Hydrotherapy Case Essay


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This annotated bibliography is based upon three journal articles, all of which address the question, is hydrotherapy as effective as land based exercise for lower limb conditions? Hydrotherapy, water based exercise performed in a heated pool and will be analysed to determine whether it is an appropriate and beneficial type of physical therapy.

Search Process

Once the topic of hydrotherapy was of interest, keywords such as “effectiveness of hydrotherapy” and “benefits of hydrotherapy for lower limbs” were used in search engines such as Google Scholar and SciVerse. Once articles appeared to be of relevance to the guiding question, the abstracts of each of these articles were read and only those that were easily understood, were interesting and matched closely to the guiding question were selected to be used in the bibliography.

After sorting approximately 5 articles that were of relevance to the guiding question, they were then searched for in the VU Library so their full text could be read, as there was only an abstract available when searching through Google Scholar and SciVerse. After reading the 5 articles in full the decision was made on three by how relevant they were to the guiding question and having slight similarities to each other also helped in the decision making process.

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The three articles that make up the annotated bibliography each compare hydrotherapy to land based exercise for patients suffering from a certain lower limb condition. The first article compares the two types of therapies for patients with osteoarthritis and whether their strength and physical function will be improved by which type of therapy. The second compares hydrotherapy to land based exercise for patients who have undergone a total knee replacement where as the final article bases its investigation on whether water therapy can be as effective as land based exercise for patients who have osteoarthritis in the knee. Each article used a different type of study design.

Article 1

Foley, A, Halbert, J, Hewitt, T, Crotty, M, 2003. 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. EULAR Journal, 62, 1162-1167.

The aim of this article was to compare the effects of a hydrotherapy resistance exercise program with a gym based resistance exercise program focusing on strength and function in the treatment of osteoarthritis.

It consisted of participants who were randomised into one of three groups: hydrotherapy (n = 35), gym (n = 35), or control (n = 35). There were 105 participants, 52 (49.5%) were women and 53 males. Having such an even number of both men and women allowed the study to be evenly distributed leaving little judgement of being one gender dominated which may effect the study’s results.

The mean (SD) age of the sample was 70.9 years. Originally it was decided to have only 22 subjects in each group as a sample size of 66 was required however, the sample size calculation was based on the assumption of an effect size of 1.0 with a level of 0.05 and 90% power. Therefore, to allow for drop outs and injuries, this sample was increased to 35 people in each group. This proved to be beneficial to the study as there were several subjects that discontinued with the study. Being prepared with a higher sample size to allow for subjects failing to attend would leave the study with very few subjects to test, therefore increasing the numbers to more than what was needed prepared any unsuspecting drop outs if they occurred.

The warm up in the land based exercise group involved about four minutes of stationary cycling. The strengthening exercises included seated bench press, hip adduction and abduction, knee extension, and double leg press. It can be suggested that the strength exercises for land based focused more on lower limb and quadricep muscles such as double leg press with a resistance of 10 RM compared to hydrotherapy which was more focused on ROM and hip exercises such as hip extension and flexion, knee extension and flexion, hip abduction and adduction and knee cycling.

It would be expected that land based group’s quadricep muscles would be stronger as their exercises were more related to strengthening this area. As one of this study’s major testing methods was to test the strength of the quadriceps, it should have focused on more quadriceps strengthening exercises for the water based group to complete to ensure both groups were evenly distributed with similar exercises.

One of the strengths of this study was that the exercise intensity between the two intervention groups were closely matched as much as possible. However, it was stated that progressive overloading of the musculature and loading through the eccentric phase of muscle contraction is not possible in water as it is on land.

Therefore, the exercise intensity would not have been as high in the water based group, hence the greater increases in strength are seen in the gym group. To balance this difference, the hydrotherapy program had an underlying aerobic training component, as higher and faster repetitions were used to increase the exercise intensity. Furthermore, the hydrotherapy group continuously worked for the full half hour session, moving immediately from one exercise to the next. Although this helped to keep both mediums on a level field, a limitation to this modification was that the water based participants heart rate’s were not measured suggesting that it may have been difficult to assess if they were exercising at a higher and more vigorous intensity compared to the land based exercise group.

Furthermore, the land based group participants may have been exercising with just as much intensity as the water based group which would suggest they would be doing even more work than the water based group. It can be suggested that one of the limitations of this study was that it may have been too short in duration of the entire study. Only running for 6 weeks may have been too little time to be able to show obvious improvements within the subject’s lower limb strength and aerobic endurance levels. Although improvements were seen with both groups it may have been beneficial to continue to a longer period for further improvements to be shown.

Another limitation to this study was that only participants who could provide their own transport to the rehabilitation hospital where the study took place three times a week were eligible to take part in the trial. This would have made it difficult for those who may have wanted to participate but were excluded due to not being able to drive. Having osteoarthritis in the knee and hip joints may prevent some subjects from driving therefore limiting them form taking part in this trial. It may be beneficial for this study to have the hospital organise transportation services for subjects that would have been eligible to participate but were unable to due to transportation. This article has high relevance to the guiding question as it is based closely on comparing hydrotherapy to land based exercises and shows that hydrotherapy is just as effective when dealing with osteoarthirtis as land based exercises.

Article 2

Harmor, A, Naylor, J, Crosbie, J, Russell, T, 2009. Land-Based Versus Water-Based Rehabilitation Following Total Knee Replacement: A Randomized, Single-Blind Trial. Arthritis & Rheumatism (Arthritis Care & Research), 61, 184-191.

The aim of this article is to compare outcomes between land-based and water-based exercise programs delivered in the early subacute phase up to 6 months after total knee replacement.

This study was a randomized single-blind trial of patients undergoing physiotherapy after primary total knee replacement surgery was conducted in a metropolitan public hospital. All patients provided voluntary, written informed consent prior to study enrollment and were allocated into either land based or water based program with the use of a random number generator. Outcome measures were assessed at baseline (2 weeks post surgery), after 6 weeks of rehabilitation treatment, and at 26 weeks post surgery. It was determined that a sample size of 40 patients per group would provide 80% power to detect a 20% difference between groups in 6-minute walk distance, at a significance level of P 0.05. Therefore, 102 patients were recruited to allow for a 25% dropout rate.

This was a positive implication made by the conductors of the study as there were several subjects that were unable to complete the full 26 week trial. The primary outcome measured at each assessment was the 6-Minute Walk test and the secondary outcomes were stair climbing power (SCP), the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index, a visual analog scale (VAS) for pain in the operated knee, passive knee joint range of motion (ROM), and edema of the knee. One of the strengths of using the 6-Minute Walk as the primary outcome measurement was because it has a high efficiency of test–retest reliability and responsiveness after total knee replacement and permits decision making at an individual patient level.

It was also beneficial because as the clients were recovering from knee replacement surgery, it was a non invasive, less intense outcome measure test. The patient is able to walk at their own pace and does not involve using an extreme amount of strength and effort which could put a high amount of pressure of their effected area. Walking not only allows the patients to become well practiced with their gait mobility but as it was re tested, did not put a high amount of pressure on the patient as it did not involve high amounts of pain on the newly replaced knee.

This functional test for mobility-impaired older adults, in whom leg power is more important than strength for mobility, may be an optimal tool for measuring the magnitude of impairment and effects of therapy, and stair climb power test has good reliability and responsiveness after total knee replacements. Although the stair climb power test is a reliable test it can be suggested that it may be slightly dangerous and strenuous for elderly patients to complete especially after undergoing knee replacement surgery.

8 flights of 10 steps may seem daunting for elderly individuals especially if they need to use gait aid up and down the stairs which could become uncomfortable and awkward, therefore this test could have been modified to a smaller amount of steps instead of a large flight of stairs or another test that tests lower limb power could have been used in its place such as sit to stand test. In addition to the group exercise programs, all patients were instructed on a simple home exercise program, which was recommended to be undertaken daily and consisted of general active ROM exercises and walking as tolerated. However it was discovered that the home exercise program compliance was not formally monitored nor was the intensity of the exercises stated for the home program.

Therefore it cannot be certain that the exercise prescription was similar for both land based and water based groups or even of sufficient amount to generate physiologic change. As the home exercises were not monitored it could be suggested that not all participants even completed the program on a daily basis while at home. If these home programs were monitored and logged by the subjects and also were made clear with the correct intensity to use this may have altered the results of the study and could have benefited the subjects further by improving in the measured outcome tests. One of the positives of this study was that during the outcome measures the patients were assessed by a blinded assessor so there was no bias shown to either group. However, this could also have been a weakness within the study as it was discovered that on a few occasions unblinding assessments occurred due to the initial blinded assessor being absent.

This could have effected the outcome measure results for those particular tests that were held by the unblinded assessors. These results could have then effected the final results of the study favouring more so to one particular group. Another strength of this study was that most of the passive lower limb measurements were able to be re tested during the middle and end of the study and would be reliable tests. Knee edema was estimated by circumferential measurements at 4 locations (apex, midline, superior border, and 4 cm proximal to the superior border of the patella) with the knee in extension. The 4 measures were averaged for each knee and used as the knee edema outcome measure.

These measurements which were very precise and specific to the affected area and would be a beneficial test to note the improvements and changes made around the affected knee area. An exclusion in this study which may have resulted in being a limitation to the trial was that there was no control group. Which would have made it difficult to compare the two trial groups as there was nothing to compare them to besides each other. It could suggest that having a control group would have made it easier to see improvements of each trial group compared to those who did not participate in either group. It could have provided a comparison to those who underwent knee replacement surgery and were not doing any physical activity program during the subacute stage.

This may have showed actual significance of participating in physical activity compared to being sedentary and provided an indication if the subjects in the study were actually improving due to the exercises or if it was only due to their natural healing process. One of the limitations to this study was that during the water based program the hydrotherapy pool that was used was heated to a mean SD temperature of 25°C. Generally, the temperature should be increased to approximately 32–36°C for hydrotherapy for patients with knee and hip arthritis and recommended for reducing musculoskeletal stiffness. It was discovered that hydrotherapy could have produced more favourable results if the pool temperature was warmer. Not only would it have been more beneficial for the patients with their rehabilitation and recovery for reducing muscle stiffness but would have felt far more comfortable in the warmer water which would have made the program more inviting, hence reducing the number of drop outs in the study.

Another limitation involved in this trail was that patients who were not proficient in English were excluded from answering the WOMAC questionnaires which were used by the patients to answer questions in relation to pain, stiffness and functionality. Therefore this resulted in 8 participants in the land based and 9 in the water based groups that were excluded from this part of the study. This became a limitation because patients of language were able to be included in this study up until the questionnaires and reviews were being conducted. Furthermore, it could be suggested that having an interpreter or family member to assist with asking the patient the questions would ensure they were given the opportunity to complete the WOMAC questionnaire just as all the other participants had and may have even changed or effected the results slightly by there answers.

Following the questionnaires, complications from the study were monitored up to 26 weeks post surgery using a standardized question form administered through a patient interview at review clinics or via a followup phone call after discharge. By reviewing the patients with a question form, it can indicate that those of non English speaking background would be again excluded from this part of the study. However, if these patients were still asked the questions the patient may not have fully understood the questions and given an incorrect answer. Furthermore the patient themselves may have questions they would like to ask the physical therapist about their recovery and would not be abel to communicate that across to the therapists. Therefore having someone who can understand them would be beneficial. .

Follow up phone calls over the phone only allows for subjective assessments to be made which could lead to serious concerns if the reviewer is unable to see the patient. The patient may need to be further assessed or monitored objectively to ensure they are progressing throughout the study and finished the study without any further damage occurring and to ensure they are not in any pain due to the exercise program. The reviewer needs to see the patient’s surgical area to ensure the area has not been harmed or declined in the healing process from the study’s exercise regime and to ensure they have recovered well after the program. It can be presumed that interviewing over the phone could be dangerous and too risky to assess the patients and should be sought out to ensure all reviews are done in person.

Allowing patients who may not be fluent in English to participate in the study, may result in misinterpreting important information when reviewing patients or even while they are participating in the sessions. Again, having an interpreter on hand for those who are unable to communicate well enough with the assessors and instructors would be beneficial for both parties to ensure all information is passed on correctly with no misunderstandings occurring. This article was closely based on the guiding question as it gives a specific look at whether hydrotherapy is as effective or even more effective for patients recovering from a knee replacement to improve their gait mobility and knee range of motion.

Article 3

Silva, L, Valim, V, Pessanha, A, Oliveira, L, Myamoto, S, Jones, A, Natour, J, 2007. Hydrotherapy Versus Conventional Land-Based Exercise for the Management of Patients With Osteoarthritis of the Knee: A Randomized Clinical Trial . Physical Therapy, 88, 12-21.

The aim of this article was to evaluate the effectiveness of hydrotherapy in subjects with osteoarthritis of the knee compared with subjects with osteoarthritis of the knee who performed land-based exercises.

This study was a randomized clinical trail where patients with osteoarthritis of the knee were selected from the Rheumatology Outpatient Clinics at São Paulo Hospital and were invited to participate in this study. Sixty-four participants were included in the study. Thirty-two participants (30 female, 2 male) were randomly assigned to the water-based exercise group, and 32 participants (29 female, 3 male) were randomly assigned to the land-based exercise group. A noticeable difference is the very high number of females in the study, this could suggest that it was a limitation as it may have been beneficial use more male participants to have an even distribution of both genders as this may have effected the results and the outcomes of the tests.

Within this study both programs had the same types of exercise were used for both. Land based exercises were adapted to be performed underwater in order to exercise the same muscles. The exercises used for both groups included stretching and strengthening of the major muscle groups of the lower limbs, as well as gait training. Both groups had 50 minute training sessions 3 times a week for 18 weeks. This suggests a strength of the study as having the same type of program for both groups would even both groups and by using the same muscle groups throughout the entire programs allows for an balanced investigation where no groups is focusing more on one aspect of their body. This allows to truly investigate which medium actually is more effective when testing the muscular strength and mobility of the lower limbs.

An area of limitation was the lack of a control group to compare with the 2 exercise treatment groups. The authors did however take not having a control group into consideration, and stated that because there is considerable evidence that land based exercises are effective in patients with osteoarthritis of the knee, they decided to compare hydrotherapy with the gold standard of exercise intervention.

However, the lack of a control group meant that it was unable to determine whether the improvements in both groups resulted from exercise or other factors, such as the duration of therapy or the degree of participant attention or motivation. Nevertheless, it was believed that most of the improvement seen was attributable to the interventions used, as osteoarthritis is a degenerative disease and would be expected to cause a progressive worsening of the participants’ conditions. It may still have been beneficial to include a control group to prove that their study was accurate and improvements were actually made due to the exercise programs.

The reduction in pain found in both groups is a very important benefit for such patients. Although we believe that this improvement occurred due to the strengthening of the leg muscles, we cannot affirm this due to the fact that we did not directly assess the strength of these muscles, as our primary objective was to assess improvement regarding pain and quality of life. We had expected pain to decrease more in the water-based exercise group than in the land-based exercise group. However, reductions in pain were found in both groups, thereby failing to demonstrate a greater benefit in the water-based exercise group and showing that water-based exercise is a real option for patients with OA of the knee.

A positive of this study’s method was that when assessing pain, it was assessed at the time of evaluation instead of assessing the pain experienced during the previous week. It suggests that this method may be a better representation of the pain experienced during daily activities compared to measuring pain experienced during the previous week. This is a positive outcome as it provides the assessors with answers to their patients pain as it was occurring and did not have to try and recall how they felt after their previous sessions. At times, pain can be present and concerning the patient however once it has been relieved it becomes forgotten and assessors may consider this valuable information about their pain levels.

Another strength of this study was the use of the number of NSAIDs as a good quality measure for the assessment of pain. Patients were allowed to use sodium diclofenac to relieve pain during their sessions, however, it was discovered that the use of this medication was decreased significantly in both groups by the third month of the study, and a further reduction was seen in the fourth month in the water-based exercise group.

Overall, a 50% reduction in sodium diclofenac use was observed by the end of the study. This was an effective and precise way of determining the patient’s pain levels throughout the study. From this it could be proven that patients pain levels were decreasing due to their exercise programs and the decrease in pain relief intake.

This article was of close relevance to the guiding question as it provided information relating to the effectiveness of hydrotherapy compared to land based exercises. It proved that hydrotherapy was as effective as land based programs through pain level testing for patients with osteoarthritis.


In all three articles patients improved equally well in most outcome measures comparing land based with hydrotherapy. In the first article is was stated that neither mode was clearly superior to the other as both showed improvements and gained strength. Similarly, the second article showed findings of both being effective ways of treating lower limb conditions. However, not one medium was more superior than the other.

The final article indicate that water based and land based exercises reduced pain and improved function in patients with osteoarthritis of the knee and that water based exercise was superior to land based exercise for relieving pain before and after walking. These studies findings indicated that hydrotherapy is a suitable and effective way of exercising for patients with lower limb conditions as water buoyancy reduces the weight that joints, bones and muscles have to bear.

Aquatic exercises have been widely used in physical therapy programs, especially when exercising under normal conditions of gravity is difficult and painful. Water buoyancy reduces the weight that joints, bones, and muscles have to bear. The warmth and pressure of the water also reduce swelling and increase blood circulation. Consequently, an underwater environment allows early active mobilization and dynamic strengthening.

Reflection on Process

On reflection of this process, there were many challenges that were presented. Throughout analysing the articles more knowledge may have been needed when critiquing the statistical analysis of the articles. Being able to find positives and negatives within the results areas of the articles proved to be difficult.

Some of the barriers that occurred during this process was that not all relevant articles that proved to be interesting and closely matched the guiding question were unable to be viewed in full. This proved to be a difficult process and only some articles were found in the VU Library that had full text available.

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