Lincolnshire Knowledge and Resource Service

This search summary contains the results of a literature search

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Literature Search Results

Search completion date: 3rd May 2012
Search completed by: Alison Price

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Please review the evidence of effectiveness for hydrotherapy.

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Evidence-Based Reports

Evidence-based systematic review of the effectiveness of hydrotherapy in acute

and chronic medical conditions.
Dr. Gordon Doig, Senior Lecturer in Intensive Care, University of Sydney
The purpose of this systematic review was to identify and summarise the evidence
from randomised controlled trials supporting the use of hydrotherapy (aquatic exercise,
pool therapy) in acute and chronic medical conditions. For the purposes of this review,
no limits were set on water temperature but to be considered as hydrotherapy, some
form of exercise had to be conducted in pool water.
Full text at: www.evidencebased.net/files/EBDMReviewofHydrotherapy2008.pdf

HYDROTHERAPY. Review on the effectiveness of its application in physiotherapy

and occupational therapy. By Dr. Craig W. Martin, Senior Medical Advisor
Kukuh Noertjojo, Health Care Analyst (May 2004)
Attached as an Appendix.
Systematic Reviews

Water-based exercises for improving activities of daily living after stroke.

Citation: Cochrane Database of Systematic Reviews, 2011, vol./is. /1(CD008186), 1361-
Author(s): Mehrholz J, Kugler J, Pohl M
Abstract: BACKGROUND: Water-based exercises are used in rehabilitation and might
help to reduce disability after stroke.OBJECTIVES: To investigate the effect of water-
based exercises for reducing disability after stroke.SEARCH STRATEGY: We searched
the Cochrane Stroke Group Trials Register (last searched August 2010), the Cochrane
Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 4),
MEDLINE (1966 to April 2010), EMBASE (1980 to April 2010), CINAHL (1982 to April
2010), AMED (1985 to April 2010), SPORTDiscus (1949 to April 2010), the
Physiotherapy Evidence Database (PEDro, April 2010) and OT Seeker (1969 to April
2010). In an effort to identify further published, unpublished and ongoing trials we
handsearched relevant journals and conference proceedings, searched trials and
research registers, checked reference lists and contacted authors.SELECTION
CRITERIA: We included studies using random assignment.DATA COLLECTION AND
ANALYSIS: Two review authors independently selected trials for inclusion, assessed
trial quality and extracted the data. The primary outcome was activities of daily
living.MAIN RESULTS: We included four trials involving 94 participants in this review.
There was a significant improvement in activity of daily living (mean difference (MD)
13.20 points on the 'Capacidad funcional' (functional capacity) subscale of the Brazilian-
Portuguese version of the SF-36; 95% confidence interval (CI) 8.36 to 18.04; P <
0.00001) and on muscle strength (MD 1.01 Nm/kg; 95% CI 0.19 to 1.83; P = 0.02) but
these results should be interpreted with caution because population numbers were small
and the results are based on single studies. There was no significant improvement in
ability to walk (MD 0.14 m/s; 95% CI -0.32 to 0.606; P = 0.55), postural balance (MD
3.05 points; 95% CI -3.41 to 9.52; P = 0.35) or fitness (MD 3.6 (VO(2max); 95% CI -0.53
to 7.73; P = 0.09) after water-based exercises treatment compared to control. Adverse
effects were not reported.AUTHORS' CONCLUSIONS: The evidence from randomised
controlled trials so far does not confirm or refute that water-based exercises after stroke
might help to reduce disability after stroke. There is a lack of hard evidence for water-
based exercises after stroke. Better and larger studies are therefore required.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008186.pub2/abstract

Effectiveness of aquatic interventions for children with cerebral palsy: systematic

review of the current literature.
Citation: Journal of Aquatic Physical Therapy, 01 March 2011, vol./is. 19/1(19-29),
Author(s): Blohm, Dietmar
Abstract: Background. At present, physical therapists use a growing number of
interventions to treat children with cerebral palsy. Recently, aquatic training seems to be
gaining in popularity for use with this population. Purpose. The aim of this paper was to
systematically review the available evidence regarding the effectiveness of aquatic
interventions for children with cerebral palsy. Methods. The author electronically
searched for related articles and rated each article using the PEDro scale. Summary of
the Literature. Eight articles met inclusion criteria. Two randomized controlled trials, 3
non-randomized trials, one cohort study, one case series, and one case report were
found.. Across all studies, beneficial effects on functioning, activity, or participation were
reported. Conclusion. The evidence examined suggested that aquatic interventions are
beneficial for children and adolescents with cerebral palsy, particularly in the function
and activity dimensions; however, more well-designed trials are required to define
conclusions on the effectiveness of aquatic interventions for children with cerebral palsy.

Effectiveness of aquatic exercise and balneotherapy: a summary of systematic

reviews based on randomized controlled trials of water immersion therapies.
Citation: Journal of Epidemiology, 2010, vol./is. 20/1(2-12), 0917-5040;1349-9092 (2010)
Author(s): Kamioka H, Tsutani K, Okuizumi H, Mutoh Y, Ohta M, Handa S, Okada S,
Abstract: BACKGROUND: The objective of this review was to summarize findings on
aquatic exercise and balneotherapy and to assess the quality of systematic reviews
based on randomized controlled trials.METHODS: Studies were eligible if they were
systematic reviews based on randomized clinical trials (with or without a meta-analysis)
that included at least 1 treatment group that received aquatic exercise or balneotherapy.
We searched the following databases: Cochrane Database Systematic Review,
MEDLINE, CINAHL, Web of Science, JDream II, and Ichushi-Web for articles published
from the year 1990 to August 17, 2008.RESULTS: We found evidence that aquatic
exercise had small but statistically significant effects on pain relief and related outcome
measures of locomotor diseases (eg, arthritis, rheumatoid diseases, and low back pain).
However, long-term effectiveness was unclear. Because evidence was lacking due to
the poor methodological quality of balneotherapy studies, we were unable to make any
conclusions on the effects of intervention. There were frequent flaws regarding the
description of excluded RCTs and the assessment of publication bias in several trials.
Two of the present authors independently assessed the quality of articles using the
AMSTAR checklist.CONCLUSIONS: Aquatic exercise had a small but statistically
significant short-term effect on locomotor diseases. However, the effectiveness of
balneotherapy in curing disease or improving health remains unclear.
https://www.jstage.jst.go.jp/article/jea/advpub/0/advpub_JE20090030/_pdf

Efficacy of hydrotherapy in fibromyalgia syndrome--a meta-analysis of

randomized controlled clinical trials.
Citation: Rheumatology, September 2009, vol./is. 48/9(1155-9), 1462-0324;1462-0332
Author(s): Langhorst J, Musial F, Klose P, Hauser W
Abstract: OBJECTIVE: To systematically review the efficacy of hydrotherapy in FM
syndrome (FMS).METHODS: We screened MEDLINE, PsychInfo, EMBASE, CAMBASE
and CENTRAL (through December 2008) and the reference sections of original studies
and systematic reviews on hydrotherapy in FMS. Randomized controlled trials (RCTs)
on the treatment of FMS with hydrotherapy (spa-, balneo- and thalassotherapy,
hydrotherapy and packing and compresses) were analysed. Methodological quality was
assessed by the van Tulder score. Effects were summarized using standardized mean
differences (SMDs).RESULTS: Ten out of 13 RCTs with 446 subjects, with a median
sample size of 41 (range 24-80) and a median treatment time of 240 (range 200-300)
min, were included into the meta-analysis. Only three studies had a moderate quality
score. There was moderate evidence for reduction of pain (SMD -0.78; 95% CI -1.42, -
0.13; P < 0.0001) and improved health-related quality of life (HRQOL) (SMD -1.67; 95%
CI -2.91, -0.43; P = 0.008) at the end of therapy. There was moderate evidence that the
reduction of pain (SMD -1.27; 95% CI -2.15, -0.38; P = 0.005) and improvement of
HRQOL (SMD -1.16; 95% CI -1.96, -0.36; P = 0.005) could be maintained at follow-up
(median 14 weeks).CONCLUSIONS: There is moderate evidence that hydrotherapy has
short-term beneficial effects on pain and HRQOL in FMS patients. There is a risk to
over-estimate the effects of hydrotherapy due to methodological weaknesses of the
studies and to small trials included in meta-analysis.
http://rheumatology.oxfordjournals.org/content/48/9/1155.full.pdf+html
Therapeutic aquatic exercise in the treatment of low back pain: a systematic
review.
Citation: Clinical Rehabilitation, January 2009, vol./is. 23/1(3-14), 0269-2155;0269-2155
Author(s): Waller B, Lambeck J, Daly D
Abstract: OBJECTIVE: To examine the effectiveness of therapeutic aquatic exercise in
the treatment of low back pain.DESIGN: A systematic review.METHODS: A search was
performed of PEDro, CINAHL (ovid), PUBMED, Cochrane Controlled Trials Register and
SPORTDiscus databases to identify relevant studies published between 1990 and
2007.POPULATION: Adults suffering from low back pain.INTERVENTION: All types of
therapeutic aquatic exercise. COMPARISON: All clinical trials using a control
group.OUTCOMES: Oswestry Disability Index, McGill Pain Questionnaire, subjective
assessment scale for pain (e.g. visual analogue scale) and number of work days lost as
a direct result of low back pain. Methodological quality was assessed using the PEDro
scale and the SIGN 50 assessment forms.RESULTS: Thirty-seven trials were found and
seven were accepted into the review. Therapeutic aquatic exercise appeared to have a
beneficial effect, however, no better than other interventions. Methodological quality was
considered low in all included studies. The heterogeneity among studies, in numbers of
subjects, symptoms durations, interventions and reporting of outcomes, precluded any
extensive meta-analysis of the results.CONCLUSION: There was sufficient evidence to
suggest that therapeutic aquatic exercise is potentially beneficial to patients suffering
from chronic low back pain and pregnancy-related low back pain. There is further need
for high-quality trials to substantiate the use of therapeutic aquatic exercise in a clinical
setting.
http://journals.ohiolink.edu/ejc/pdf.cgi/Waller_Benjamin.pdf?issn=02692155&issue=v23i0
001&article=3_taeittlbpasr

Components of effective randomized controlled trials of hydrotherapy programs

for fibromyalgia syndrome: A systematic review
Citation: Journal of Pain Research, 2009, vol./is. 2/(165-173), 1178-7090 (2009)
Author(s): Perraton L., Machotka Z., Kumar S.
Abstract: Aim: Previous systematic reviews have found hydrotherapy to be an effective
management strategy for fibromyalgia syndrome (FMS). The aim of this systematic
review was to summarize the components of hydrotherapy programs used in
randomized controlled trials. Method: A systematic review of randomized controlled trials
was conducted. Only trials that have reported significant FMS-related outcomes were
included. Data relating to the components of hydrotherapy programs (exercise type,
duration, frequency and intensity, environmental factors, and service delivery) were
analyzed. Results: Eleven randomized controlled trials were included in this review.
Overall, the quality of trials was good. Aerobic exercise featured in all 11 trials and the
majority of hydrotherapy programs included either a strengthening or flexibility
component. Great variability was noted in both the environmental components of
hydrotherapy programs and service delivery. Conclusions: Aerobic exercise, warm up
and cool-down periods and relaxation exercises are common features of hydrotherapy
programs that report significant FMS-related outcomes. Treatment duration of 60
minutes, frequency of three sessions per week and an intensity equivalent to 60%-80%
maximum heart rate were the most commonly reported exercise components. Exercise
appears to be the most important component of an effective hydrotherapy program for
FMS, particularly when considering mental health-related outcomes. 2009 Perraton et al,
publisher and licensee Dove Medical Press Ltd.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3004626/pdf/jpr-2-165.pdf
The effectiveness of hydrotherapy in the management of fibromyalgia syndrome:
a systematic review.
Citation: Rheumatology International, December 2008, vol./is. 29/2(119-30), 0172-
Author(s): McVeigh JG, McGaughey H, Hall M, Kane P
Abstract: Hydrotherapy is often used in the treatment of fibromyalgia syndrome (FMS),
however there has been limited evaluation of its effectiveness. The aim of this
systematic review was therefore to examine the effectiveness of hydrotherapy in the
management of FMS. AMED, BNI, CINAHL, The Cochrane Library, EMBASE,
MEDLINE, ProQuest, PubMed, Science Direct and Web of Science were searched
(1990-July 2006). Key words used 'fibromyalgia' and 'hydrotherapy', 'balneotherapy',
'aqua therapy', 'pool therapy', 'water therapy', 'swimming', 'hydrogalvanic', 'spa therapy',
'physiotherapy', 'physical therapy' and 'rehabilitation'. Searches were supplemented with
hand searches of selected journals. Randomised controlled trials (RCTs) were assessed
for methodological quality using the van Tulder scale. Ten RCTs met the inclusion
criteria. Mean methodological quality was 4.5/9 on the van Tulder scale. Positive
outcomes were reported for pain, health-status and tender point count. There is strong
evidence for the use of hydrotherapy in the management of FMS.
http://journals.ohiolink.edu/ejc/pdf.cgi/McVeigh_Joseph_G.pdf?issn=01728172&issue=v
29i0002&article=119_teohitofsasr

Does aquatic exercise relieve pain in adults with neurologic or musculoskeletal

disease? A systematic review and meta-analysis of randomized controlled trials.
Citation: Archives of Physical Medicine & Rehabilitation, May 2008, vol./is. 89/5(873-83),
Author(s): Hall J, Swinkels A, Briddon J, McCabe CS
Abstract: OBJECTIVE: To evaluate the literature on the effectiveness of aquatic exercise
in relieving pain in adults with neurologic or musculoskeletal disease.DATA SOURCES:
A systematic literature search of 14 databases was examined for research on aquatic
exercise over the period January 1980 to June 2006.STUDY SELECTION: Randomized
controlled trials (RCTs) that included adults with neurologic or musculoskeletal disease,
pain as an outcome measure, and exercise in water were included.DATA
EXTRACTION: Information on the participants, interventions, and outcomes was
extracted from the included studies. Quality appraisal was assessed using the Scottish
Intercollegiate Guidelines Network criteria for RCTs.DATA SYNTHESIS: Nineteen
studies met the inclusion criteria; 8 were of moderate to low risk of bias, and 5 of these
had data suitable for meta-analyses. This showed that aquatic exercise has a small
posttreatment effect in relieving pain compared with no treatment (P=.04; standardized
mean difference [SMD], -.17; 95% confidence interval [CI], -.33 to -.01), but it is not
possible to draw a firm conclusion because of the lack of consistency of evidence across
studies. Comparable pain-relieving effects were found between aquatic and land-based
exercise (P=.56; SMD=.11; 95% CI, -.27 to .50).CONCLUSIONS: There is sound
evidence that there are no differences in pain-relieving effects between aquatic and land
exercise. Compared with no treatment, aquatic exercise has a small pain-relieving effect;
however, the small number of good-quality studies and inconsistency of results means
that insufficient evidence limits firm conclusions. Future studies should aim for focused
research questions on specific aquatic exercise techniques, using robust methodologic
designs and detailed reporting of temperature, depth, and care setting.
http://journals.ohiolink.edu/ejc/pdf.cgi/Hall_Jane.pdf?issn=00039993&issue=v89i0005&article=873_daerpiamorct
Aquatic exercise for the treatment of knee and hip osteoarthritis.
Citation: Cochrane Database of Systematic Reviews, 2007, vol./is. /4(CD005523), 1361-
Author(s): Bartels EM, Lund H, Hagen KB, Dagfinrud H, Christensen R, Danneskiold-
Abstract: 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.
MAIN RESULTS: There 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 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.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005523.pub2/abstract

Aquatic physical therapy for low back pain: what are the outcomes?
Citation: Journal of Aquatic Physical Therapy, 01 September 2007, vol./is. 15/2(18-24),
Author(s): Barone D, Gangaway JMK
Abstract: Background: APT (APT) is a pool based treatment program developed to take
advantage of the properties of water in order to reduce stress on the joints and muscles
by reducing the effects of gravity on the body. APT generally benefits those with low
back pain (LBP). The warm water reduces muscle tone and pain, and the buoyancy
reduces joint compressive forces associated with land-based treatment. Purpose: The
purpose of this literature review is to assess the available literature related to aquatic PT
treatment of patients with orthopedic LBP tp find available evidence, and identify areas
of future exploration. Method: A systematic review of available and relevant articles was
conducted using main databases including Pubmed, Pedro, Cochrane, and CINAHL.
Results: Overall, aquatic PT has been found to allow for early initiation of exercise and a
shorter rehabilitation period. The articles reviewed have also found that aquatic therapy
reduces pain, increases the quality of life and functional mobility, and increases range of
motion (ROM) and strength in patients with low back injuries.
Effects of aquatic interventions in children with neuromotor impairments: a
systematic review of the literature.
Citation: Clinical Rehabilitation, November 2006, vol./is. 20/11(927-36), 0269-
Author(s): Getz M, Hutzler Y, Vermeer A
Abstract: OBJECTIVE: To determine the effectiveness of aquatic interventions in
children with neuromotor impairments.DESIGN: A search of electronic databases that
included MEDLINE, PubMed, ERIC, PsychLit, PEDro, Sport Discus, CINAHL and
Cochrane between 1966 and January 2005 was conducted using the following
keywords: 'hydrotherapy', 'aquatic therapy', 'water exercise', 'aquatics', 'adapted
aquatics', 'aquatic exercise' and 'swimming'. An additional resource, the Aquatic Therapy
Research Bibliography until 1999, was explored manually. Titles and abstracts were
assessed manually according to the following inclusion criteria: (1) population (children
with neuromotor or neuromuscular impairments), (2) intervention (aquatic programme).
Articles were reviewed according to merit of design, population participants and outcome
measures with respect to International Classification of Function and Disability
terminology (changes in body function, activity level and participation).RESULTS: Eleven
of the 173 articles that were retrieved met the inclusion criteria: one randomized control
trial, two quasi-experimental studies, one cohort study, two case control studies and five
case reports. Seven articles reported improvement in body functions, and seven articles
reported improvement in activity level. Two of the four articles that investigated outcome
measures regarding participation described positive effects while the findings of the
other two revealed no change. None of the articles reported negative effects due to
aquatic interventions.CONCLUSION: According to this review, there is a substantial lack
of evidence-based research evaluating the specific effects of aquatic interventions in this
population.
http://journals.ohiolink.edu/ejc/pdf.cgi/Getz_Miriam.pdf?issn=02692155&issue=v20i0011
&article=927_eoaiicasrotl

Title: Efficacy of balneotherapy for osteoarthritis of the knee: a systematic review

Citation: Physical Therapy Reviews, December 2002, vol./is. 7/4(209-22), 1083-3196
Author(s): Brosseau L, Macleay L, Robinson V, Casimiro L, Pelland L, Wells G, Tugwell
Abstract: Balneotherapy's role in treating patients with arthritic disease is much debated.
More common in treating patients with rheumatoid arthritis, balneotherapy's efficacy for
patients with osteoarthritis needs further exploration. Our systematic review included
three randomized controlled trials examining the effect of various types of balneotherapy
on osteoarthritis of the knee. Thermal water balneotherapy showed clinical benefit but no
statistical significance for pain relief. Combination of hot sulphur and Dead Sea baths
were more statistically significant and clinically effective than single bath treatments for
short-term measures of pain and function. A combination of both regime also had a
significant effect on pain severity at one-month follow-up. No significant long-term (three
months) benefits were observed for pain or function. We conclude that balneotherapy in
the form of combination baths has short-term benefits for pain relief and function, which
suggests that balneotherapy may require a standard treatment regime for optimal
efficacy.
Efficacy of balneotherapy for rheumatoid arthritis: a meta-analysis
Citation: Physical Therapy Reviews, June 2002, vol./is. 7/2(67-87), 1083-3196 (2002
Author(s): Brosseau L, Robinson V, Leonard G, Casimiro L, Pelland L, Wells G, Tugwell
Abstract: Balneotherapy is an accepted therapeutic approach in Europe. However, its
efficacy for treating rheumatoid arthritis (RA) remains controversial in North America.
This is a meta-analysis of randomized (RCT) and controlled clinical trials (CCT), case-
control and cohort studies of balneotherapy compared to control (no treatment) or active
therapy (head to head studies). All the included studies (n = 7) in this review were
identified as RCTs. This meta-analysis examines different balneotherapy modalities:
Radon-carbon dioxide baths, mud packs, hot sulphur baths, Dead Sea baths, Red Sea
baths, and grey sand. Several types of balneotherapy, including radon-carbon dioxide
baths, mud packs, hot sulphur baths, combination of hot sulphur baths and mud packs,
Dead Sea baths, combination of Dead Sea baths and sulphur baths, and Grey sand and
Red Sea baths compared to control were found to be beneficial for RA. These modalities
were found to be especially beneficial for pain, grip strength, tender swollen joints,
patient and physician, and global function. These improvements ranged from 5-93%
greater improvement relative to the control group. However, methodological
considerations including the poor quality of trials impact the conclusions of this review.

Balneotherapy for rheumatoid arthritis and osteoarthritis.

Citation: Cochrane Database of Systematic Reviews, 2000, vol./is. /2(CD000518), 1361-
Author(s): Verhagen AP, de Vet HC, de Bie RA, Kessels AG, Boers M, Knipschild PG
Abstract: BACKGROUND: Balneotherapy (hydrotherapy or spa therapy) for patients with
arthritis is one of the oldest forms of therapy. One of the aims of balneotherapy is to
soothe the pain and as a consequence to relieve patients' suffering and make them feel
well.OBJECTIVES: To perform a systematic review to assess the effects of
balneotherapy for rheumatoid arthritis and osteoarthritis.SEARCH STRATEGY: Using
the Cochrane search strategy, studies were found by screening: 1) The Medline CD-
ROM database from 1966 to June 1999 and 2) the database from the Cochrane Field
'Rehabilitation and Related Therapies', which contains also studies published in journals
not covered by Medline. Also, 3) reference checking and 4) personal communications
with authors was carried out to retrieve eligible studies. To perform an adequate
assessment of the methodological quality the languages of the publications had to be:
Dutch, English, French or German. Date of the most recent literature search: June,
1999SELECTION CRITERIA: Studies were eligible if they were randomized controlled
trials (RCT) comparing balneotherapy with any intervention or with no intervention.
Patients included had rheumatoid arthritis (RA), osteoarthritis (OA) or some other form of
arthritis. Trials incorporating patients with definite or classical rheumatoid arthritis (RA)
as defined by the American Rheumatism Association Criteria (ARA) (Ropes 1958)
(these criteria have changed over time) or by the criteria of Steinbrocker (1949) were
regarded as a separate group. At least one of the WHO/ILAR core set of endpoints for
RA clinical trials had to be the main outcome measures.DATA COLLECTION AND
ANALYSIS: A criteria list used to assess the methodological quality was the one
developed at the Department of Epidemiology at the Maastricht University, called "the
Maastricht list". The quality scores and data abstraction of the studies were carried out
independently by two reviewers (HdV, RdB). Disagreements were solved by
consensus.MAIN RESULTS: Ten trials with 607 patients were included in this review.
Most trials reported positive findings, but were methodologically flawed to some extent.
A 'quality of life' outcome was reported by two trials. Just one of the randomized trials
mentioned an intention-to-treat analysis and only three performed a comparison of
effects between groups. Pooling of the data was not performed, because of
heterogeneity of the studies, multiple outcome measurements, and, apart from two
studies, the overall data presentation was too scarce to enable pooling of the
data.REVIEWER'S CONCLUSIONS: One cannot ignore the positive findings reported in
most trials. However the scientific evidence is weak because of the poor methodological
quality, the absence of an adequate statistical analysis, and the absence, for the patient,
of most essential outcome measures (pain, quality of life), Therefore, the noted "positive
findings" should be viewed with caution. Because of the methodological flaws an answer
about the efficacy of balneotherapy cannot be provided at this time. Flaws found in the
reviewed studies could be avoided in future trials.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000518/abstract

Literature Reviews

Towards evidence-based emergency medicine: best BETs from the Manchester

Royal Infirmary. BET 4: Hydrotherapy following rotator cuff repair.
Citation: Emergency Medicine Journal, July 2011, vol./is. 28/7(634-5), 1472-0205;1472-
Author(s): Hay L, Wylie K
Abstract: A short cut review was carried out to establish whether hydrotherapy is
beneficial in rehabilitation after rotator cuff repair. 27 papers were found using the
reported searches, of which one presented the best evidence to answer the clinical
question. The author, date and country of publication, patient group studied, study type,
relevant outcomes, results and study weaknesses of that best paper are tabulated. It is
concluded that while there may be some short term benefit to passive range of
movement, further research is needed.

Mechanisms of action of spa therapies in rheumatic diseases: what scientific

evidence is there?.
Citation: Rheumatology International, January 2011, vol./is. 31/1(1-8), 0172-8172;1437-
Author(s): Fioravanti A, Cantarini L, Guidelli GM, Galeazzi M
Abstract: Spa therapy represents a popular treatment for many rheumatic diseases. The
mechanisms by which immersion in mineral or thermal water or the application of mud
alleviates suffering in rheumatic diseases are not fully understood. The net benefit is
probably the result of a combination of factors, with mechanical, thermal and chemical
effects among the most prominent ones. Buoyancy, immersion, resistance and
temperature all play important roles. According to the gate theory, pain relief may be due
to the pressure and temperature of the water on skin; hot stimuli may influence muscle
tone and pain intensity, helping to reduce muscle spasm and to increase the pain
threshold. Mud-bath therapy increases plasma beta-endorphin levels and secretion of
corticotrophin, cortisol, growth hormone and prolactin. It has recently been demonstrated
that thermal mud-pack therapy induces a reduction in the circulating levels of
prostaglandin E2 (PGE2), leukotriene B4 (LTB4), interleukin-1beta (IL-1beta) and
tumour necrosis factor-alpha (TNF-alpha), important mediators of inflammation and pain.
Spa therapy has been found to cause an increase in insulin-like growth factor-1 (IGF1),
which stimulates cartilage metabolism, and transforming growth factor-beta (TGF-beta).
There is also evidence of the positive action of mud-packs and thermal baths on the
oxidant/antioxidant system, with a reduction in the release of reactive oxygen (ROS) and
nitrogen (RNS) species. Overall, thermal stress has an immunosuppressive effect. Many
other non-specific factors may also contribute to the beneficial effects observed after spa
therapy in some rheumatic diseases, including effects on cardiovascular risk factors, and
changes in the environment, pleasant surroundings and the absence of work duties.
Land- and water-based exercise therapies for musculoskeletal conditions.
Best Practice & Research in Clinical Rheumatology, 2008, 22/3(407-18)
Author(s): Dziedzic K, Jordan JL, Foster NE
Abstract: This chapter summarizes current evidence from recently published systematic
reviews of land- and water-based exercise therapies for musculoskeletal conditions. The
aim is to present an overview of the evidence and highlight gaps where more research is
still needed. This is not a systematic review, but a systematic search of the literature and
a summary of results of the best, most recent systematic reviews evaluating
interventions for musculoskeletal conditions. There have been two previous summaries
of systematic reviews of evidence for exercise therapies in musculoskeletal conditions.
We have updated these searches, and additionally considered the evidence for the
clinical effectiveness of exercise in fibromyalgia and chronic widespread pain and of
hydrotherapy and water-based exercise treatments on pain and disability.

Aquatic physical therapy improves joint mobility, strength, and edema in lower
extremity orthopedic injuries.
Citation: Journal of Aquatic Physical Therapy, 01 March 2008, vol./is. 16/1(10-15),
Author(s): Fappiano M, Gangaway JMK
Abstract: Background: Aquatic exercise programs can incorporate large muscle activity
in the lower extremities with full range of motion and minimal joint stress, and result in
fewer musculoskeletal injuries. Purpose: The purposes of this literature review were to
review available aquatic therapy literature in treating orthopedic lower extremity injuries
and to identify gaps in the current body of knowledge to determine further research
needs. Methods: Relevant articles were searched on main databases. All articles were
then reviewed, standardized by title, author, journal, year, subject number and
characteristics, purpose and type of study, methods, results, and limitations, and
analyzed. Results: The articles evaluated demonstrated that aquatic physical therapy is
beneficial in reducing pain and increasing quality of life, range of motion, joint
extensibility, and strength. The studies also reported water and land based interventions
used together are more effective in treating lower extremity injuries than land based
interventions alone.

Evidence-based treatment of aquatic physical therapy in the rehabilitation of

upper-extremity orthopedic injuries.
Citation: Journal of Aquatic Physical Therapy, 01 March 2007, vol./is. 15/1(19-26),
Author(s): Watts KE, Gangaway JMK
Abstract: Background: Aquatic physical therapy is one means therapists use to facilitate
the return to function in the treatment of orthopedic upper-extremity (UE) injuries.
Therapists make informed decisions through critical analysis of research, which provides
scientific evidence to support aquatic treatment. Purpose: To identify evidence that
exists to support the treatment of orthopedic UE injuries with aquatic physical therapy.
Methods: A review of the published literature was conducted through online databases
including: Pubmed, Pedro, Cochrane, CINAHL, and Hooked on Evidence, as well as in
the published bibliography of the Aquatic Section of the APTA. Results: One randomized
control trial (RCT), one case study and 7 expert opinion articles were identified.
Discussion and Clinical Relevance: Early activation of motion, improvement in joint
mobility, muscle strength, proprioception and core strengthening, minimization of pain,
decreased risk of further injury, and the use of equipment to increase resistance were all
factors supporting aquatic physical therapy intervention for UE injuries. Future
experimental studies are recommended to explore the rehabilitation of UE orthopedic
injuries through aquatic physical therapy.
Hydrotherapy, balneotherapy, and spa treatment in pain management.
Citation: Rheumatology International, April 2005, vol./is. 25/3(220-4), 0172-8172;0172-
Author(s): Bender T, Karagulle Z, Balint GP, Gutenbrunner C, Balint PV, Sukenik S
Abstract: The use of water for medical treatment is probably as old as mankind. Until the
middle of the last century, spa treatment, including hydrotherapy and balneotherapy,
remained popular but went into decline especially in the Anglo-Saxon world with the
development of effective analgesics. However, no analgesic, regardless of its potency, is
capable of eliminating pain, and reports of life-threatening adverse reactions to the use
of these drugs led to renewed interest in spa therapy. Because of methodologic
difficulties and lack of research funding, the effects of 'water treatments' in the relief of
pain have rarely been subjected to rigorous assessment by randomised, controlled trials.
It is our opinion that the three therapeutic modalities must be considered separately, and
this was done in the present paper. In addition, we review the research on the
mechanism of action and cost effectiveness of such treatments and examine what
research might be useful in the future.

Hydrotherapy in labor.
Citation: Journal of Nursing Scholarship, 2002, vol./is. 34/4(347-52), 1527-6546;1527-
Author(s): Benfield RD
Abstract: PURPOSE: To review the literature on hydrotherapy in labor to direct
prescription of the intervention and design studies to test its effectiveness.METHODS:
Studies of hydrotherapy were identified via searching literature and electronic
databases.FINDINGS: A primary effect of immersion is a central blood volume bolus,
which occurs almost immediately after bathing begins. Subjective maternal responses to
bathing in labor have been favorable. No maternal or infant infections have been
attributed to bathing by parturients with either intact or ruptured membranes. Maternal
bathing in labor does not appear to affect infant Apgar scores or stress hormones at
birth. No clear evidence exists to indicate that hydrotherapy increases cervical dilation,
increases fetal descent, reduces uterine dyskinesia, shortens labor, decreases use of
epidurals or analgesia, or decreases rates of operative delivery or
hemorrhage.CONCLUSIONS: Study findings indicate support for using hydrotherapy for
relief of rapid pain and anxiety in labor. A methodical approach must be taken to
determine for whom and under what circumstances intervention with hydrotherapy in
labor is efficacious. Studies of the maternal and fetal effects of hydrotherapy in labor,
including mechanisms of action, as well as large, prospective, randomized clinical
outcome trials with control for intervening variables, are needed to help practitioners
decide whether to prescribe hydrotherapy.
Randomised Controlled Trials

Multicenter randomized controlled trial comparing early versus late aquatic

therapy after total hip or knee arthroplasty.
Citation: Archives of Physical Medicine & Rehabilitation, February 2012, vol./is.
93/2(192-9), 0003-9993;1532-821X (2012 Feb)
Author(s): Liebs TR, Herzberg W, Ruther W, Haasters J, Russlies M, Hassenpflug J,
Abstract: OBJECTIVE: To evaluate if the timing of aquatic therapy influences clinical
outcomes after total knee arthroplasty (TKA) or total hip arthroplasty (THA).DESIGN:
Multicenter randomized controlled trial with 3-, 6-, 12-, and 24-month follow-
up.SETTING: Two university hospitals, 1 municipal hospital, and 1 rural
hospital.PARTICIPANTS: Patients (N=465) undergoing primary THA (n=280) or TKA
(n=185): 156 men, 309 women.INTERVENTION: Patients were randomly assigned to
receive aquatic therapy (pool exercises aimed at training of proprioception, coordination,
and strengthening) after 6 versus 14 days after THA or TKA.MAIN OUTCOME
MEASURES: Primary outcome was self-reported physical function as measured by the
Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 3-, 6-, 12-,
and 24-months postoperatively. Results were compared with published thresholds for
minimal clinically important improvements. Secondary outcomes included the Medical
Outcomes Study 36-Item Short-Form Health Survey, Lequesne-Hip/Knee-Score,
WOMAC-pain and stiffness scores, and patient satisfaction.RESULTS: Baseline
characteristics of the 2 groups were similar. Analyzing the total study population did not
result in statistically significant differences at all follow-ups. However, when performing
subanalysis for THA and TKA, opposite effects of early aquatic therapy were seen
between TKA and THA. After TKA all WOMAC subscales were superior in the early
aquatic therapy group, with effect sizes of WOMAC physical function ranging from .22 to
.39. After THA, however, all outcomes were superior in the late aquatic therapy group,
with WOMAC effect sizes ranging from .01 to .19. However, the differences between
treatment groups of these subanalyses were not statistically significant.CONCLUSIONS:
Early start of aquatic therapy had contrary effects after TKA when compared with THA
and it influenced clinical outcomes after TKA. Although the treatment differences did not
achieve statistically significance, the effect size for early aquatic therapy after TKA had
the same magnitude as the effect size of nonsteroidal anti-inflammatory drugs in the
treatment of osteoarthritis of the knee. However, the results of this study do not support
the use of early aquatic therapy after THA. The timing of physiotherapeutic interventions
has to be clearly defined when conducting studies to evaluate the effect of
physiotherapeutic interventions after TKA and THA. Copyright Copyright 2012 American
Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
A randomized controlled trial to investigate the effects of water-based exercise to
improve falls risk and physical function in older adults with lower-extremity
osteoarthritis.
Citation: Archives of Physical Medicine & Rehabilitation, January 2012, vol./is. 93/1(27-
Author(s): Hale LA, Waters D, Herbison P
Abstract: OBJECTIVE: To investigate the efficacy of a water-based exercise program
specifically targeting balance to reduce falls risk and improve measures of balance and
physical function in older adults with osteoarthritis (OA).DESIGN: Randomized controlled
trial.SETTING: Community.PARTICIPANTS: Persons (N=39; mean+/-SD age, 74+/-6y;
26 women) with mild to moderate OA and at risk for falling met study criteria, were
measured at baseline, and were randomly assigned to the intervention (n=23) and
control groups (n=16).INTERVENTIONS: Water-based program (12wk, twice weekly;
intervention group) or a time-matched computer training program (control group).MAIN
OUTCOME MEASURE: The primary outcome was the short-form Physiological Profile
Assessment (PPA). Secondary outcomes included the Step Test, Timed Up and Go
Test, Western Ontario and McMaster Universities OA Index (Likert 3.0 version), Arthritis
Impact Measurement Scales 2, and Activity-specific Balance Confidence
Scale.RESULTS: No statistically significant between-group differences were found for
any outcome measured (n=35; 4 lost to follow-up). Within-group analysis indicated that
Step Test results improved significantly in both groups (mean change: control group, left
leg, 2.07; 95% confidence interval, 3.19-.95; P=.002; intervention group, 2.14; 95%
confidence interval, 3.20-1.08; P=.000). Two PPA item scores (reaction time, contrast
sensitivity) improved significantly (86.83; 95% confidence interval, 9.86-163.79; P=.03;
1.43; 95% confidence interval, 2.35-.50; P=.005, respectively) in the control group,
resulting in a lower falls risk score.CONCLUSIONS: Water-based exercise did not
reduce falls risk in our sample compared with attending a computer skills training class.
Our study is, to our knowledge, the first to compare water-based exercise in this
population with a control group that attended a time-dose-equivalent seated community-
based activity. Whether gaining computer skills and going out into the community twice
weekly is adequate stimulus to reduce falls risk in people with OA requires further
investigation. Copyright Copyright 2012 American Congress of Rehabilitation Medicine.
Published by Elsevier Inc. All rights reserved.

Aquatic therapy versus conventional land-based therapy for Parkinson's disease:

an open-label pilot study.
Citation: Archives of Physical Medicine & Rehabilitation, August 2011, vol./is. 92/8(1202-
Author(s): Vivas J, Arias P, Cudeiro J
Abstract: OBJECTIVES: To assess and compare 2 different protocols of physiotherapy
(land or water therapy) for people with Parkinson's disease (PD) focused on postural
stability and self-movement, and to provide methodological information regarding
progression within the program for a future larger trial.DESIGN: Randomized, controlled,
open-label pilot trial.SETTING: Outpatients, Parkinson's disease Center of Ferrol-Galicia
(Spain).PARTICIPANTS: Individuals (N=11) with idiopathic PD in stages 2 or 3
according to the Hoehn and Yahr Scale completed the investigation (intervention period
plus follow-up).INTERVENTIONS: After baseline evaluations, participants were
randomly assigned to a land-based therapy (active control group) or a water-based
therapy (experimental group). Participants underwent individual sessions for 4 weeks,
twice a week, for 45 minutes per session. Both interventions were matched in terms of
exercise features, which were structured in stages with clear objectives and progression
criteria to pass to the next phase.MAIN OUTCOME MEASURES: Participants underwent
a first baseline assessment, a posttest immediately after 4 weeks of intervention, and a
follow-up assessment after 17 days. Evaluations were performed OFF-dose after
withholding medication for 12 hours. Functional assessments included the Functional
Reach Test (FRT), the Berg Balance Scale (BBS), the UPDRS, the 5-m walk test, and
the Timed Up and Go test.RESULTS: A main effect of both therapies was seen for the
FRT. Only the aquatic therapy group improved in the BBS and the
UPDRS.CONCLUSIONS: In this pilot study, physiotherapy protocols produced
improvement in postural stability in PD that was significantly larger after aquatic therapy.
The intervention protocols are shown to be feasible and seem to be of value in
amelioration of postural stability-related impairments in PD. Some of the methodological
aspects detailed here can be used to design larger controlled trials. Copyright Copyright

Hydrotherapy added to endurance training versus endurance training alone in

elderly patients with chronic heart failure: a randomized pilot study.
Citation: International Journal of Cardiology, April 2011, vol./is. 148/2(199-203), 0167-
5273;1874-1754 (2011 Apr 14)
Author(s): Caminiti G, Volterrani M, Marazzi G, Cerrito A, Massaro R, Sposato B, Arisi A,
Abstract: PURPOSE: To assess if Hydrotherapy (HT) added to endurance training (ET)
is more effective than ET alone in order to improve exercise tolerance of elderly male
patients with chronic heart failure (CHF).METHODS: Twenty-one male CHF patients,
age 68+/-7 (mean+/-DS) years; ejection fraction 32+/-9. NYHA II-III were enrolled.
Eleven pts were randomized to combined training (CT) group performing HT+ET and 10
patients to ET group (ET only). At baseline and after 24 weeks all patients underwent: 6-
minute walking test (6MWT), assessment of quadriceps maximal voluntary contraction
(MVC) and peak torque (PT), blood pressure and heart rate (HR), echocardiography and
non-invasive hemodynamic evaluation. HT was performed 3 times/week in upright
position at up to the xyphoid process at a temperature of 31degreesC. ET was
performed 3 times/week.RESULTS: Exercise was well tolerated. No patients had
adverse events. Distance at 6MWT improved in both groups (CT group: 150+/-32 m; ET
group:105+/-28 m) with significant intergroup differences (p 0.001). On land diastolic BP
and HR significantly decreased in the CT group while remained unchanged in the ET
group (-11 mmHg+/-2, p 0.04; e - 12 bpm, p 0.03; respectively) CO and SV had a
relative despite no significant increase in CT group TPR on land significantly decreased
in CT group (-23+/-3 mmHg/l/m; p 0.01) while remained unchanged in ET group.
Patients of CT group had no significant higher increase of both MVC and PT than ET
group.CONCLUSIONS: CT training, significantly improves exercise tolerance and
hemodynamic profile of patients with CHF. Copyright Copyright 2009 Elsevier Ireland

The efficacy of balneotherapy and physical modalities on the pulmonary system

of patients with fibromyalgia.
Citation: Journal of Back & Musculoskeletal Rehabilitation, 2011, vol./is. 24/1(57-65),
Author(s): Kesiktas N, Karagulle Z, Erdogan N, Yazicioglu K, Yilmaz H, Paker N
Abstract: Effects of balneotherapy on Primary Fibromyalgia Syndrome (FMS) have been
studied well, except for its effect on the respiratory symptoms of FMS. In this study we
allocated 56 patients with FMS into three groups who matched according to age, gender
and duration of illness. All three groups received the same three physical therapy
modalities (PTM): transcutaneous electrical nerve stimulation (TENS), ultrasound (US)
and infrared (IR). The first group received PTM plus balneotherapy (PTM+BT), the
second group received PTM alone (PTM), whilst the third group received PTM plus
hydrotherapy (PTM+HT). All groups were treated for three weeks and in the same
season. All patients were assessed at four time points: (a) at baseline, (b) on the 7th day
of therapy, (c) at the end of therapy (after 3 weeks) and (d) at 6 months after the end of
therapy. The effectiveness of treatments in all groups were evaluated in three main
categories (pain, depressive and respiratory symptoms). Tender point count, total
algometric measurements and pain with visual analog scale for pain; Beck Depression
Inventory (BDI) and Hamilton Depression Rating Scale (HDRS) for depression; dyspnea
scale, and spirometric measurements for respiratory symptoms; plus quality of life with
visual analog scale as a general measurement of effectiveness were taken at all four
assessment time points.Both at the end of therapy and at the 6 months follow up
significant improvements in dyspnea scale, and spirometric measurements, as well as in
other measured parameters were observed in group PTM+BT. All groups achieved
significant improvements in BDI and HDRS but scores of PTM and PTM+HT groups had
overturned at 6 months follow up. Except second group which receieved PTM alone,
pain evaluation assessments were improved at 6 month follow up in PTM+HT and
PTM+BT groups. But PTM+BT group had more significant improvements at the end of
therapy. PTM group had no significant change for dyspnea scale and spirometric
measurements. PTM combined BT and HT groups achieved significant improvements at
the end of therapies for dyspnea scale and spirometric measurements, but only PTM
+BT group had significant improvements for dyspnea scale and spirometric
measurements at six month follow up. The group of PTM+BT was significantly better
than other groups. Our results suggest that supplementation of PTM with balneotherapy
is effective on the respiratory and other symptoms of FMS and these effects were better
than other protocols at 6 month follow up.

Effects of aquatic resistance training on mobility limitation and lower-limb

impairments after knee replacement.
Citation: Archives of Physical Medicine & Rehabilitation, June 2010, vol./is. 91/6(833-9),
Author(s): Valtonen A, Poyhonen T, Sipila S, Heinonen A
Abstract: OBJECTIVE: To study the effects of aquatic resistance training on mobility,
muscle power, and cross-sectional area.DESIGN: Randomized controlled
trial.SETTING: Research laboratory and hospital rehabilitation pool.PARTICIPANTS:
Population-based sample (N=50) of eligible women and men 55 to 75 years old 4 to 18
months after unilateral knee replacement with no contraindications who were willing to
participate in the trial.INTERVENTIONS: Twelve-week progressive aquatic resistance
training (n=26) or no intervention (n=24).MAIN OUTCOME MEASURES: Mobility
limitation assessed by walking speed and stair ascending time, and self-reported
physical functional difficulty, pain, and stiffness assessed by Western Ontario and
McMaster University Osteoarthritis Index (WOMAC) questionnaire. Knee extensor power
and knee flexor power assessed isokinetically, and thigh muscle cross-sectional area
(CSA) by computed tomography.RESULTS: Compared with the change in the control
group, habitual walking speed increased by 9% (P=.005) and stair ascending time
decreased by 15% (P=.006) in the aquatic training group. There was no significant
difference between the groups in the WOMAC scores. The training increased knee
extensor power by 32% (P<.001) in the operated and 10% (P=.001) in the nonoperated
leg, and knee flexor power by 48% (P=.003) in the operated and 8% (P=.002) in the
nonoperated leg compared with controls. The mean increase in thigh muscle CSA of the
operated leg was 3% (P=.018) and that of the nonoperated leg 2% (P=.019) after
training compared with controls.CONCLUSIONS: Progressive aquatic resistance training
had favorable effects on mobility limitation by increasing walking speed and decreasing
stair ascending time. In addition, training increased lower limb muscle power and muscle
CSA. Resistance training in water is a feasible mode of rehabilitation that has wide-
ranging positive effects on patients after knee replacement surgery. Copyright 2010
Hydrotherapy after total hip arthroplasty: a follow-up study.
Citation: Archives of Gerontology & Geriatrics, January 2010, vol./is. 50/1(92-5), 0167-
4943;1872-6976 (2010 Jan-Feb)
Author(s): Giaquinto S, Ciotola E, Dall'armi V, Margutti F
Abstract: The aim of the study was to evaluate the subjective functional outcome of total
hip arthroplasty (THA) in patients who underwent hydrotherapy (HT) 6 months after
discharge. A prospective randomized study was performed on 70 elderly inpatients with
recent THA, who completed a rehabilitation program. After randomization, 33 of them
were treated in conventional gyms (no-hydrotherapy group=NHTG) and 31 received HT
(hydrotherapy group=HTG). Interviews with the Western-Ontario MacMasters
Universities Osteoarthritis Index (WOMAC) were performed at admission, at discharge
and 6 months later. Kruskal-Wallis, Mann-Whitney and Wilcoxon tests were applied for
statistical analysis. Both groups improved. Pain, stiffness and function were all positively
affected. Statistical analysis indicated that WOMAC sub-scales were significantly lower
for all patients treated with HT. The benefits at discharge still remained after 6 months.
We conclude that HT is recommended after THA in a geriatric population.

A specific inpatient aquatic physiotherapy program improves strength after total

hip or knee replacement surgery: a randomized controlled trial.
Citation: Archives of Physical Medicine & Rehabilitation, May 2009, vol./is. 90/5(745-55),
Author(s): Rahmann AE, Brauer SG, Nitz JC
Abstract: OBJECTIVE: To evaluate the effect of inpatient aquatic physiotherapy in
addition to usual ward physiotherapy on the recovery of strength, function, and gait
speed after total hip or knee replacement surgery.DESIGN: Pragmatic randomized
controlled trial with blinded 6-month follow-up.SETTING: Acute-care private
hospital.PARTICIPANTS: People (n=65) undergoing primary hip or knee arthroplasty
(average age, 69.6+/-8.2y; 30 men).INTERVENTIONS: Participants were randomly
assigned to receive supplementary inpatient physiotherapy, beginning on day 4: aquatic
physiotherapy, nonspecific water exercise, or additional ward physiotherapy.MAIN
OUTCOME MEASURES: Strength, gait speed, and functional ability at day
14.RESULTS: At day 14, hip abductor strength was significantly greater after aquatic
physiotherapy intervention than additional ward treatment (P=.001) or water exercise
(P=.011). No other outcome measures were significantly different at any time point in the
trial, but relative differences favored the aquatic physiotherapy intervention at day 14. No
adverse events occurred with early aquatic intervention.CONCLUSIONS: A specific
inpatient aquatic physiotherapy program has a positive effect on early recovery of hip
strength after joint replacement surgery. Further studies are required to confirm these
findings. Our research indicates that aquatic physiotherapy can be safely considered in
this early postoperative phase.

Effectiveness of aquatic therapy in the treatment of fibromyalgia syndrome: a

randomized controlled open study.
Citation: Rheumatology International, July 2008, vol./is. 28/9(885-90), 0172-8172;0172-
Author(s): Evcik D, Yigit I, Pusak H, Kavuncu V
Abstract: The aim of this study was to investigate the efficacy of aquatic exercises in
fibromyalgia syndrome (FMS). A total of 63 patients were included and allocated to two
groups. Group I (n = 33) received an aquatic exercise program and Group II (n = 30)
received a home-based exercise program for 60 min, 3x a week, over 5 weeks. Patients
were evaluated for pain (visual analogue scale, VAS), number of tender points (NTP),
Beck depression inventory (BDI), and functional capacity (fibromyalgia impact
questionnaire, FIQ). All assessment parameters were measured at baseline, and at
weeks 4, 12, and 24. There were statistically significant differences in FIQ and NTP in
both groups at the end and during follow-up (P < 0.05). Group I showed a statistically
significant decrease in BDI scores after 4 and 12 weeks (P < 0.05) that remained after
24 weeks (P < 0.001). In Group II, a significant decrease in BDI scores was observed at
the end and during follow-up (P < 0.001). Also, a significant improvement was found in
VAS at weeks 4 and 12 in both groups (P < 0.001). The average of reduction in pain
scores was 40% in Group1 and 21% in Group II. However, this was still significant at
week 24 only in the aquatic therapy group. A comparison of the two groups showed no
statistically significant difference for FIQ, NTP, and BDI scores except VAS (P < 0.001)
Our results showed that both aquatic therapy and home-based exercise programs have
beneficial effects on FIQ, BDI, and NTP. In pain management, only aquatic therapy
seems to have long-term effects.

Hydrotherapy versus conventional land-based exercise for the management of

patients with osteoarthritis of the knee: a randomized clinical trial.
Citation: Physical Therapy, January 2008, vol./is. 88/1(12-21), 0031-9023;0031-9023
Author(s): Silva LE, Valim V, Pessanha AP, Oliveira LM, Myamoto S, Jones A, Natour J
Abstract: BACKGROUND AND PURPOSE: This study was designed to evaluate the
effectiveness of hydrotherapy in subjects with osteoarthritis (OA) of the knee compared
with subjects with OA of the knee who performed land-based exercises.SUBJECTS
AND METHODS: Sixty-four subjects with OA of the knee were randomly assigned to 1
of 2 groups that performed exercises for 18 weeks: a water-based exercise group and a
land-based exercise group. The outcome measures included a visual analog scale
(VAS) for pain in the previous week, the Western Ontario and McMaster Universities
Osteoarthritis Index (WOMAC), pain during gait assessed by a VAS at rest and
immediately following a 50-foot (15.24-m) walk test (50FWT), walking time measured at
fast and comfortable paces during the 50FWT, and the Lequesne Index. Measurements
were recorded by a blinded investigator at baseline and at 9 and 18 weeks after initiating
the intervention.RESULTS: The 2 groups were homogenous regarding all parameters at
baseline. Reductions in pain 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. However, the water-based exercise group experienced a
significantly greater decrease in pain than the land-based exercise group before and
after the 50FWT at the week-18 follow-up.DISCUSSION AND CONCLUSION: Both
water-based and land-based exercises reduced knee pain and increased knee function
in participants with OA of the knee. Hydrotherapy was superior to land-based exercise in
relieving pain before and after walking during the last follow-up. Water-based exercises
are a suitable and effective alternative for the management of OA of the knee.

Physical activity for osteoarthritis management: a randomized controlled clinical

trial evaluating hydrotherapy or Tai Chi classes.
Citation: Arthritis & Rheumatism, April 2007, vol./is. 57/3(407-14), 0004-3591;0004-3591
Author(s): Fransen M, Nairn L, Winstanley J, Lam P, Edmonds J
Abstract: OBJECTIVE: To determine whether Tai Chi or hydrotherapy classes for individuals
with chronic symptomatic hip or knee osteoarthritis (OA) result in measurable clinical
benefits.METHODS: A randomized controlled trial was conducted among 152 older persons
with chronic symptomatic hip or knee OA. Participants were randomly allocated for 12 weeks
to hydrotherapy classes (n = 55), Tai Chi classes (n = 56), or a waiting list control group (n =
41). Outcomes were assessed 12 and 24 weeks after randomization and included pain and
physical function (Western Ontario and McMaster Universities Osteoarthritis Index), general
health status (Medical Outcomes Study Short Form 12 Health Survey [SF-12], version 2),
psychological well-being, and physical performance (Up and Go test, 50-foot walk time,
timed stair climb).RESULTS: At 12 weeks, compared with controls, participants allocated to
hydrotherapy classes demonstrated mean improvements (95% confidence interval) of 6.5
(0.4, 12.7) and 10.5 (3.6, 14.5) for pain and physical function scores (range 0-100),
respectively, whereas participants allocated to Tai Chi classes demonstrated improvements
of 5.2 (-0.8, 11.1) and 9.7 (2.8, 16.7), respectively. Both class allocations achieved significant
improvements in the SF-12 physical component summary score, but only allocation to
hydrotherapy achieved significant improvements in the physical performance measures. All
significant improvements were sustained at 24 weeks. In this almost exclusively white
sample, class attendance was higher for hydrotherapy, with 81% attending at least half of the
available 24 classes, compared with 61% for Tai Chi.CONCLUSION: Access to either
hydrotherapy or Tai Chi classes can provide large and sustained improvements in physical
function for many older, sedentary individuals with chronic hip or knee OA.

A pragmatic randomised controlled trial of hydrotherapy and land exercises on overall

well being and quality of life in rheumatoid arthritis.
Citation: BMC Musculoskeletal Disorders, 2007, vol./is. 8/(23), 1471-2474;1471-2474
Author(s): Eversden L, Maggs F, Nightingale P, Jobanputra P
Abstract: BACKGROUND: Hydrotherapy is highly valued by people with rheumatoid arthritis
yet few studies have compared the benefits of exercises in heated water against exercises
on land. In particular, data on quality of life is rarely reported. This is especially important
because patients treated with hydrotherapy often report an enhanced sense of well-being.
We report a randomised controlled trial in which we compared the effects of hydrotherapy
with exercises on land on overall response to treatment, physical function and quality of life
in patients with rheumatoid arthritis.METHODS: One hundred and fifteen patients with RA
were randomised to receive a weekly 30-minute session of hydrotherapy or similar exercises
on land for 6 weeks. Our primary outcome was a self-rated global impression of change--a
measure of treatment effect on a 7-point scale ranging from 1(very much worse) to 7 (very
much better) assessed immediately on completion of treatment. Secondary outcomes
including EuroQol health related quality of life, EuroQol health status valuation, HAQ, 10
metre walk time and pain scores were collected at baseline, after treatment and 3 months
later. Binary outcomes were analysed by Fisher's exact test and continuous variables by
Wilcoxon or Mann-Whitney tests.RESULTS: Baseline characteristics of the two groups were
comparable. Significantly more patients treated with hydrotherapy (40/46, 87%) were much
better or very much better than the patients treated with land exercise (19/40, 47.5%), p <
0.001 Fisher's exact test. Eleven patients allocated land exercise failed to complete
treatment compared with 4 patients allocated hydrotherapy (p = 0.09). Sensitivity analyses
confirmed an advantage for hydrotherapy if we assumed non-completers would all not have
responded (response rates 70% versus 38%; p < 0.001) or if we assumed that non-
completers would have had the same response as completers (response rates 82% versus
55% p = 0.002). Ten metre walk time improved after treatment in both cases (median pre-
treatment time for both groups combined 10.9 seconds, post-treatment 9.1 s, and 3 months
later 9.6 s). There was however no difference between treatment groups. Similarly there
were no significant differences between groups in terms of changes to HAQ, EQ-5D utility
score, EQ VAS and pain VAS.CONCLUSION: Patients with RA treated with hydrotherapy
are more likely to report feeling much better or very much better than those treated with land
exercises immediately on completion of the treatment programme. This perceived benefit
was not reflected by differences between groups in 10-metre walk times, functional scores,
quality of life measures and pain scores.
Balneotherapy and tap water therapy in the treatment of knee osteoarthritis.
Citation: Rheumatology International, November 2006, vol./is. 27/1(19-27), 0172-
Author(s): Yurtkuran M, Yurtkuran M, Alp A, Nasircilar A, Bingol U, Altan L, Sarpdere G
Abstract: To investigate if spa water is superior to tap water (TW) in relieving the
symptoms of pain, joint motion, life quality in knee osteoarthritis (KOA) patients. In this
randomized placebo-controlled trial, 52 patients with KOA were followed in two groups.
In group I (n = 27), patients were treated in the pool full of spa water at 37 degrees C for
20 min a day, 5 days a week, for a period of 2 weeks. In group II (n = 25), the same
protocol was used but spa water was replaced by TW heated to 37 degrees C. Patients
in both groups were given a home-based standardized exercise program. Evaluation
parameters were pain (pVAS), tenderness score (TS), 50-ft walking duration, quadriceps
muscle strength (QMS), active flexion degree (AFD), WOMAC OA index, and
Nottingham Health Profile (NHP). The first evaluation was done after the informed
consent was obtained. Second and third evaluations were done at the 2nd and 12th
week. PVAS, 50-ft walking duration, AFD, TS, WOMAC, and NHP variables improved in
group I. Same variables except QMS improved also in group II. Comparison of the
groups just after treatment showed that only pVAS (P = 0.015), NHP pain score (P =
0.020), and TS (P = 0.002) differed significantly in favor of group I at the 2nd or 12th
week. Both of the thermal treatment modalities were found to be effective in the
management of the clinical symptoms and quality of life in KOA patients. However, pain
and tenderness improved statistically better with balneotherapy. There were no
significant differences between the groups for the other variables.

Hydrotherapy and conventional physiotherapy improve total sleep time and

quality of life of fibromyalgia patients: randomized clinical trial.
Citation: Sleep Medicine, April 2006, vol./is. 7/3(293-6), 1389-9457;1389-9457 (2006
Author(s): Vitorino DF, Carvalho LB, Prado GF
Abstract: OBJECTIVE: To compare hydrotherapy (HT) and conventional physiotherapy
(CP) in the treatment of fibromyalgia (FM), regarding quality of life (QOL), total sleep
time (TST), and total nap time (TNT).METHODS: Fifty outpatients, all female, 30-60
years old, diagnosed with FM, were randomly assigned to two groups to carry out 3
weeks of treatment with HT or CP. In the beginning and in the end of treatment, patients
were evaluated with the SF-36 questionnaire to measure QOL and the sleep diary for
TST and TNT. Data analyses were blind.RESULTS: All 24 HT patients increased 1h in
TST compared to 19 CP patients. TNT decreased in the HT group. QOL improved for
the two groups in all domains when pre- and post-intervention were compared, but there
was no difference between groups.CONCLUSION: HT is more effective than CP to
improve TST and to decrease TNT in FM patients.

Exercise in waist-high warm water decreases pain and improves health-related

quality of life and strength in the lower extremities in women with fibromyalgia.
Citation: Arthritis & Rheumatism, February 2006, vol./is. 55/1(66-73), 0004-3591;0004-
Author(s): Gusi N, Tomas-Carus P, Hakkinen A, Hakkinen K, Ortega-Alonso A
Abstract: OBJECTIVE: To evaluate the short- and long-term efficacy of exercise therapy
in a warm, waist-high pool in women with fibromyalgia.METHODS: Thirty-four women
(mean +/- SD tender points 17 +/- 1) were randomly assigned to either an exercise
group (n = 17) to perform 3 weekly sessions of training including aerobic, proprioceptive,
and strengthening exercises during 12 weeks, or to a control group (n = 17). Maximal
unilateral isokinetic strength was measured in the knee extensors and flexors in
concentric and eccentric actions at 60 degrees /second and 210 degrees /second, and in
the shoulder abductors and adductors in concentric contractions. Health-related quality
of life (HRQOL) was assessed using the EQ-5D questionnaire; pain was assessed on a
visual analog scale. All were measured at baseline, posttreatment, and after 6
months.RESULTS: The strength of the knee extensors in concentric actions increased
by 20% in both limbs after the training period, and these improvements were maintained
after the de-training period in the exercise group. The strength of other muscle actions
measured did not change. HRQOL improved by 93% (P = 0.007) and pain was reduced
by 29% (P = 0.012) in the exercise group during the training, but pain returned close to
the pretraining level during the subsequent de-training. However, there were no changes
in the control group during the entire period.CONCLUSION: The therapy relieved pain
and improved HRQOL and muscle strength in the lower limbs at low velocity in patients
with initial low muscle strength and high number of tender points. Most of these
improvements were maintained long term.

Aquatics, health-promoting self-care behaviours and adults with brain injuries.

Citation: Brain Injury, February 2006, vol./is. 20/2(133-41), 0269-9052;0269-9052 (2006
Author(s): Driver S, Rees K, O'Connor J, Lox C
Abstract: PRIMARY OBJECTIVE: To determine the effect of an aquatic programme on
the health promoting behaviours of adults with brain injuries.MAIN OUTCOMES AND
RESULTS: Eighteen individuals participated in the programme and were randomly
assigned to an experimental (n = 9) or control group (n = 9). Health promoting
behaviours, physical self-concept and self-esteem were measured pre- and post-
intervention. Significant differences and large effect sizes were found between scores for
the experimental group only, indicating an increase in health promoting behaviours,
physical self-concept and self-esteem.CONCLUSIONS: Results have useful implications
for health professionals as exercise prescription may enhance health promoting
behaviours and decrease health care costs after a brain injury.

Is hydrotherapy cost-effective? A randomised controlled trial of combined

hydrotherapy programmes compared with physiotherapy land techniques in
children with juvenile idiopathic arthritis.
Citation: Health Technology Assessment (Winchester, England), October 2005, vol./is.
9/39(iii-iv, ix-x, 1-59), 1366-5278;1366-5278 (2005 Oct)
Author(s): Epps H, Ginnelly L, Utley M, Southwood T, Gallivan S, Sculpher M, Woo P
Abstract: OBJECTIVES: To compare the effects of combined hydrotherapy and land-
based physiotherapy (combined) with land-based physiotherapy only (land) on cost,
health-related quality of life (HRQoL) and outcome of disease in children with juvenile
idiopathic arthritis (JIA). Also to determine the cost-effectiveness of combined
hydrotherapy and land-based physiotherapy in JIA.DESIGN: A multicentre randomised
controlled, partially blinded trial was designed with 100 patients in a control arm
receiving land-based physiotherapy only (land group) and 100 patients in an intervention
arm receiving a combination of hydrotherapy and land-based physiotherapy (combined
group).SETTING: Three tertiary centres in the UK.PARTICIPANTS: Patients aged 4-19
years diagnosed more than 3 months with idiopathic arthritides, onset before their 16th
birthday, stable on medication with at least one active joint.INTERVENTIONS: Patients
in the combined and land groups received 16 1-hour treatment sessions over 2 weeks
followed by local physiotherapy attendances for 2 months.MAIN OUTCOME
MEASURES: Disease improvement defined as a decrease of > or =30% in any three of
six core set variables without there being a 30% increase in more than one of the
remaining three variables was used as the primary outcome measure and assessed at 2
months following completion of intervention. Health services resource use (in- and
outpatient care, GP visits, drugs, interventions, and investigations) and productivity costs
(parents' time away from paid work) were collected at 6 months follow-up. HRQoL was
measured at baseline and 2 and 6 months following intervention using the EQ-5D, and
quality-adjusted life-years (QALYs) were calculated. Secondary outcome measures at 2
and 6 months included cardiovascular fitness, pain, isometric muscle strength and
patient satisfaction.RESULTS: Seventy-eight patients were recruited into the trial and
received treatment. Two months after intervention 47% patients in the combined group
and 61% patients in the land group had improved disease with 11 and 5% with
worsened disease, respectively. The analysis showed no significant differences in mean
costs and QALYs between the two groups. The combined group had slightly lower mean
costs (-6.91 pounds Sterling) and lower mean QALYs (-0.0478, 95% confidence interval
-0.11294 to 0.0163 based on 1000 bootstrap replications). All secondary measures
demonstrated a mean improvement in both groups, with the combined group showing
greater improvements in physical aspects of HRQoL and cardiovascular
fitness.CONCLUSIONS: JIA is a disease in which a cure is not available. This research
demonstrates a beneficial effect from both combined hydrotherapy and land-based
physiotherapy treatment and land-based physiotherapy treatment alone in JIA without
any exacerbation of disease, indicating that treatments are safe. The caveat to the
results of the cost-effectiveness and clinical efficacy analysis is that the restricted
sample size could have prevented a true difference being detected between the groups.
Nevertheless, there appears to be no evidence to justify the costs of building pools or
initiating new services specifically for use in this disease. However, this conclusion may
not apply to patients with unremitting active disease who could not be entered into the
trial because of specified exclusion criteria. For this group, hydrotherapy or combined
treatment may still be the only physiotherapy option. Further research is suggested into:
the investigation and development of appropriate and sensitive outcome measures for
use in future hydrotherapy and physiotherapy trials of JIA; preliminary studies of
methodologies in complex interventions such as physiotherapy and hydrotherapy to
improve recruitment and ensure protocol is acceptable to patients and carers;
hydrotherapy in the most common paediatric user group, children with neurological
dysfunction, ensuring appropriate outcome measures are available and methodologies
previously tried; patient satisfaction and compliance in land-based physiotherapy and
hydrotherapy and European studies of hydrotherapy in rare disorders such as JIA.

Effects of a water-based program on women 65 years and over: a randomised

controlled trial.
Citation: Australian Journal of Physiotherapy, 2005, vol./is. 51/2(102-8), 0004-
Author(s): Devereux K, Robertson D, Briffa NK
Abstract: The purpose of this study was to assess the effects of a water-based exercise
and self-management program on balance, fear of falling, and quality of life in
community-dwelling women 65 years of age or older with a diagnosis of osteopenia or
osteoporosis. Fifty women with an average age of 73.3 years (range 65.5-82.4, SD 3.9)
were randomised to intervention or control groups. The intervention group received a 10-
week water-based exercise and self-management program compiled by Community
Physiotherapy Services and conducted by a physiotherapist at an aquatic centre twice a
week for one hour. The control group did not receive any instructions and were not
encouraged to change their physical activity, activities of daily living or social habits
during the study. Change in balance, measured using the step test, from baseline to
follow-up differed between intervention and control groups, with mean (95% CI)
between-group differences of 1.7 (0.9 to 2.6) and 2.1 (1.1 to 3.1) steps on the left and
right sides respectively. Between-group differences in score changes were also
significant in four of the eight domains of quality of life measured using the Short Form
36 questionnaire (SF36; physical function 8.6 (0.4 to 16.8), vitality 12.0 (2.3 to 21.8),
social function, and 14.1 (0.6 to 27.7) mental health 10.2 (2.0 to 18.4)), but not fear of
falling measured using the modified falls efficacy scale (0.25 (-0.3 to 0.81). It is
concluded that a water-based exercise and self-management program produced
significant changes in balance and quality of life, but not fear of falling, in this group of
community-dwelling women 65 years of age or older with a diagnosis of osteopenia or
osteoporosis.

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.
Citation: Annals of the Rheumatic Diseases, December 2003, vol./is. 62/12(1162-7),
Author(s): Foley A, Halbert J, Hewitt T, Crotty M
Abstract: OBJECTIVE: To compare the effects of a hydrotherapy resistance exercise
programme with a gym based resistance exercise programme on strength and function
in the treatment of osteoarthritis (OA).DESIGN: Single blind, three arm, randomised
controlled trial.SUBJECTS: 105 community living participants aged 50 years and over
with clinical OA of the hip or knee.METHODS: Participants were randomised into one of
three groups: hydrotherapy (n = 35), gym (n = 35), or control (n = 35). The two
exercising groups had three exercise sessions a week for six weeks. At six weeks an
independent physiotherapist unaware of the treatment allocation performed all outcome
assessments (muscle strength dynamometry, six minute walk test, WOMAC OA Index,
total drugs, SF-12 quality of life, Adelaide Activities Profile, and the Arthritis Self-Efficacy
Scale).RESULTS: In the gym group both left and right quadriceps significantly increased
in strength compared with the control group, and right quadriceps strength was also
significantly better than in the hydrotherapy group. The hydrotherapy group increased
left quadriceps strength only at follow up, and this was significantly different from the
control group. The hydrotherapy group was significantly different from the control group
for distance walked and the physical component of the SF-12. The gym group was
significantly different from the control group for walk speed and self efficacy satisfaction.
Compliance rates were similar for both exercise groups, with 84% of hydrotherapy and
75% of gym sessions attended. There were no differences in drug use between groups
over the study period.CONCLUSION: Functional gains were achieved with both exercise
programmes compared with the control group.

Six- and 24-month follow-up of pool exercise therapy and education for patients
with fibromyalgia.
Citation: Scandinavian Journal of Rheumatology, 2002, vol./is. 31/5(306-10), 0300-
Author(s): Mannerkorpi K, Ahlmen M, Ekdahl C
Abstract: OBJECTIVE: To follow patients with fibromyalgia six and 24 months after they
finished a six-month treatment programme. The programme comprised pool exercise
therapy, adjusted to the patients' limitations, and education based on their health
problems.METHODS: Twenty-six patients were examined six and 24 months after the
completion of the treatment programme with the Fibromyalgia Impact Questionnaire
(FIQ), SF-36, the 6-minute walk test, and the Grippit measure. The values obtained at
the follow-up examinations were compared with the baseline and post-treatment
values.RESULTS: As compared with baseline, symptom severity (FIQ, SF-36), physical
function (FIQ, SF-36, 6-minute walk test) and quality of life (SF-36) still showed
improvements six months after the completion of treatment (p <0.05). Pain (FIQ, SF-36),
fatigue (FIQ, SF-36), walking ability, and social function (SF-36) still showed
improvements 2 years after the completion of the programme as compared with the
baseline values (p < 0.05). No significant changes were found for these variables, when
the values obtained at the two follow-up examinations were compared with those of the
post-treatment examination.CONCLUSIONS: Improvements in symptom severity,
physical function and social function were still found six and 24 months after the
completed treatment programme.

Combined spa-exercise therapy is effective in patients with ankylosing

spondylitis: a randomized controlled trial.
Citation: Arthritis & Rheumatism, October 2001, vol./is. 45/5(430-8), 0004-3591;0004-
Author(s): van Tubergen A, Landewe R, van der Heijde D, Hidding A, Wolter N, Asscher
Abstract: OBJECTIVE: To determine the efficacy of combined spa-exercise therapy in
addition to standard treatment with drugs and weekly group physical therapy in patients
with ankylosing spondylitis (AS).METHODS: A total of 120 Dutch outpatients with AS
were randomly allocated into 3 groups of 40 patients each. Group 1 (mean age 48 +/- 10
years; male:female ratio 25:15) was treated in a spa resort in Bad Hofgastein, Austria;
group 2 (mean age 49 +/- 9 years; male:female ratio 28:12) in a spa resort in Arcen, The
Netherlands. The control group (mean age 48 +/- 10 years; male:female ratio 34:6)
stayed at home and continued their usual drug treatment and weekly group physical
therapy during the intervention weeks. Standardized spa-exercise therapy of 3 weeks
duration consisted of group physical exercises, walking, correction therapy (lying supine
on a bed), hydrotherapy, sports, and visits to either the Gasteiner Heilstollen (Austria) or
sauna (Netherlands). After spa-exercise therapy all patients followed weekly group
physical therapy for another 37 weeks. Primary outcomes were functional ability,
patient's global well-being, pain, and duration of morning stiffness, aggregated in a
pooled index of change (PIC).RESULTS: Analysis of variance showed a statistically
significant time-effect (P < 0.001) and time-by-treatment interaction (P = 0.004),
indicating that the 3 groups differed over time with respect to the course of the PIC. Four
weeks after start of spa-exercise therapy, the mean difference in PIC between group 1
and controls was 0.49 (95% confidence interval [CI] 0.16-0.82, P = 0.004) and between
group 2 and controls was 0.46 (95% CI 0.15-0.78, P = 0.005). At 16 weeks, the
difference between group 1 and controls was 0.63 (95% CI 0.23-1.02, P = 0.002) and
between group 2 and controls was 0.34 (95% CI--0.05-0.73; P = 0.086). At 28 and 40
weeks, more improvement was found for group 1 compared with controls (P = 0.012 and
P = 0.062, respectively) but not for group 2 compared with controls.CONCLUSION: In
patients with AS, a 3-week course of combined spa-exercise therapy, in addition to drug
treatment and weekly group physical therapy alone, provides beneficial effects. These
beneficial effects may last for at least 40 weeks.