Aquatic exercise for the treatment of knee and hip osteoarthritis

 

Characteristics of included studies [ordered by study ID]

Cochrane 2005

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Methods	Intention to treat Blinded assessor Losses to follow up 25-27% Concealment of allocation
Participants	312 volunteers randomised into Aquatic: 153, Control: 159 63% female Mean age 70 All with pain and stiffness in the knee or hip were included, the ACR criteria was not followed.
Interventions	Aquatic exercise: stretching, strengthening and aerobic exercises, primarily low to moderate intensity. 3 months supervised, 9 months unsupervised. Sessions of 1 hour, twice a week. Total: 84 sessions. Control: Telephone interview quarterly monitoring changes in exercise behaviour and other treatment
Outcomes	Pain (WOMAC), stiffness (WOMAC) and function (WOMAC). Quality of life (SF-36 & EuroQol). Walk ability (8 foot walk)
Notes	GOLD
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Foley 2003

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Methods	Intention to treat Blinded assessor Losses to follow up 20% (aquatic) 26% (land-based) Concealment of allocation
Participants	105 volunteers randomised into Aquatic: 35 Land-based: 35 Control: 35 Mean age 71 49.5 % female Radiological diagnosis of hip or knee OA
Interventions	Aquatic exercise: Stretching and strengthening exercise. Land-based: Strengthening exercise Both exercise groups: 30 min each session, 3 times per week for 6 weeks. Control: 3 telephone calls to record any changes in condition and treatment
Outcomes	Pain (WOMAC), stiffness (WOMAC), function (WOMAC), Quality of life (SF-12)
Notes	GOLD
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Patrick 2001

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Methods	Intention to treat Blinding of assessor unclear Losses to follow up 19% Concealment of allocation unclear
Participants	249 volunteers randomised into Aquatic: 125 Control: 124 Mean age 66 86 % female Clinically confirmed diagnosis of OA
Interventions	Aquatic: Joint range-of-motion, maintenance of muscle strength Control: Follow used activities, abstain from new exercise programs
Outcomes	Pain (HAQ), function (HAQ), quality of life (QOL), quality of well being (QWB)
Notes	GOLD
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Stener-Victorin 2004

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Methods	Intention to treat Patient, therapist and assessor was not blinded Losses to follow up 31% Unclear concealment of allocation
Participants	45 volunteers randomised into Electro-acupuncture: 15 Aquatic: 15 Patient education: 15
Interventions	Patient education + electro-acupuncture Patient education + hydrotherapy Patient education alone
Outcomes	Disability rating index (DRI) Global self rating index (GSI)
Notes	SILVER
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	B - Unclear

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Wang 2004

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Methods	Intention to Treat Patient, therapist and assessor was not blinded Losses to follow up 18.3 % Concealment of allocation
Participants	43 volunteers randomised into aquatic exercise: 21 control: 22
Interventions	Aquatic exercise with focus on strengthening exercise
Outcomes	Pain in joint Six-minute walk Functional status Psychological distress
Notes	GOLD
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Yes	A - Adequate

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Wyatt 2001

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Methods	No intention to treat analysis Blinded assessor Losses to follow up not reported Unclear concealment of allocation
Participants	46 volunteers randomised into a land-based and aquatic exercise program. Number of participants in each group not reported
Interventions	Aquatic and Land-based exercise was the same: resistance exercise over knee, straight leg raises, mini-squat and walking
Outcomes	VAS pain 1 mile walk time Stiffness
Notes	SILVER
Risk of bias
Item	Authors' judgement	Description
Allocation concealment?	Unclear	D - Not used

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 See grading system in text for definition of Gold and Silver.
ACR criteria for the hip joint: age greater than 40 years, weight-bearing pain, pain relieved by sitting, antalgic gait, decreased painful range of motion, a normal erythrocyte sedimentation rate (ESR) and a negative rheumatoid factor test.
ACR criteria for the knee joint: age greater than 50 years, knee pain, stiffness < 30 min, crepitus, bony tenderness, bony enlargement, no palpable warmth, a normal erythrocyte sedimentation rate (ESR) and a negative rheumatoid factor test.
EUROQOL: The EuroQol is a multidimensional health profile developed by the EuroQol Group in 1990 and revised in 1993.
HAQ: Health Assessment Questionnaire.
PQOL: The Perceived Quality of Life Scale is a generic instrument for assessing perceived quality of life among adults.
VAS: Visual analogue scale
WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index

 

Characteristics of excluded studies [ordered by study ID]

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Study	Reason for exclusion
Ahern 1995	Poor randomization procedure. No follow up. But the immediate effect is described for pain, stiffness, depression, self-efficacy.
Alexander 2001	Not randomized. Mix of different patient categories (OA, 27; RA 3; FMS 1; Psoriasis 1).
Belza 2002	OA in different joints not hip and/or knee alone.
Borchers 2003	No aquatic exercise, not possible to assess the effect of water treatment alone,
Cusack 2003	Abstract only
D'Lima 1996	Aquatic exercise is combined with land exercise. Mix of both OA and RA.
Elkayam 1991	No exercise, only water immersion.
Green 1993	Only data on surrogate outcomes
Guillemin 2001	No exercise (only SPA therapy). No randomization.
Gyurcsik 2003	Not possible to evaluate the effect on KNEE OA (Mix of OA, RA and FMS). No randomization.
Hill 1999	No exercise, only water immersion.
Kostopoulos 2000	Only comparing two different types of aquatic exercises
Kovacs 2002	No exercise, only immersion.
Lin 2004	Not randomised
Minor 1989	When it is possible to distinguish between OA and RA, it is not possible to distinguish between aquatic and non-aquatic exercise / control.
Nguyen 1997	Mix of hip, knee and lumbar OA. No exercise, a mixed modality of spa and balneotherapy.
Norton 1999	Only effect sizes reported, and no SD was given, thus it was impossible to include the results in the meta-analysis
Silva 2005	No exercise
Suomi 1997	Mix of RA and OA.
Suomi 2000	Mix of RA and OA.
Suomi 2003	Mix of RA and OA.
Tishler 2004	No exercise, only water immersion.

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 OA: Osteoarthritis
RA: Rheumatoid arthritis
FMS: Fibromyalgia syndrome
SPA therapy: treatment including water, but not including exercise
SD: Standard deviation

 

Comparison 1. Aquatic exercise versus control after treatment - knee&hip mixed

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Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

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 1 Pain

4

638

Std. Mean Difference (IV, Random, 95% CI)

0.19 [0.04, 0.35]

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1.1 WOMAC pain

2

380

Std. Mean Difference (IV, Random, 95% CI)

0.20 [-0.00, 0.40]

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1.2 Visual Analogue Pain

1

43

Std. Mean Difference (IV, Random, 95% CI)

0.50 [-0.10, 1.11]

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1.3 HAQ pain

1

215

Std. Mean Difference (IV, Random, 95% CI)

0.12 [-0.15, 0.39]

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 2 Function

4

648

Std. Mean Difference (IV, Random, 95% CI)

0.26 [0.11, 0.42]

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2.1 WOMAC function

2

375

Std. Mean Difference (IV, Random, 95% CI)

0.23 [0.03, 0.44]

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2.2 HAQ function

2

273

Std. Mean Difference (IV, Random, 95% CI)

0.31 [0.07, 0.55]

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 3 Walking ability

2

355

Std. Mean Difference (IV, Random, 95% CI)

0.18 [-0.03, 0.39]

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3.1 Six-minute walk

1

43

Std. Mean Difference (IV, Random, 95% CI)

-0.03 [-0.63, 0.57]

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3.2 8-foot walk time

1

312

Std. Mean Difference (IV, Random, 95% CI)

0.21 [-0.01, 0.43]

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 4 Stiffness

2

380

Std. Mean Difference (IV, Random, 95% CI)

0.14 [-0.06, 0.34]

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4.1 WOMAC stiffness

2

380

Std. Mean Difference (IV, Random, 95% CI)

0.14 [-0.06, 0.34]

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 5 Quality of life

3

599

Std. Mean Difference (IV, Random, 95% CI)

0.32 [0.03, 0.61]

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5.1 SF-12 physical

1

70

Std. Mean Difference (IV, Random, 95% CI)

0.69 [0.21, 1.17]

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5.2 PQOL - perceived quality of life

1

222

Std. Mean Difference (IV, Random, 95% CI)

0.35 [0.09, 0.62]

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5.3 EURO-QOL

1

307

Std. Mean Difference (IV, Random, 95% CI)

0.10 [-0.12, 0.33]

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 6 Mental health

4

642

Std. Mean Difference (IV, Random, 95% CI)

0.16 [0.01, 0.32]

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6.1 SF-36 mental

1

307

Std. Mean Difference (IV, Random, 95% CI)

0.15 [-0.08, 0.37]

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6.2 SF-12 mental

1

70

Std. Mean Difference (IV, Random, 95% CI)

0.19 [-0.28, 0.66]

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6.3 Psychological Distress

1

43

Std. Mean Difference (IV, Random, 95% CI)

0.37 [-0.24, 0.97]

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6.4 QWB - quality of well being

1

222

Std. Mean Difference (IV, Random, 95% CI)

0.13 [-0.13, 0.40]

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Comparison 2. Aquatic exercise versus control after treatment -hip

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Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

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 1 Function

1

28

Std. Mean Difference (IV, Random, 95% CI)

0.76 [-0.02, 1.53]

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1.1 DRI-disability rating index

1

28

Std. Mean Difference (IV, Random, 95% CI)

0.76 [-0.02, 1.53]

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 2 Quality of life

1

28

Std. Mean Difference (IV, Random, 95% CI)

0.76 [-0.02, 1.53]

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2.1 GSI - global self rating index

1

28

Std. Mean Difference (IV, Random, 95% CI)

0.76 [-0.02, 1.53]

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Comparison 3. Aquatic exercise versus land after treatment - knee

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Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

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 1 Pain

1

46

Std. Mean Difference (IV, Random, 95% CI)

0.86 [0.25, 1.47]

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1.1 VAS pain

1

46

Std. Mean Difference (IV, Random, 95% CI)

0.86 [0.25, 1.47]

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 2 Walking ability

1

46

Std. Mean Difference (IV, Random, 95% CI)

0.43 [-0.16, 1.01]

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2.1 1 MILE walk time

1

46

Std. Mean Difference (IV, Random, 95% CI)

0.43 [-0.16, 1.01]

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 3 Stiffness

1

46

Std. Mean Difference (IV, Random, 95% CI)

-0.26 [-0.84, 0.32]

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Comparison 4. Aquatic exercise versus control at follow up - knee&hip mixed

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Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

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 1 Pain

1

310

Std. Mean Difference (IV, Random, 95% CI)

0.11 [-0.12, 0.33]

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1.1 WOMAC pain

1

310

Std. Mean Difference (IV, Random, 95% CI)

0.11 [-0.12, 0.33]

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 2 Function

1

306

Std. Mean Difference (IV, Random, 95% CI)

0.10 [-0.12, 0.33]

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2.1 WOMAC function

1

306

Std. Mean Difference (IV, Random, 95% CI)

0.10 [-0.12, 0.33]

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 3 Stiffness

1

310

Std. Mean Difference (IV, Random, 95% CI)

0.13 [-0.09, 0.36]

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3.1 WOMAC stiffness

1

310

Std. Mean Difference (IV, Random, 95% CI)

0.13 [-0.09, 0.36]

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 4 Mental health

1

309

Std. Mean Difference (IV, Random, 95% CI)

0.05 [-0.17, 0.27]

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4.1 SF-36 mental

1

309

Std. Mean Difference (IV, Random, 95% CI)

0.05 [-0.17, 0.27]

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Comparison 5. Aquatic exercise versus control at follow up - hip

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Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

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 1 Pain

1

17

Std. Mean Difference (IV, Random, 95% CI)

1.00 [-0.04, 2.04]

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1.1 VAS pain

1

17

Std. Mean Difference (IV, Random, 95% CI)

1.00 [-0.04, 2.04]

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 2 Function

1

17

Std. Mean Difference (IV, Random, 95% CI)

1.00 [-0.04, 2.04]

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2.1 DRI-disability rating index

1

17

Std. Mean Difference (IV, Random, 95% CI)

1.00 [-0.04, 2.04]

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 3 Quality of life

1

17

Std. Mean Difference (IV, Random, 95% CI)

1.00 [-0.04, 2.04]

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3.1 GSI - global self rating index

1

17

Std. Mean Difference (IV, Random, 95% CI)

1.00 [-0.04, 2.04]

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Table 1. Clinical relevance table - Knee and hip mixed OA

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Study	Outcome (scale)	# patients (# trials	Ctl baseline mean,SD	Wt absolute change	Relative % change	Statistical Sig.	Quality of evidence
Cochrane (2005) ; Foley (2003)	WOMAC (Western Ontario McMaster Osteoarthritis Index) (pain) (0-20)	380 (2)	9.10 (3.14)	3.0% (0.6 fewer points on a scale 0 to 20 scale)	6.6% (I)	statistically significant but not clinically significant	GOLD
Wang (2004)	VAS (Visual Analogue Scale) pain (0-100)	43 (1)	55.3 (24.6)	12% (12.3 fewer points on a 0-100 scale)	0.2% (I)	not significant	GOLD
Patrick (2001)	HAQ (Health Assessment Questionnaire) pain (0-3)	249 (1)	1.05 (0.61)	2% (0.07 fewer points on a 0-3 scale)	7% (I)	not significant	GOLD
Cochrane (2005); Foley (2003)	WOMAC function (0-68)	380 (2)	31.05 (11.24)	4.3% (2.9 points on scale of 0 to 68)	9.4% (1)	statistically significant but not clinically significant	GOLD
Patrick (2001); Wang (2004)	HAQ function (0-3)	292 (2)	0.95 (0.5)	5.2% (0.16 fewer points on a 0-3 scale)	16.3% (I)	statistically significant	GOLD
Cochrane (2005)	WOMAC pain (0-20)	310 (1)	9.10 (3.14)	0.3% (0.35 points fewer on a 0-20 scale)	4% (I)	not significant	GOLD
Cochrane (2005)	WOMAC function (0-68)	310 (1)	31.05 (11.24)	0.1% (0.11 fewer points on a 0-68 scale)	0.4% (I)	not significant	GOLD
Legend: ctl=control group; SD=standard deviation; wt=weighted; I=improvement; sig=significance;

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Table 2. Clinical relevance table - Hip OA

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Study	Outcome (scale)	#patients #(trials)	Ctl baseline mean,SD	Absolute change	Relative % change	Statistical sig.	Quality of evidence
Stener-Victorin (2004)	VAS (Visual Analog Scale) pain (0-100)	28 (1)	56.0 (21.89)	22% (21.9 fewer points on a 0-100 scale)	40% (I)	not statistically significant	SILVER
Legend: ctl=control group, SD=standard deviation, sig=significance, I=improvement

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Table 3. Clinical relevance table - Knee OA

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Study	Outcome (scale)	#patients (# trials)	Ctl baseline mean,SD	Absolute change	Relative % change	Statisitical sig.	Quality of evidence
Wyatt (2001)	VAS (Visual Analog Scale) pain (0-10)	46 (1)	5.6 (1.4)	12% (1.2 fewer points on a 0-10 scale)	22% (I)	statistically significant	SILVER
Legend: ctl=control group; sig=significance; I=improvement

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