) ⬍.001b ⬍.001b
Lequesne Index
T0 11.96⫾3.82 (10.65–13.27) 12.24⫾3.78 (10.95–13.53) .33
T9 8.06⫾3.37 (6.91–9.21) 8.80⫾4.96 (7.1–10.5)
T18 6.70⫾4.21 (5.25–8.15) 8.64⫾5.48 (4.82–8.58)
P (intragroup) ⬍.001b ⬍.001b
WOMAC
T0 32.86⫾13.99 (28.12–37.8) 34.92⫾12.62 (30.55–39.29) .18
T9 18.80⫾13.37 (14.18–23.42) 23.64⫾17.95 (17.43–19.85)
T18 15.56⫾12.55 (11.23–19.89) 22.68⫾18.34 (16.33–29.03)
P (intragroup) ⬍.001b
⬍.001b
a
CI⫽confidence interval.
b
P value statistically significant.

the protocol; 1 participant had fibro- T9 (P⬍.001) and only for the water- ductions in pain before and after the
myalgia, which was diagnosed in the based exercise group between T9 50FWT in both groups, with these
4th week; and 1 participant had to and T18 (P⬍.001). Accordingly, differences occurring between T0
leave São Paulo due to personal there was no significant intergroup and T9 and between T0 and T18;
problems in the 13th week. Data for difference in the WOMAC scores there was no significant difference
all 64 patients were included in the (P⫽.185). As with the Lequesne In- between T9 and T18 in either group.
analysis (intention-to-treat) by carry- dex scores, there was a significant
ing the last available score forward. reduction in the WOMAC scores be- Table 5 also displays significant
tween T0 and T9 for both groups. intragroup differences for walking
There was no significant difference in at a comfortable pace in the 50FWT
pain in the previous week (P⫽.198) After intervention, the water-based at T0, T9, and T18 (P⬍.001), again
between groups. However, intragroup exercise group exhibited significant suggesting that both interventions
comparisons (Tab. 3) revealed that decreases in pain (measured by VAS) improved the participants’ phys-
participants in both groups experi- before (P⫽.04) and after (P⫽.02) the ical performance. For the fast
enced significant reductions in pain 50FWT compared with the land- pace in the 50FWT, this differ-
in the previous week over time based exercise group (Tab. 4). Inter- ence was observed between T0
(P⬍.001). group comparisons over time re- and T9 in the land-based exercise
vealed significant differences in pain group (P⬍.001) and between T9
Mean Lequesne Index scores were before (P⫽.009) and after (P⬍.000) and T18 in the water-based exer-
not significantly different between the 50FWT only at T18, with the cise group.
groups (P⫽.333) (Tab. 3). Intra- water-based exercise group improv-
group analyses of this parameter ing more than the land-based exer- The use of sodium diclofenac did not
demonstrated a significant improve- cise group (Figure). Intragroup differ significantly between groups
ment in both groups between T0 and comparisons revealed significant re- (Tab. 5). Intragroup analyses re-

January 2008 Volume 88 Number 1 Physical Therapy f 17


Hydrotherapy Versus Conventional Land-Based Exercise

Table 4.
Visual Analog Scale (VAS) Scores for Pain Before and After the 50-foot (15.24-m) Walk Test (50FWT) in Participants With
Osteoarthritis of the Knee at 0 Weeks (T0), 9 Weeks (T9), and 18 Weeks (T18) After Intervention

Water-Based Exercise Group Land-Based Exercise Group P (Intergroup)


(nⴝ32) (nⴝ32)
MeanⴞSD (95% CIa) MeanⴞSD (95% CI)
VAS for pain before 50FWT (mm)
T0 39.6⫾23.4 (31.0–48.1) 53.0⫾24.4 (43.6–62.4) .045b
T9 21.7⫾20.7 (13.0–30.5) 26.5⫾28.1 (16.9–36.1)
T18 14.8⫾21.4 (5.4–24.2) 28.8⫾30.8 (18.5–39.1)
P (intragroup) ⬍.001b
⬍.001b
VAS for pain after 50FWT (mm)
T0 48.2⫾25.6 (39.9–56.5) 61.1⫾19.6 (52.0–70.2) .028b
T9 25.4⫾22.3 (16.3–34.6) 30.3⫾28.4 (20.4–40.3)
T18 15.1⫾19.8 (5.8–24.4) 33.4⫾31.7 (23.2–43.6)
P (intragroup) ⬍.001b
⬍.001b
a
CI⫽confidence interval.
b
P value statistically significant.

vealed that NSAID use was reduced superior to land-based exercises. At based exercise group and showing
by the third month in both groups the end of the study, there were re- that water-based exercise is a real
and again in the fourth month only in ductions in VAS scores in both option for patients with OA of the
the water-based exercise group. groups (89% and 45% reductions in knee.
the water-based and land-based exer-
Discussion and Conclusions cise groups, respectively). This de- At the end of our protocol, there was
Our findings demonstrated that both crease in pain was statistically signif- a significant and equal improvement
water-based and land-based exer- icant and clinically relevant, as a as measured by the WOMAC and the
cises reduced pain and improved reduction of ⬎17.5 mm in the VAS Lequesne Index. This improvement
function in individuals with OA of for pain has been recommended as was seen by the ninth week in both
the knee. Pain is an important symp- the minimum clinically relevant groups. Interestingly, only partici-
tom in patients with OA of the knee. change in therapeutic trials involving pants in the water-based exercise
Thus, a main goal of any therapeutic OA of the knee.26 group continued to show improve-
intervention should be to reduce this ment in these indexes up to the end
clinical component of the disease. In The reduction in pain found in both of the study. Hurley and Scott27 eval-
a systematic review,5 the European groups is a very important benefit for uated the effectiveness of a land-
League Against Rheumatism (EULAR) such patients. Although we believe based rehabilitation regimen for pa-
found that a VAS was used for pain that this improvement occurred due tients with OA of the knee (2
assessment in almost all of the stud- to the strengthening of the leg mus- exercise sessions per week for 5
ies reviewed. This instrument has cles, we cannot affirm this due to the weeks) and reported initial mean Le-
frequently been used to evaluate the fact that we did not directly assess quesne Index scores similar to ours,
effect of exercises on patients with the strength of these muscles, as our whereas the final scores were higher
OA of the knee. In the present study, primary objective was to assess im- than ours. This difference probably
the participants were asked about provement regarding pain and qual- reflected the longer duration of our
pain experienced during the week ity of life. We had expected pain to protocol (18 weeks versus 5 weeks
before entering the study, and initial decrease more in the water-based ex- in the study by Hurley and Scott) as
mean VAS scores for pain were ercise group than in the land-based well as the fact that Hurley and Scott
higher than those reported in previ- exercise group. However, reduc- used a protocol designed solely to
ous studies. As expected, there was a tions in pain were found in both strengthen the quadriceps femoris
significant decrease in pain in both groups, thereby failing to demon- muscles, whereas our protocol was
groups, but hydrotherapy was not strate a greater benefit in the water- designed to strengthen all of the ma-

18 f Physical Therapy Volume 88 Number 1 January 2008


Hydrotherapy Versus Conventional Land-Based Exercise

jor muscles of the lower limb and


also included gait training.

The participants were asked about


their pain before and after the
50FWT, which at T18 was signifi-
cantly lower, suggesting that hydro-
therapy reduces pain associated with
OA of the knee.3,4 We believe that
assessing pain at the time of evalua-
tion may be a better representation
of the pain experienced during daily
activities than measuring pain expe-
rienced during the previous week.
The assessment of current pain by a
VAS at rest before the walk test also
has been used by other authors.28
We do not have a good explanation
for the difference in pain between
groups found before and after the
50FWT, and we consider the possi-
bility that this reduction in pain may
be a spurious finding.

People with OA of the knee gener-


ally have reduced gait speed due to
pain.29,30 The effects of exercise on Figure.
gait as well as the use of walk tests to Mean visual analog scale (VAS) for pain before (A) and after (B) the 50-foot (15.24-m)
assess performance and therapeutic walk test (50FWT) in participants with osteoarthritis of the knee at 0 weeks (T0), 9 weeks
(T9), and 18 weeks (T18) after intervention. LBEG⫽land-based exercise group,
response have been evaluated in a
WBEG⫽water-based exercise group.
systematic review.7 Eight studies
evaluating gait using 5 different gait
tests reported either a small effect or
a significant improvement in gait af- for the assessment of pain in thera- contrast to our findings, Van Baar et
ter exercise.7 In the present study, peutic trials. In a review by Petrella,7 al31 observed no significant effect of
the 50FWT was divided into walking monitoring medication use also was exercise therapy on the use of
time at comfortable and fast paces. A found to be a good outcome measure NSAIDs in subjects with OA of the
comfortable pace is normally used in for assessing pain. In our study, the hip and knee (reductions of 35%
daily activities, whereas a fast pace is use of sodium diclofenac to relieve and 23% in the exercise and control
more suitable for exercises such as pain decreased significantly in both groups, respectively, at the end of the
aerobic activities. A significant im- groups by the third month of the study). However, these authors used a
provement in walking time at com- study, and a further reduction was weekly medication count compared
fortable and fast paces was observed seen in the fourth month in the with our monthly count and reported
in both groups during the study. We water-based exercise group. Overall, a higher mean use of NSAIDs than we
believe that this improvement may a 50% reduction in sodium diclofe- observed in our study.
be explained by the reduction in nac use was observed by the end of
pain and by potential improvements the study. It is important to empha- More participants concluded the
in strength and control of move- size that the reduction in the use of water-based exercise program (96%)
ment, which were not tested during NSAIDs in this population is of ex- than the land-based exercise pro-
this study. treme importance due to the risk of gram (81%), indicating greater adher-
gastrointestinal and renal complica- ence to the treatment protocol in the
The EULAR recommendations5 re- tions associated with the constant former group. A recent study32 com-
ported 65 studies using the number use of these medications for pain re- pared the adherence of subjects un-
of NSAIDs as a good quality measure lief in the elderly population.5 In dergoing hydrotherapy with that of a

January 2008 Volume 88 Number 1 Physical Therapy f 19


Hydrotherapy Versus Conventional Land-Based Exercise

Table 5.
Comfortable and Fast Paces in the 50-foot (15.24-m) Walk Test (50FWT) and Monthly Use of Sodium Diclofenac in Participants
With Osteoarthritis of the Knee at 0 Weeks (T0), 9 Weeks (T9), and 18 Weeks (T18) After Intervention

Water-Based Exercise Group Land-Based Exercise Group P (Intergroup)


(nⴝ32) (nⴝ32)
MeanⴞSD (95% CIa) MeanⴞSD (95% CI)
50FWT, comfortable pace (s)
T0 12.94⫾15.12 (7.70–18.17) 13.19⫾15.57 (7.79–18.58)
T9 11.64⫾13.14 (7.09–16.19) 11.81⫾13.46 (7.15–16.47) .52
T18 10.72⫾12.22 (6.49–14.95) 11.11⫾12.75 (6.7–15.52)
P (intragroup) ⬍.001b
⬍.001b
50FWT, fast pace (s)
T0 8.71⫾10.33 (5.14–12.28) 8.58⫾10.34 (5.02–12.14)
T9 7.87⫾9.27 (4.66–11.08) 7.93⫾9.45 (4.66–11.20) .69
T18 7.36⫾8.66 (4.36–10.36) 7.81⫾9.22 (4.62–11.00)
P (intragroup) ⬍.001b
⬍.001b
Sodium diclofenac 50 mg
(no. of tablets)
First month 31.63⫾19.79 (24.78–38.48) 31.1⫾19.78 (24.26–37.94) .73
Second month 26.90⫾19.30 (20.22–33.58) 29.62⫾23.81 (21.38–37.86)
Third month 17.10⫾19.52 (10.34–23.86) 20.37⫾21.91 (12.79–27.95)
Fourth month 14.33⫾17.82 (8.16–20.50) 15.37⫾18.18 (9.08–21.66)
P (intragroup) ⬍.001b
⬍.001b
a
CI⫽confidence interval.
b
P value statistically significant.

control group (patients on a waiting considerable evidence that land- gram were aware of the purpose of
list), and the authors concluded that based exercises are effective in pa- the study and tried to be impartial
patient adherence is fundamental to tients with OA of the knee,7,9,10 we with both groups. We believe it is
improving well-being, physical func- decided to compare hydrotherapy unlikely that their knowledge intro-
tion, and quality of life. We believe with the gold standard of exercise duced any relevant bias. Moreover,
that the adherence of our partici- intervention. Although the lack of a the therapists were not involved
pants to treatment was high due to control group meant that we were with testing.
difficulties regarding access to such unable to determine whether the im-
treatments in the public health sys- provements in both groups resulted Foley et al16 compared the effective-
tem. They did not want to miss the from exercise or other factors, such ness of hydrotherapy in patients
opportunity to participate in the pro- as the duration of therapy or the de- with OA of the knee and hip with
gram. This was especially true for gree of participant attention or mo- land-based exercises and an unex-
the participants who received hydro- tivation, we nevertheless believe ercised (control) group. There were
therapy, which is even more difficult that most of the improvement seen many differences between our study
to come across in the public health was attributable to the interventions and Foley and colleagues’ study. Our
system than land-based exercises. used, as OA is a degenerative disease program was longer than theirs
and would be expected to cause a (18 weeks versus 6 weeks), as were
The present study has some limita- progressive worsening of the partic- our sessions (50 minutes versus 30
tions, including the lack of a control ipants’ conditions. minutes), and our participants were
group (without exercise) to com- younger (mean age⫽59 years versus
pare with the 2 exercise treatment The 2 physical therapists responsible 70 years). The outcomes measured
groups. However, because there is for instruction in the exercise pro- also were different between the stud-

20 f Physical Therapy Volume 88 Number 1 January 2008


Hydrotherapy Versus Conventional Land-Based Exercise

ies. Foley et al assessed quadriceps 3 Wollheim FA. Osteoarthritis. Curr Opin 18 Wyatt FB, Milam S, Manske RC, Deere R.
Rheumatol. 2002;14:571–572. The effects of aquatic and traditional ex-
femoris muscle strength, gait speed (6- ercise programs on persons with knee os-
4 Brooks PM. Impact of osteoarthritis on in-
minute walk test), and function and dividuals and society: how much disabil- teoarthritis. J Strength Cond Res. 2001;15:
337–340.
pain (WOMAC). The subjects in the ity? Social consequences and health eco-
nomic implications. Curr Opin Rheumatol. 19 Kovacs I, Bender T. The therapeutic ef-
study by Foley and colleagues were 2002;14:573–577. fects of Cserkeszolo thermal water in os-
patients with OA of the knee and hip, 5 Mazières B, Bannwarth B, Dougados M, teoarthritis of the knee: a double blind,
controlled, follow-up study. Rheumatol
which could have introduced signifi- Lequesne M. EULAR recommendations for Int. 2002;21:218 –221.
the management of knee osteoarthritis: re-
cant bias in their analysis. Although port of a task force of the Standing Com- 20 Altman R, Asch E, Bloch D, et al Develop-
their findings for pain and function mittee for International Clinical Studies In- ment of criteria for the classification and
cluding Therapeutic Trials. Joint Bone reporting of osteoarthritis: classification of
were similar to ours, improvements Spine. 2001;68:231–240. osteoarthritis of the knee. Arthritis
were found over time in both studies, 6 Albright J, Altman R, Bonglio RP, Conill Rheum. 1986;29:1039 –1049.
with no significant differences be- A. Philadelphia Panel Evidence-Based 21 Bellamy N. Osteoarthritis clinical trials:
Clinical Practice Guidelines on Selected candidate variables and clinimetric prop-
tween groups. Rehabilitation Interventions: Overview erties. J Rheumatol. 1997;24:768 –778.
and Methodology. Phys Ther. 2001;81: 22 Lequesne MG, Mery C, Samson M, Gerard
1675–1680.
Our results indicate that water-based P. Indexes of osteoarthritis of the hip and
7 Petrella RJ. Is exercise effective treatment knee. Scand J Rheumatol Suppl. 1987;65:
and land-based exercises reduced for osteoarthritis of the knee? Br J Sports 85– 89.
pain and improved function in pa- Med. 2000;34:326 –331. 23 Bellamy N, Buchanan WW, Goldsmith CH,
tients with OA of the knee and that 8 Bautch JD, Clayton MK, Chu Q, Johnson Campbell LW. Validation study of
KA. Synovial fluid chondroitin sulphate WOMAC: a health status instrument for
water-based exercise was superior to epitopes 3B3 and 7D4 and glycosamino- measuring clinically important patient rel-
land-based exercise for relieving glycan in human knee osteoarthritis evant outcomes to antirheumatic drug
after exercise. Ann Rheum Dis. 2000; therapy in patients with osteoarthritis of
pain before and after walking. These 59:887– 891. the hip or knee. J Rheumatol. 1988;15:
findings indicate that hydrotherapy 9 Roddy E, Zhang W, Doherty M. Aerobic 1833–1840.
is a suitable and effective exercise walking or strengthening exercise for 24 Grace EM, Gerecz EM, Kaassam YB, et al.
osteoarthritis of the knee? A systematic 50-foot walking time: a critical assessment
for patients with OA of the knee and review. Ann Rheum Dis. 2005;64: of an outcome measure in clinical thera-
should be included in the therapeu- 544 –548. peutic trials of antirheumatic drugs. Br J
Rheumatol. 1988;27:372–374.
tic approaches recommended for 10 Fransen M, McConnell S, Bell M. Thera-
peutic exercise for people with osteoar- 25 Deyle GD, Henderson NE, Matekel RL,
the management of such patients. thritis of the hip or knee: a systematic et al. Effectiveness of manual physical
Further research should investigate review. J Rheumatol. 2002;29:1737–1745. therapy and exercise in osteoarthritis of
the knee: a randomized, controlled trial.
additional aspects of hydrotherapy, 11 Tapani P, Kari LK, Heikki K, et al. Neuro- Ann Intern Med. 2000;132:173–181.
muscular function during therapeutic
such as the long-term effects of this knee exercise under water and on dry 26 Bellamy N, Carette S, Ford P, et al. Osteo-
form of exercise and its ability to land. Arch Phys Med Rehabil. 2001;82: arthritis antirheumatic drug trials, III: set-
1146 –1152. ting the delta for clinical trials—results of
improve strength in patients with a consensus development (Delphi) exer-
12 Biscarini A, Cerulli G. Modeling of the
OA of the knee. knee joint load in rehabilitative knee ex- cise. J Rheumatol. 1992;19:451– 457.
tension exercises under water. J Biomech. 27 Hurley MV, Scott DL. Improvements in
2006;17:1–11. quadriceps sensorimotor function and dis-
Ms Silva, Ms Jones, and Dr Natour provided ability of patients with knee osteoarthritis
13 Green J, McKenna F, Chamberlain MA.
writing. Ms Silva, Ms Pessanha, and Ms My- following a clinically practicable exercise re-
Home exercises are as effective as out- gime. Br J Rheumatol. 1998;37:1181–1187.
amoto provided data collection. Ms Silva, Ms patient hydrotherapy for osteoarthritis
of the hip. Br J Rheumatol. 1993;32: 28 Maurer BT, Stern AG, Kinossian B, Cook
Jones, and Dr Natour provided data analysis. 812– 815. KD. Osteoarthritis of the knee: isokinetic
Dr Valim, Ms Oliveira, and Dr Natour pro- quadriceps exercise versus an educational
14 Verhagen AP, Henrica CW, Bie RA.
vided project management. intervention. Arch Phys Med Rehabil.
Taking baths—the efficacy of balneo- 1999;80:1293–1299.
therapy in patients with arthritis: a sys-
The study protocol was approved by the eth- tematic review. J Rheumatol. 1997;24: 29 Kaufman KR, Hughes C, Morrey BF, Mor-
ics committee at Universidade Federal de 1964 –1971. rey M. Gait characteristics of patients
São Paulo/Escola Paulista de Medicina. with knee osteoarthritis. J Biomech. 2001;
15 Tapani P, Sarianna S, Kari LK, et al. Effects 34:907–915.
of aquatic resistance training on neuro-
This article was received February 5, 2006, and muscular performance in healthy women. 30 Chen CPC, Chen MJL, Pei YC, et al. Sagittal
was accepted August 27, 2007. Med Sci Sports Exerc. 2002;34:2103–2109. plane loading response during gait in dif-
ferent age groups and in people with knee
DOI: 10.2522/ptj.20060040 16 Foley A, Halbert J, Hewitt T, Crolty M. osteoarthritis. Am J Phys Med Rehabil.
Does hydrotherapy improve strength and 2003;82:307–312.
physical function in patients with osteoar-
thritis? A randomized controlled trial com- 31 Van Baar ME, Dekker J, Oostendorp RAB,
References paring a gym based and hydrotherapy et al. The effectiveness of exercise therapy
1 Cooper C. Osteoarthritis: epidemiology based strengthening programme. Ann in patients with osteoarthritis of the hip or
and classification. In: Hochberg MC, ed. Rheum Dis. 2003;62:1162–1167. knee: a randomized clinical trial. J Rheu-
Rheumatology. 3rd ed. Toronto, Ontario, matol. 1998;25:2432–2439.
17 Yurtkuran M, Alp A, Nasircilar A, et al. Bal-
Canada: Mosby; 2003:1781–1791. neotherapy and tap water therapy in the 32 Belza B, Topolski T, Kinne S, et al. Does
2 Adler S. Self-care in the management of the treatment of knee osteoarthritis. Rheuma- adherence make a difference? Results
degenerative knee joint. Physiotherapy. tol Int. 2006;27:19 –27. from a community-based aquatic exercise
1985;71:58 – 60. program. Nurs Res. 2002;51:285–291.

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