Curative and health enhancement effects of aquatic exercise: evidence based on interventional studies

Figures & data

Table 1 Evidence grading (US Agency for Health Care Policy and Research)

I.	Evidence systematic review obtained from meta-analysis of RCTs
II.	Evidence obtained from at least one RCT
III.	Evidence obtained from at least one well controlled study without randomization
IV.	Evidence obtained from observational study
V.	Evidence obtained from descriptive study
VI.	Evidence (without data) obtained from expert committee reports or opinions and/or clinical experience of respected authorities

Abbreviation: RCT, randomized controlled trial.

Table 2 Summary of articles based on structured abstracts¹⁰

Reference no	Author	Journal year; vol; page	Title	Aim/objective	Data source/search strategy	Selection criteria/period of intervention	Data extraction/data collection and analysis	Main results	Conclusion
^Citation39	Bartels EM, et al	Cochrane Database Syst Rev 2007; 4:CD005523 (in English)	Aquatic exercise for the treatment of knee and hip osteoarthritis.	To compare the effectiveness and safety of aquatic exercise interventions in the treatment of knee and hip osteoarthritis	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	Randomized controlled trials (RCTs) or quasi-randomized clinical trials.(br/)The duration of interventions was from 6 weeks to 12 months	Two review authors independently selected trials for inclusion, assessed the internal validity of included trials and extracted data.(br/)Pooled results were analyzed using standardized mean differences (SMD)	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) 0.1 1 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. Only two studies reported adverse effects, that is, the interventions did not increase self-reported pain or symptom scores	Aquatic exercise appears to have some beneficial short-term effects for patients with hip and/or knee osteoarthritis; no long-term effects were documented. The controlled and randomized 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
^Citation40	Pittler MH, et al	Rheumatol 2006;45: 880–883 (in English)	Spa therapy and balneotherapy for treating low back pain: meta-analysis of randomized trials	To assess the evidence for or against the effectiveness of spa therapy and balneotherapy for treating low back pain	Systematic searches were conducted on Medline, Embase, Amed Cochrane Central, the UK National Research Register and Clinical Trials. gov (all until July 2005)	All trials reporting that the sequence of allocation was randomized (RCTs). Testing balneotherapy or spa therapy for treating patients with low back pain were included. Trials reported in duplicate were excluded.(br/)The duration of interventions was from 3 weeks to 4 weeks	Data abstraction was performed systematically and independently according to design, quality, sample size, intervention, water characteristics, results, adverse events and concomitant treatment	Five randomized clinical trials met all inclusion criteria. Quantitative data synthesis was performed. The data for spa therapy, assessed on a 100-mm visual analog scale (VAS), suggest significant beneficial effects compared with waiting list control groups (weighted mean difference 26.6 mm, 95% confidence interval 20.4–32.8, n = 442) for patients with chronic low back pain. For balneotherapy, the data, assessed on a 100-mm VAS, also suggest beneficial effects compared with control groups (weighted mean difference 18.8 mm, 95% confidence interval 10.3–27.3, n = 138)	Even though the data are scarce, there is encouraging evidence suggesting that spa therapy and balneotherapy may be effective for treating patients with low back pain. These data are not compelling but warrant rigorous large-scale trials
^Citation41	Hall J, et al	Arch Phys Med Rehabil 2008;89: 873–883 (in English)	Does aquatic exercise relieve pain in adults with neurologic or musculoskeletal disease?(br/) A systematic review and meta-analysis of randomized controlled trials	To evaluate the literature on the effectiveness of aquatic exercise in relieving pain in adults with neurologic or musculoskeletal disease	A systematic literature search of 14 databases was examined for research on aquatic exercise over the period from January 1980 to June 2006	Randomized controlled trials that included adults with neurologic or musculoskeletal disease, pain as an outcome measure, and exercise in water were included. The duration of interventions was from 4 weeks to 12 months	Information on the participants, interventions, and outcomes was extracted from the included studies. Quality appraisal was assessed using the Scottish Intercollegiate Guidelines Network criteria for RCTs	Nineteen studies met the inclusion criteria; 8 had a moderate-to-low risk of bias, and 5 of these had data suitable for metaanalyses. This showed that aquatic exercise has a small posttreatment effect in relieving pain compared with no treatment (P = 0.04; standardized mean difference [SMD], −0.17; 95% confidence interval [CI], −0.33 to −0.01), but it is not possible to draw a firm conclusion because of the lack of consistency of evidence across studies. Comparable pain-relieving effects were found betweenaquatic and landbased exercise (P = 0.56; SMD = 0.11; 95% CI,−0.27 to 0.50)	There is sound evidence that there are no differences in pain-relieving effects between aquatic and land exercise. Compared with no treatment, aquatic exercise has a small pain-relieving effect; however, the small number of good-quality studies and inconsistency of results means that insufficient evidence limits firm conclusions

Table 3 Future research agenda on aquatic exercise intervention¹¹

Item	Concrete agenda
Target disease* or prevention	1. The prevention and curative effect of metabolic syndrome
	2. The prevention and the curative effect of mental diseases such as depression
Strengthening of quality	1. Set of research protocol, practice, description based on each respective checklist
	2. Description of adverse event and withdrawal
Feasibility and intrinsic characteristic	1. Comparison with land exercise and/or the other dynamic intervention
	2. Description of intervention cost

Note:

* The pain-relieving effect of chronic locomotorium diseases has already become clear from many RCTs.

Abbreviation: RCT, randomized controlled trial.

Figure 1 Effects and expectations from aquatic exercise.

KamiokaHTsutaniKOkuizumiHEffectiveness of aquatic exercise and balneotherapy: a summary of systematic reviews based on randomized controlled trials of water immersion therapiesJ Epidemiol201020121219881230

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BartelsEMLundHHagenKBDagfinrudHChristensenRDanneskiold-SamsøeBAquatic exercise for the treatment of knee and hip osteoarthritisCochrane Database Syst Rev20074CD00552317943863

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PittlerMHKaragülleMZKaragülleMErnstESpa therapy and balneotherapy for treating low back pain: meta-analysis of randomized trialsRheumatology20064588088416449365

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HallJSwinkelsABriddonJMcCabeCSDoes aquatic exercise relieve pain in adults with neurologic or musculoskeletal disease? A systematic review and meta-analysis of randomized controlled trialsArch Phys Med Rehabil20088987388318452734

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KamiokaHTsutaniKMutohYA systematic review of nonrandomized controlled trials on curative effects of aquatic exerciseInt J General Med2011b4239260

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