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Water-based exercise training for chronic obstructive pulmonary disease

  1. Renae J McNamara1,2,3,*,
  2. Zoe J McKeough1,
  3. David K McKenzie3,
  4. Jennifer A Alison1,4

Editorial Group: Cochrane Airways Group

Published Online: 18 DEC 2013

Assessed as up-to-date: 13 AUG 2013

DOI: 10.1002/14651858.CD008290.pub2


How to Cite

McNamara RJ, McKeough ZJ, McKenzie DK, Alison JA. Water-based exercise training for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD008290. DOI: 10.1002/14651858.CD008290.pub2.

Author Information

  1. 1

    The University of Sydney, Clinical and Rehabilitation Sciences, Faculty of Health Sciences, Lidcombe, Australia

  2. 2

    Prince of Wales Hospital, Department of Physiotherapy, Randwick, Australia

  3. 3

    Prince of Wales Hospital, Department of Respiratory and Sleep Medicine, Randwick, Australia

  4. 4

    Royal Prince Alfred Hospital, Department of Physiotherapy, Camperdown, Australia

*Renae J McNamara, Department of Physiotherapy, Prince of Wales Hospital, Randwick, Australia. renae.mcnamara@sesiahs.health.nsw.gov.au.

Publication History

  1. Publication Status: New
  2. Published Online: 18 DEC 2013

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Characteristics of included studies [ordered by study ID]
de Souto Araujo 2012

MethodsRandomised controlled trial


ParticipantsCOPD, n = 32

Land-based exercise training, n = 13, eight male, age mean (SD) 57 (8) years, FEV1 39 (11) % predicted

Water-based exercise training, n = 8, four male, age mean (SD) 62 (10) years, FEV1 44 (10) % predicted

No exercise training, n = 11, eight male, age mean (SD) 71 (10) years, FEV1 45 (13) % predicted


InterventionsLand-based exercise training: eight-week exercise programme, three times a week, 90 minutes, consisting of continuous exercise for upper and lower limbs (callisthenic activities with the respiratory cycle) for 15 minutes without weights; unsupported upper limb exercises using weights (initial weight 50% of maximum load and increased weekly) and diagonal movements for two minutes with equal rest periods; lower limb cycling for 30 minutes (intensity determined by Borg dyspnoea and perceived effort score of 5); 15 minutes of cool-down exercise for muscle groups used during the session

Water-based exercise training: eight-week exercise programme, three times a week, 90 minutes, consisting of continuous warm-up exercises for upper and lower limbs (callisthenic activities with the respiratory cycle) for 15 minutes without weights; unsupported upper limb exercises using two diagonal movements and weights for two minutes with an equal rest period (initial weight 50% of maximum load and increased weekly); lower limb training using floats positioned between the legs and performing bicycling movements for 30 minutes (intensity determined by Borg dyspnoea and perceived effort score of 5); 15 minutes of cool-down exercise for muscle groups used during the session

No exercise training: no exercise training


OutcomesSpirometry

Respiratory muscle strength

Six-minute walk test

BODE (body mass, airway obstruction, dyspnoea, exercise capacity) index

St George's Respiratory Questionnaire

All measured before and after intervention period


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskInsufficient information provided; 'randomly assigned'

Allocation concealment (selection bias)Unclear riskNot specified

Blinding of participants and personnel (performance bias)
All outcomes
High riskNot possible to blind participants or personnel because of the physical nature of the intervention

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot specified

Incomplete outcome data (attrition bias)
All outcomes
High riskTen dropouts with no reporting of data

Selective reporting (reporting bias)Low riskStudy protocol documented in methods and prespecified outcomes reported in prespecified methods

McNamara 2013

MethodsRandomised controlled trial


ParticipantsCOPD with physical comorbid conditions, n = 53

Land-based exercise training, n = 20, 10 male, age mean (SD) 73 (7) years, FEV1 62 (15) % predicted

Water-based exercise training, n = 18, five male, age mean (SD) 72 (10) years, FEV1 60 (10) % predicted

No exercise training, n = 15, seven male, age mean (SD) 70 (9) years, FEV1 55 (20) % predicted


InterventionsLand-based exercise training: eight-week outpatient exercise programme, three times a week, 60 minutes, supervised sessions consisting of upper limb endurance exercise and lower limb endurance exercise (walking and cycling) in a gym with initial intensity at 80% of walking speed on initial six-minute walk test either over-ground or on a treadmill, and progressed to maintain an intensity rating of three to five on the modified category ratio 0 to 10 dyspnoea and rating of perceived exertion scales

Water-based exercise training: eight-week outpatient exercise programme, three times a week, 60 minutes, supervised sessions consisting of exercises in hydrotherapy pool matched as closely as possible for intensity, duration and muscle groups trained to the land-based training exercises, and progressed by increasing water turbulence, speed and range of motion (specific exercise programme detailed in main publication)

No exercise training: usual medical care, no exercise training, requested not to alter exercise level over study period


OutcomesSpirometry

Respiratory muscle strength

Six-minute walk test

Incremental shuttle walk test

Endurance shuttle walk test

Chronic Respiratory Disease Questionnaire

Hospital Anxiety and Depression Scale

All measured before and after intervention period


NotesSupported by the Physiotherapy Research Foundation


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated random number sequence

Allocation concealment (selection bias)Low riskSequentially numbered, opaque, sealed envelopes

Blinding of participants and personnel (performance bias)
All outcomes
High riskNot possible to blind participants or personnel because of the physical nature of the intervention

Blinding of outcome assessment (detection bias)
All outcomes
Low riskData collected by investigator blinded to treatment allocation

Incomplete outcome data (attrition bias)
All outcomes
High riskNo missing outcome data for participants who completed the study; information about participants withdrawing from the study provided but not included in intention-to-treat analysis

Selective reporting (reporting bias)Low riskStudy protocol documented in methods and prespecified outcomes reported in prespecified methods

O'Brien 2004

MethodsRandomised cross-over trial


ParticipantsCOPD, n = 11

Land followed by water training, n = 6, four male, age mean (SD) 63 (23) years, FEV1 61 (18) % predicted

Water followed by land training, n = 5, four male, age mean (SD) 71 (11) years, FEV1 58 (32) % predicted


InterventionsLand-based exercise training: six weeks, twice a week, 45 minutes, supervised in gym, including warm-up of walking and stretches, aerobic training and strength and resistance training using free weights, at an intensity of three to four on the modified Borg rating of perceived exertion scale

Water-based exercise training: six weeks, twice a week, 45 minutes, supervised in hydrotherapy pool using similar muscle groups to ensure standardisation to land-based exercise programme and using properties of water to provide resistance, at an intensity of three to four on the modified Borg rating of perceived exertion scale

Both groups were also encouraged to complete a 20-minute home walking programme twice per week with distance calculated at 80% of the average speed of the baseline six-minute walk test


OutcomesSpirometry

Six-minute walk test

St George's Respiratory Questionnaire

All measured before and after each six-week intervention period


NotesAbstract: full text copy of thesis was obtained

Only data from the first arm of the cross-over trial were used


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskInsufficient information provided

'Subjects were randomly assigned into two groups'

Allocation concealment (selection bias)Low risk'Randomisation was conducted via the sealed envelope method, with envelopes created previously, by investigators other than the principal, who was blinded to the randomisation process'

Blinding of participants and personnel (performance bias)
All outcomes
High riskNot possible to blind participants or personnel because of the physical nature of the intervention

Blinding of outcome assessment (detection bias)
All outcomes
Low riskData collected by investigator blinded to treatment allocation

Incomplete outcome data (attrition bias)
All outcomes
High riskOne dropout with no reporting of data

Selective reporting (reporting bias)Low riskStudy protocol documented in methods and prespecified outcomes reported in prespecified methods

Ozdemir 2010

MethodsRandomised controlled trial


ParticipantsCOPD, n = 50

Water-based exercise training, n = 25, all male, age mean (SD) 61 (9) years, FEV1 55 (16) % predicted

No exercise training, n = 25, all male, age mean (SD) 64 (9) years, FEV1 54 (20) % predicted


InterventionsWater-based exercise training: four weeks, three times a week, 35 minutes, supervised in an aquatic centre with a warm-up, stretches and strengthening exercises for shoulder girdle and upper extremity muscles utilising floatation devices for resistance

No exercise training: medical therapy only


OutcomesSpirometry

Arterial blood gases

Six-minute walk test

Chronic Respiratory Disease Questionnaire

Hospital Anxiety and Depression Scale

All measured before and after intervention period


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandomly assigned according to table of random numbers

Allocation concealment (selection bias)Unclear riskNot specified

Blinding of participants and personnel (performance bias)
All outcomes
High riskNot possible to blind participants or personnel because of the physical nature of the intervention

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot specified

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot specified

Selective reporting (reporting bias)Low riskStudy protocol documented in methods and prespecified outcomes reported in prespecified methods

Wadell 2004

MethodsSemi-randomised controlled trial


ParticipantsCOPD, n = 43

Land-based exercise training, n = 15, five male, age mean (SD) 65 (7) years, FEV1 53 (12) % predicted

Water-based exercise training, n = 15, four male, age mean (SD) 65 (4) years, FEV1 56 (11) % predicted

No exercise training, n = 13, seven male, age mean (SD) 63 (7) years, FEV1 49 (12) % predicted


InterventionsLand-based exercise training: 12 week outpatient group programme, three times a week, 45 minutes, supervised, intensity guided by music to achieve a mean heart rate of 80% to 100% of peak heart rate according to maximal cycle ergometer test and a Borg dyspnoea score of 5 and rating of perceived exertion score of 15, including warm-up and flexibility exercises, followed by four minutes of endurance exercises and three minutes of strength exercises (repeated three times while focusing on the legs, arms and torso each time) and finally flexibility, stretching and cool-down exercises

Water-based exercise training: as per land-based exercise training but in water

No exercise training: no intervention


OutcomesSpirometry

Incremental shuttle walk test

Endurance shuttle walk test

Incremental cycle ergometer test

St George's Respiratory Questionnaire

Short Form-36 questionnaire

All measured before and after intervention period


NotesSupported by the Swedish Heart and Lung Foundation, the National Patient Federation for Heart and Lung Diseases in Sweden and the Swedish Vardal Foundation

Data from the control group were not used because of the non-randomised nature of the group


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskRandomly assigned on the basis of distance living away from study location

Allocation concealment (selection bias)Unclear riskNot specified

Blinding of participants and personnel (performance bias)
All outcomes
High riskNot possible to blind participants or personnel because of the physical nature of the intervention

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot specified

Incomplete outcome data (attrition bias)
All outcomes
Low riskIntention-to-treat analysis

Selective reporting (reporting bias)Low riskStudy protocol documented in methods and prespecified outcomes reported in prespecified methods

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Kurabayashi 1997Not a randomised controlled trial; no physical exercise training

Kurabayashi 1998Not a randomised controlled trial; no physical exercise training

Kurabayashi 2000No physical exercise training

Kurabyashi 1997Not a randomised controlled trial; no physical exercise training

Lopez Varela 2006Abstract; randomisation not stated; author of study did not respond to review author's request for clarification; no full text published

Lopez Varela 2008Water-based exercise training combined with land-based exercise training in 50:50 ratio (i.e. water-based exercise training not greater than 50%)

Lotshaw 2001Not a randomised controlled trial

Lotshaw 2002Not a randomised controlled trial

Lotshaw 2003Not a randomised controlled trial

Lotshaw 2007Not a randomised controlled trial

Millard 1999Not a randomised controlled trial

Mitsunobu 2004Not a randomised controlled trial

Perk 1996Not a randomised controlled trial

Rae 2009Not a randomised controlled trial

 
Comparison 1. Water-based exercise versus no exercise

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Exercise capacity (mean change in metres)3Mean Difference (IV, Fixed, 95% CI)Subtotals only

    1.1 Functional - six-minute walk test
399Mean Difference (IV, Fixed, 95% CI)62.09 [44.34, 79.85]

    1.2 Peak - incremental shuttle walk test
130Mean Difference (IV, Fixed, 95% CI)50.0 [19.93, 80.07]

    1.3 Endurance - endurance shuttle walk test
130Mean Difference (IV, Fixed, 95% CI)371.0 [120.83, 621.17]

 2 Quality of life (mean change in total scores)249Std. Mean Difference (IV, Fixed, 95% CI)-0.97 [-1.57, -0.37]

 3 Quality of life (mean change in individual domain scores)2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    3.1 Chronic Respiratory Disease Questionnaire - total score
130Mean Difference (IV, Fixed, 95% CI)-10.00 [-20.60, -3.40]

    3.2 Chronic Respiratory Disease Questionnaire - dyspnoea score
130Mean Difference (IV, Fixed, 95% CI)-3.0 [-5.73, -0.27]

    3.3 Chronic Respiratory Disease Questionnaire - emotional function score
130Mean Difference (IV, Fixed, 95% CI)-2.0 [-5.24, 1.24]

    3.4 Chronic Respiratory Disease Questionnaire - fatigue score
130Mean Difference (IV, Fixed, 95% CI)-5.0 [-7.53, -2.47]

    3.5 Chronic Respiratory Disease Questionnaire - mastery score
130Mean Difference (IV, Fixed, 95% CI)-2.0 [-4.26, 0.26]

    3.6 St George's Respiratory Questionnaire - total score
119Mean Difference (IV, Fixed, 95% CI)-10.0 [-19.29, -0.71]

    3.7 St George's Respiratory Questionnaire - symptom score
119Mean Difference (IV, Fixed, 95% CI)2.0 [-13.49, 17.49]

    3.8 St George's Respiratory Questionnaire - activity score
119Mean Difference (IV, Fixed, 95% CI)-13.00 [-26.18, 0.18]

    3.9 St George's Respiratory Questionnaire - impact score
119Mean Difference (IV, Fixed, 95% CI)-13.0 [-21.59, -4.41]

 4 Pulmonary function (mean change)3Mean Difference (IV, Fixed, 95% CI)Subtotals only

    4.1 FEV1 (% predicted)
249Mean Difference (IV, Fixed, 95% CI)6.32 [3.43, 9.22]

    4.2 FVC (% predicted)
399Mean Difference (IV, Fixed, 95% CI)3.82 [0.25, 7.39]

    4.3 FEV1/FVC ratio (%)
399Mean Difference (IV, Fixed, 95% CI)2.79 [-0.74, 6.33]

 5 Respiratory muscle strength (mean change)2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    5.1 MIP (cm H2O)
249Mean Difference (IV, Fixed, 95% CI)13.83 [5.30, 22.35]

    5.2 MIP (% predicted)
249Mean Difference (IV, Fixed, 95% CI)19.80 [9.36, 30.24]

    5.3 MEP (cm H2O)
249Mean Difference (IV, Fixed, 95% CI)14.25 [5.23, 23.27]

    5.4 MEP (% predicted)
249Mean Difference (IV, Fixed, 95% CI)15.22 [4.85, 25.59]

 
Comparison 2. Water-based exercise versus land-based exercise

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Exercise capacity (mean change in metres)4Mean Difference (IV, Fixed, 95% CI)Subtotals only

    1.1 Functional - six-minute walk test
362Mean Difference (IV, Fixed, 95% CI)10.85 [-10.82, 32.51]

    1.2 Peak - incremental shuttle walk test
259Mean Difference (IV, Fixed, 95% CI)9.36 [-15.22, 33.95]

    1.3 Endurance - endurance shuttle walk test
259Mean Difference (IV, Fixed, 95% CI)313.17 [232.35, 393.99]

 2 Quality of life (mean change in total scores)489Std. Mean Difference (IV, Fixed, 95% CI)-0.15 [-0.58, 0.28]

 3 Quality of life (mean change in individual domain scores)4Mean Difference (IV, Fixed, 95% CI)Subtotals only

    3.1 Chronic Respiratory Disease Questionnaire - total score
130Mean Difference (IV, Fixed, 95% CI)-8.0 [-16.38, 0.38]

    3.2 Chronic Respiratory Disease Questionnaire - dyspnoea score
130Mean Difference (IV, Fixed, 95% CI)-2.0 [-4.73, 0.73]

    3.3 Chronic Respiratory Disease Questionnaire - emotional function score
130Mean Difference (IV, Fixed, 95% CI)-2.0 [-5.24, 1.24]

    3.4 Chronic Respiratory Disease Questionnaire - fatigue score
130Mean Difference (IV, Fixed, 95% CI)-3.0 [-5.26, -0.74]

    3.5 Chronic Respiratory Disease Questionnaire - mastery score
130Mean Difference (IV, Fixed, 95% CI)-1.0 [-3.26, 1.26]

    3.6 St George's Respiratory Questionnaire - total score
360Mean Difference (IV, Fixed, 95% CI)0.31 [-4.14, 4.75]

    3.7 St George's Respiratory Questionnaire - symptom score
359Mean Difference (IV, Fixed, 95% CI)7.84 [-3.06, 18.74]

    3.8 St George's Respiratory Questionnaire - activity score
359Mean Difference (IV, Fixed, 95% CI)-2.82 [-7.67, 2.04]

    3.9 St George's Respiratory Questionnaire - impact score
359Mean Difference (IV, Fixed, 95% CI)-0.49 [-4.44, 3.45]

 4 Pulmonary function (mean change)3Mean Difference (IV, Fixed, 95% CI)Subtotals only

    4.1 FEV1 (litres)
241Mean Difference (IV, Fixed, 95% CI)0.08 [-0.04, 0.19]

    4.2 FEV1 (% predicted)
362Mean Difference (IV, Fixed, 95% CI)0.21 [-2.88, 3.31]

    4.3 FVC (litres)
241Mean Difference (IV, Fixed, 95% CI)0.12 [-0.04, 0.28]

    4.4 FVC (% predicted)
251Mean Difference (IV, Fixed, 95% CI)2.89 [-4.24, 10.02]

    4.5 FEV1/FVC ratio (%)
362Mean Difference (IV, Fixed, 95% CI)2.22 [-1.89, 6.34]

 5 Respiratory muscle strength (mean change)2Mean Difference (IV, Fixed, 95% CI)Subtotals only

    5.1 MIP (cm H2O)
251Mean Difference (IV, Fixed, 95% CI)0.06 [-7.21, 7.34]

    5.2 MIP (% predicted)
251Mean Difference (IV, Fixed, 95% CI)3.40 [-5.77, 12.58]

    5.3 MEP (cm H2O)
251Mean Difference (IV, Fixed, 95% CI)-6.80 [-16.42, 2.83]

    5.4 MEP (% predicted)
251Mean Difference (IV, Fixed, 95% CI)-3.88 [-13.88, 6.12]

 6 Body composition (mean change in kilograms)259Mean Difference (IV, Fixed, 95% CI)-1.29 [-2.65, 0.07]

 7 Attendance (mean number)2Std. Mean Difference (IV, Fixed, 95% CI)Subtotals only

    7.1 Attendance at supervised exercise sessions
241Std. Mean Difference (IV, Fixed, 95% CI)0.44 [-0.18, 1.07]

 
Summary of findings for the main comparison. Summary of findings (water exercise vs no exercise)

Water-based exercise training compared with no exercise training for people with chronic obstructive pulmonary disease (COPD)

Patient or population: people with COPD

Settings: pulmonary rehabilitation centres

Intervention: water-based exercise training

Comparison: no exercise training

OutcomesIllustrative comparative risks* (95% CI)No. of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

No exercise trainingWater-based exercise training

Exercise capacity - functional

Six-minute walk test (mean distance change in metres)
Mean change in six-minute walk distance ranged across control groups from -39 metres to -16 metresMean change in six-minute walk distance in the intervention groups was 62 metres higher (44 metres to 80 metres higher)99

(three)
⊕⊕⊕⊝
moderate1

Exercise capacity - peak

Incremental shuttle walk test (mean distance change in metres)
Mean change in incremental shuttle walk distance in the control group was -1 metreMean change in incremental shuttle walk distance in the intervention group was 50 metres higher (20 metres to 80 metres higher)30
(one)
⊕⊕⊕⊕
high

Exercise capacity - endurance

Endurance shuttle walk test (mean distance change in metres)
Mean change in endurance shuttle walk distance in the control group was -50 metresMean change in endurance shuttle walk distance in the intervention group was 371 metres higher (121 metres to 621 metres higher)30
(one)
⊕⊕⊕⊕
high

Quality of life

St George's Respiratory Questionnaire (total score)

Lower value post intervention is favourable, indicating improvement in QoL
Mean change in St George's Respiratory Questionnaire total score in the control group was +6 pointsMean change in St George's Respiratory Questionnaire total score in the intervention group was 10 points lower (1 point to 19 points lower)19
(one)
⊕⊕⊝⊝
low2

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1Two studies showed limitations in design; selection and performance bias unknown.
2Study showed limitations in design (selection and performance bias unknown).
 
Summary of findings 2. Summary of findings (water exercise vs land exercise)

Water-based exercise training compared with land-based exercise training for people with chronic obstructive pulmonary disease (COPD)

Patient or population: people with COPD

Settings: pulmonary rehabilitation centres

Intervention: water-based exercise training

Comparison: land-based exercise training

OutcomesIllustrative comparative risks* (95% CI)No. of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

Land-based exercise trainingWater-based exercise training

Exercise capacity - functional

Six-minute walk test (mean distance change in metres)
Mean change in six-minute walk distance ranged across control groups from 14 metres to 43 metresMean change in six-minute walk distance in the intervention groups was 11 metres higher (11 metres lower to 33 metres higher)62
(three)
⊕⊕⊕⊝
moderate1

Exercise capacity - peak

Incremental shuttle walk test (mean distance change in metres)
Mean change in incremental shuttle walk distance ranged across control groups from 13 metres to 37 metresMean change in incremental shuttle walk distance in the intervention groups was nine metres higher (15 metres lower to 34 metres higher)59
(two)
⊕⊕⊝⊝
low2

Exercise capacity - endurance

Endurance shuttle walk test (mean distance change in metres)
Mean change in endurance shuttle walk distance ranged across control groups from 33 metres to 117 metresMean change in endurance shuttle walk distance in the intervention groups was 313 metres higher (232 metres to 394 metres higher)59
(two)
⊕⊕⊕⊝
moderate2

Quality of life

St George's Respiratory Questionnaire (SGRQ; total score)

Lower value post intervention is favourable, indicating improvement in QoL
Mean change in SGRQ total score ranged across control groups from -1 points to -16 pointsMean change in SGRQ total score in the intervention groups was 0.3 points higher (4 points lower to 5 points higher)60
(three)
⊕⊕⊝⊝
low3

Body composition

Weight (mean change in kilograms)
Mean change in body weight ranged across control groups from -0.2 kilograms to +1.3 kilogramsThe mean change in body weight in the intervention groups was 1.3 kilograms lower (2.7 kilograms lower to 0.1 kilograms higher)59

(two)
⊕⊕⊕⊝
moderate2

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval.

GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1Two studies showed limitations in design; selection and performance bias unknown in two studies and one study, respectively.
2One study had selection bias.
3All studies showed limitations in design; selection bias present in one study and unknown in two remaining studies; performance and detection bias unknown in all three studies.
 
Table 1. Intervention characteristics

StudyWater-based exerciseLand-based exerciseOther comparison group



Description / IntensityFrequencyDescription / IntensityFrequency

de Souto Araujo 2012Continuous warm-up exercises for upper and lower limbs (callisthenic activities with the respiratory cycle) for 15 minutes without weights; unsupported upper limb exercises using two diagonal movements and weights for two minutes with an equal rest period (initial weight 50% of maximum load and increased weekly); lower limb training using floats positioned between the legs and performing bicycling movements for 30 minutes (intensity determined by Borg dyspnoea and perceived effort score of 5); 15 minutes of cool-down exercise for muscle groups used during the sessionEight weeks, three times a week, 90 minutesContinuous exercise for upper and lower limbs (callisthenic activities with the respiratory cycle) for 15 minutes without weights; unsupported upper limb exercises using weights (initial weight 50% of maximum load and increased weekly) and diagonal movements for two minutes with equal rest periods; lower limb cycling for 30 minutes (intensity determined by Borg dyspnoea and perceived effort score of five); 15 minutes of cool-down exercise for muscle groups used during the sessionSame as water-based exerciseNo exercise training

McNamara 2013Supervised sessions consisting of exercises in hydrotherapy pool matched as closely as possible for intensity, duration and muscle groups trained to the land-based training exercises, and progressed by increasing water turbulence, speed and range of motion (specific exercise programme detailed in main publication)Eight weeks, three times a week, 60 minutesSupervised sessions consisting of upper limb endurance exercise and lower limb endurance exercise (walking and cycling) in a gym with initial intensity at 80% of walking speed on initial six-minute walk test either over-ground or on a treadmill, and progressed to maintain an intensity rating of three to five on the modified category ratio 0 to 10 dyspnoea and rating of perceived exertion scalesSame as water-based exerciseUsual medical care, no exercise training, requested not to alter exercise level over study period

O'Brien 2004Supervised in hydrotherapy pool using similar muscle groups to ensure standardisation to land-based exercise programme and using properties of water to provide resistance, at an intensity of three to four on the modified Borg rating of perceived exertion scaleSix weeks, two times a week, 45 minutesSupervised warm-up of walking and stretches, aerobic training and strength and resistance training using free weights, at an intensity of three to four on the modified Borg rating of perceived exertion scaleSame as water-based exercise-

Ozdemir 2010Supervised in an aquatic centre with a warm-up, stretches and strengthening exercises for shoulder girdle and upper extremity muscles utilising floatation devices for resistanceFour weeks, three times a week, 35 minutes--Medical therapy only

Wadell 2004As per land-based exercise training but in water12 weeks, three times a week, 45 minutesSupervised, intensity guided by music to achieve a mean heart rate of 80% to 100% of peak heart rate according to maximal cycle ergometer test and a Borg dyspnoea score of 5 and rating of perceived exertion score of 15, including warm-up and flexibility exercises, followed by four minutes of endurance exercises and three minutes of strength exercises (repeated three times while focusing on the legs, arms and torso each time) and finally flexibility, stretching and cool-down exercisesSame as water-based exerciseNo intervention