Aquatic exercise for the treatment of knee and hip osteoarthritis

Bartels EM, Lund H, Hagen KB, Dagfinrud H, Christensen R, Danneskiold-Samsøe B

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Summary

Aquatic exercise for osteoarthritis
This summary of a Cochrane review presents what we know from research about the effect of aquatic exercise for osteoarthritis of the hip or knee. The review shows that:

There is gold level evidence that for osteoarthritis of the hip or knee, aquatic exercise probably slightly reduces pain and slightly improves function over 3 months.
The progression of damage in osteoarthritis as seen on x-rays was not measured. Therefore, it is not known whether aquatic exercise improves the progression of osteoarthritis.
Aquatic exercise may not cause harm. But there is not enough evidence to be certain.
More research is needed to determine long term effects and to understand which type of aquatic exercise, how often and for how long, might be beneficial.

What is osteoarthritis and what is aquatic exercise?
Osteoarthritis (OA) is the most common form of arthritis that affects the hips and knees. In OA, the cartilage that protects the ends of the bones breaks down and causes pain and swelling. Aquatic exercise is sometimes known as 'pool therapy' or 'hydrotherapy'. It involves exercises in water that is heated to about 32 to 36 degrees Celsius. Exercises may include aerobic activities, stretching and strengthening, and range of motion.

What are the effects of aquatic exercise?
In the studies, some people did aquatic exercises for different lengths of time and number of sessions per week, while other people did no exercise or exercises on land. The effects were mainly measured at 3 months.

In people with osteoarthritis of the hip or knee,

pain may decrease by 1 more point on a scale of 0 to 20 with aquatic exercise
function may improve by 3 more points on a scale of 0 to 68 with aquatic exercise
progress of damage of osteoarthritis as seen on x-rays was not measured
there may be little or no difference in harms such as pain or other symptoms with aquatic exercises than with no exercise

This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2008 Issue 3, Copyright © 2008 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
This record should be cited as: Bartels EM, Lund H, Hagen KB, Dagfinrud H, Christensen R, Danneskiold-Samsøe B. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD005523. DOI: 10.1002/14651858.CD005523.pub2

This version first published online: October 17. 2007

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.

Search strategy

We searched MEDLINE from 1949, EMBASE from 1980, CENTRAL (Issue 2, 2006), CINAHL from 1982, Web of Science from 1945, all up to May 2006. There was no language restriction.

Selection criteria

Randomised controlled trials or quasi-randomised clinical trials.

Data collection and analysis

Two review authors independently selected trials for inclusion, assessed the internal validity of included trials and extracted data. Pooled results were analyzed using standardized mean differences (SMD).

Main results

Thre 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.

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