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Comparison of the effect of aquatic physical therapy and conventional physical

therapy in patients with lumbar spinal stenosis (a randomized controlled trial)

Article  in  Journal of Musculoskeletal Research · April 2015

DOI: 10.1142/S0218957715500025

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 Journal of Musculoskeletal Research, Vol. 18, No. 1 (2015) 1550002 (7 pages)
© World Scientific Publishing Company
DOI: 10.1142/S0218957715500025

COMPARISON THE EFFECT OF AQUATIC PHYSICAL

THERAPY AND CONVENTIONAL PHYSICAL THERAPY
IN PATIENTS WITH LUMBAR SPINAL STENOSIS
(A RANDOMIZED CONTROLLED TRIAL)

Kaynoosh Homayouni
, Mahshid Naseri
,‡, Foroozandeh Zaravar†,

Leila Zaravar† and Hajar Karimian

J. Musculoskelet. Res. Downloaded from www.worldscientific.com
by Dr. Mahshid Naseri on 05/09/15. For personal use only.

Department of Physical Medicine and Rehabilitation
Shiraz University of Medical Sciences, Shiraz, Iran
†
School of Paramedical Sciences
Shiraz University of Medical Sciences, Shiraz, Iran
‡
naseri_m@sums.ac.ir

Received 29 October 2014

Accepted 28 February 2015
Published 14 April 2015

ABSTRACT
Purpose: To assess and compare the effect of aquatic and conventional physical therapy, two well-
known non-operative therapeutic options in patients with lumbar spinal stenosis (LSS). Methods: 50
patients with low back pain and the diagnosis of LSS were recruited in this prospective parallel
randomized controlled trial. Patients in group one were enrolled in aquatic therapy program and those
in group two attended physical therapy sessions through application of physical modalities
and receiving a home-based exercise program. Pain and walking ability were measured in each
group before therapy, immediately after therapy and three months later. Results: Patients in both
groups improved regarding pain either assessed immediately after therapy (repeated measure test,
p < 0:001) or three months later (Wilcoxon test, p < 0:001 for group one and p ¼ 0:005 for group
two). Functioning improved in both groups (repeated measure test, p < 0:001) but this advantage did
not remain significant after three months follow up in group two (repeated measure test, p ¼ 0:002 in

‡ Correspondence to: Mahshid Naseri, Department of physical medicine and rehabilitation, Shahid Faghihi hospital, Shiraz
University of Medical Sciences, Shiraz, Iran

1550002-1
 K. Homayouni et al.

group one and p ¼ 0:181 in group two). Patients in group one had significantly more favorable
outcome than group two regarding functioning (independent samples t-test, p ¼ 0:02) and pain
(Mann–Whitney test, p ¼ 0:001); however, this superiority didn’t sustain in long term follow up.
Conclusion: Aquatic therapy can provide greater short term improvement in pain and functioning
than conventional physical therapy in patients with LSS especially those with limited capability for
exercise on land.

Keywords: Low back pain; Hydrotherapy; Exercise.

INTRODUCTION Because of the buoyancy provided by water,

Lumbar spinal stenosis (LSS) is defined as a nar-
rowing of the lumbar spinal canal, nerve root canal
or intervertebral foramina of the lumbar spine, and
can be classified as congenital or acquired. The
J. Musculoskelet. Res. Downloaded from www.worldscientific.com
aquatic physical therapy affords several advan-
tages by reducing loads across the joints ap-
plying on the tissue by altering the depth at
which the therapy is done. These properties help

acquired type, the most common one, is usually individuals like patients with spinal stenosis do
by Dr. Mahshid Naseri on 05/09/15. For personal use only.

due to degenerative changes which are generally
related to aging and results in narrowing of the
spinal canal. It can cause progressive back and leg
pain, sensory problems and muscular weakness.4,9
Although LSS is one of the most common reasons
for spine surgery in the elderly, it is generally
accepted that most patients with LSS should be
managed non-surgically until the initial conser-
vative approach has failed.2,3,20,22,23 Conservative
treatment is recommended in patients with mild
to moderate symptoms of LSS and may include
physical therapy, pharmacotherapy, manipula-
tion, bracing, traction, electrical stimulation and
epidural injection of steroids for pain control.7,8 A
systematic review in 2012 recommended that a
trial of conservative management with land-based
exercise should be considered before surgical in-
tervention; however, a recent Cochrane database
systematic review which assessed non-operative
treatment for LSS with neurogenic claudication
could not make recommendations for guiding
clinical practice due to lack of moderate and high-
quality evidence in this regard.1,18 Passive physical
therapy seems to provide minimal benefits in
these patients, and the optimal regimen for active
physiotherapy is unknown.26
functional close chain exercises which may be
too difficult for them to perform on land. Due to
viscosity of water, aquatic exercise is a type of
strengthening exercise for muscles of the limb,
overcoming the resistance of water against the
range of motion.8,9,11,14,17,26 There is little evi-
dence supporting the effect of hydrotherapy on
patients with osteoarthritis (OA).3,10,12 A sys-
tematic review of randomized controlled trials
found just weak scientific evidence for positive
findings after hydrotherapy in comparison to no
treatment for OA and rheumatoid arthritis (RA)
cases27 and another one reported only some
short term improvement in patients with hip
and knee OA.6 Although some studies have
reported beneficial effects for patients with
chronic low back pain,5,11,16,24 well-designed
studies investigating the effect of aquatic thera-
py specifically on the patients suffering from
signs and symptoms of spinal stenosis are
lacking. To the best of our knowledge, this is the
first study with focus on the mentioned popu-
lation in order to assess and compare the effect
of aquatic-based exercises and conventional
physical therapy, two well-known non-operative
therapeutic options.

1550002-2

METHODS
We designed a parallel randomized controlled
trial with the allocation ratio of 1:1 and recruited
participants between 50 and 80 years old with the
diagnosis of LSS by an expert physiatrist accord-
ing to the signs and symptoms and magnetic
resonance imaging (MRI) findings. Antero-poste-
rior diameter of spinal canal < 10 mm and cross-
sectional area < 70 mm in MRI was considered as
the criteria for subjects enrollment as well as signs
and symptoms such as neurogenic claudication.25
Patients were enrolled from those who referred to
the pain clinics of our university from January to
October 2013. Those with disease associated with
J. Musculoskelet. Res. Downloaded from www.worldscientific.com
low back pain, including chronic inflammatory or
by Dr. Mahshid Naseri on 05/09/15. For personal use only.
infectious diseases, neoplasms, hematologic dis-
orders, traumatic vertebral injuries, having the
experience of any physical therapy in the last six
months, previous surgery on the spine, and oral
or local non-steroid anti-inflammatory drug use in
the previous four weeks were excluded. Every
patient signed an informed consent form and the
study protocol was approved by our university
ethics committee.
For allocation of the participants to enroll either
in aquatic therapy group or conventional physical
therapy group, a computer-generated list of ran-
dom numbers was used. The allocation sequence
was concealed from the researcher enrolling and
assessing participants in sequentially numbered,
opaque, sealed and stapled envelopes. Patients
could not be blinded about the therapy but the
physiatrist who measured the outcomes and sta-
tistical expert who analyzed the data were blinded.
Patients in group one were treated in thera-
peutic pools with water temperature of 29  –30  of
Celsius. Every aquatic session started with warm
up and ended with cool down, with duration of
10–15 min for each of them. Participants should
have attended aquatic physical therapy sessions
every other day for a total duration of 24 sessions.
1550002-3
Aquatic or Conventional Physiotherapy in LSS
Each session included ambulation, side walking,
chain walking, forward walking with kickboard,
stretching of each muscle group including
adductors, abductors, flexors and extensors of the
hip, knee flexors and ankle plantar flexors and
dorsiflexors. Other interventions were mini-squat,
pelvic curl, pelvic tilt, and knee to chest, double
knee lift, and deep water exercise.
Patients in group two referred to physical
therapists in order to use passive modalities in-
cluding continuous mode ultrasound (US) 1.5 W/
cm2 for 10 min and hot pack and trans-electrical
nerve stimulation (TENS) for 20 min to the lumbar
region. Also, the therapists instructed the patients
in this group to perform trunk muscle endurance,
William’s and stretching exercises. The patients
were treated using these passive modalities and
were given exercises under supervision of phy-
siotherapists for 10 sessions. They were instructed
to perform the learned exercises 30 min a day at
home in the following weeks until the end of the
eighth week. The subjects were followed through
regular phone calls once a week to check for their
adherence.
Pain on movement over the previous week
was measured by the visual analog scale (VAS)
from 0 to 10 in one cm intervals (zero: no pain,
10: greatest pain imaginable). Six minute walk
test (6MWT) was used to evaluate walking ability
as a measure of functional status and the indivi-
duals were instructed to walk as fast as they can
during six min and then the total distance was
measured. All assessments according to the VAS
and 6MWT were done before the intervention
in each group, in a separate session immediately
after the end of each intervention period and
three months after the end of intervention.
All analyses were done in SPSS, version 17.
Data were presented as mean (S.D.). Chi-square
test, independent samples t-test, repeated mea-
sure test, Mann–Whitney U-test and Wilcoxon
 K. Homayouni et al.

signed ranks test were used for data comparison. Table 3 Comparison of the Pain and Function Be-
P-value less than 0.05 was considered significant. tween Groups Before and After Therapy.

Group 1 Group 2
Mean (S.D.) Mean (S.D.) P-Value

RESULTS VAS1 a 6.96 (2.42) 6.84 (2.42) 0.82 d

VAS2 b 2.25 (1.67) 4.79 (2.68) 0.001 d
From 25 patients included in each group at first,
VAS3 c 4.39 (2.06) 5.79 (2.55) 0.06 d
24 subjects in group one and 23 in group two 6MWT1 a 389.68 (49.21) 388.64 (51.91) 0.89 e
(totally 47 subjects) completed the study period. 6MWT2 b 438.04 (49.26) 402.58 (55.18) 0.02 e
One patient in group one did not complete total 6MWT3 c 417.74 (45.60) 391.79 (55.85) 0.08 e
sessions of the therapy due to traveling and two Abbreviations: S.D.: Standard deviation; VAS: visual
in group two did not follow the sessions. No analog scale; 6MWT: six minute walk test; a before
adverse effect was reported by patients during therapy; b after therapy; c three months later; d Mann–
the study period. There was no significant dif- Whitney U-test; e independent samples t-test.

ference between the groups regarding the age,

J. Musculoskelet. Res. Downloaded from www.worldscientific.com

gender (chi-square test, p ¼ 0:77), and body mass improvement was seen in both groups (repeated
measure test, p < 0:001), but the level of im-
by Dr. Mahshid Naseri on 05/09/15. For personal use only.

index (BMI) (Tables 1 and 2).

Using repeated measure test, we found statis- provement declined during the study and func-
tically significant improvement in pain (VAS) tional improvement based on 6MWT remained
after each intervention ( p < 0:001); although this significant just in group one after three months
improvement declined during the follow up pe- (repeated measure test, p ¼ 0:002 in group one
riod, it remained significant for three months and p ¼ 0:181 in group two). Also, between group
after the therapy (Wilcoxon signed ranks test, analyses showed a significant statistical difference
p < 0:001 for group one and p ¼ 0:005 for regarding 6MWT immediately after the interven-
group two). Regarding functioning, significant tion as patients in group one who underwent
aquatic therapy had significantly better outcome
Table 1 Comparison of Initial Data Including than those in the conventional physical therapy
Age and BMI. group (independent samples t-test, p ¼ 0:02, 95%
Group 1 Group 2 CI:5.06–65.80); however, this difference did not
Mean (S.D.) Mean (S.D.) P-Value remain statistically significant three months later
Age 55.56 (7.62) 55.68 (7.20) 0.95* (independent samples t-test, p ¼ 0:08). Similar
BMI 27.46 (4.08) 27.58 (4.34) 0.91* results were found with respect to the pain which
was assessed by VAS as the patients in group one
Abbreviations: S.D.: Standard deviation; BMI:
body mass index; *independent samples t-test. had better outcome immediately after therapy
(Mann–Whitney test, p ¼ 0:001). It did not remain
significant three months later (Mann–Whitney
Table 2 Distribution of Patients Regarding Sex in test, p ¼ 0:06) (Table 3).
Both Groups.

Group 1 Group 2 Total

Number (%) Number (%) Number (%) DISCUSSION
Male 12 (48) 11 (44) 23 (46) We could find some advantages for both aquatic
Female 13 (52) 14 (56) 27 (54)
therapy and conventional physical therapy in
Total 25 (100) 25 (100) 50 (100)
patients with LSS. However, the positive effect

1550002-4

regarding functioning did not sustain at the end
of three months of follow up period in group two
who underwent conventional physical therapy.
Also, aquatic therapy had a better outcome than
conventional physical therapy in our sample, but
this superiority did not remain significant in long
term.
To the best of our knowledge, this is the first
study investigating the effect of aquatic therapy
in a group with LSS. There are few studies which
evaluated aquatic-based physical therapy in
patients suffering from low back pain without
especial focus on patients with spinal stenosis. A
study in 2004 proposed that exercise produces
J. Musculoskelet. Res. Downloaded from www.worldscientific.com
large reductions in pain and disability and plays
by Dr. Mahshid Naseri on 05/09/15. For personal use only.
a major role in the management of chronic low
back pain. Also, the author stated that physical
treatments, such as back school, hydrotherapy,
TENS and US, are either of unknown value or
ineffective and should not be considered.22 The
study population was different to our sample;
this might explain this inconsistency. We studied
patients with signs and symptoms of LSS rather
than all patients with chronic low back pain and
obtained some benefits. On the other hand, dif-
ferent exercises used by different practitioners in
distinct hydrotherapy programs might explain
the variability of reports regarding the effect of
aquatic therapy.
Despite the abovementioned recommendation
by Maher,22 a systematic review in 2002 pro-
posed supported benefit from hydrotherapy in
multiple aspects particularly among older adults,
patients with rheumatic conditions, and chronic
low back pain.13 A randomized controlled trial in
2009 compared the effectiveness of aquatic exer-
cise interventions with land-based exercises in
treatment of chronic low back pain without leg
pain and found that water-based exercises pro-
duce better improvement in disability and quality
of life than a land-based home exercise pro-
gram.11 This finding is somewhat in the same
1550002-5
Aquatic or Conventional Physiotherapy in LSS
line with our results; however, the samples were
different. Both therapeutic programs used by
Dundar et al.,11 resulted in significant improve-
ment in pain, disability and quality of life either
week four or week 12 after treatment, the finding
which somewhat confirms our results. Although
we added modalities like US and TENS to the
home-based exercise in group two, functional
improvement in our study sustained for 12 weeks
just in group one which was recruited in aquatic
exercise program, not in conventional physical
therapy group.
Physical therapy including applications of US
1.5 W/cm2 for 10 min, hot pack and TENS for
20 min to the lumbar region has been suggested
to be effective and could provide significant im-
provement in pain and functional parameters in
LSS patients up to six months of follow-up;19
however, the efficacy of physical agent modalities
alone is not well supported. Goren et al.,15 could
not find any statistically significant difference
between patients with LSS who received US plus
exercise and those treated with sham US plus
exercise. They reported that addition of US
to exercise therapy can just just lower the anal-
gesic intake. A recent systematic review provided
low-quality evidence, suggesting that modalities
have no additional effect on exercise.21
Because it seems that most of the advantages of
physical therapy programs are related to exercise
protocols not passive modalities, our results re-
garding the better outcome in aquatic therapy
group might be due to potential reduction of joint
loading by hydrotherapy. This provides a very
good environment for LSS patients, who are often
old subjects suffering from multiple joints pain,
to exercise at higher intensities than would be
possible on land.
We faced some limitation in this study. First of
all, we could not enroll a placebo-control group
and patients could not be blinded about the in-
tervention. Second, patients in the aquatic
 K. Homayouni et al.
therapy group attended 24 sessions under su-
pervision of the therapist but patients in the
conventional physical therapy group were visited
by the therapist for only 10 sessions; however, to
reduce the effect of this difference, those in group
two were instructed to continue performing the
learned exercises at home until the end of the
eighth week. Although we followed patients in
group two by regular phone calls, it cannot be as
effective as direct supervision by the therapist to
check the correct exercise technique. Thus, the
effect of conventional physical therapy might be
underestimated. Third, we just assessed pain and
walking ability for outcome measurement and
J. Musculoskelet. Res. Downloaded from www.worldscientific.com
did not evaluate the quality of life, the factor
by Dr. Mahshid Naseri on 05/09/15. For personal use only.
which is one of the most important goals of every
therapeutic intervention.
CONCLUSION
Aquatic therapy as a safe and enjoyable inter-
vention can provide better short term improve-
ment in pain and function than conventional
physical therapy including physical agent mo-
dalities and home-based land exercise in patients
with LSS. Due to lack of the sufficient evidence,
we recommend performing further well-designed
controlled trials comparing the effect of aquatic
therapy and conventional physical therapy in
patients with LSS.
ACKNOWLEDGMENTS
We would like to thank Shiraz University of
Medical Sciences due to supporting the research.
SUBMISSION STATEMENT
We represent that this submission is original
work, and is not under consideration for publi-
cation with any other journal.
1550002-6
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