Doig (2008) Evidence-based systematic review of the effectiveness of hydrotherapy in acute and chronic medical conditions

The purpose of this systematic review was to identify and summarize the evidence from randomized controlled trials supporting the use of hydrotherapy (aquatic exercise, pool therapy) in acute and chronic medical conditions. For the purposes of this review, no limits were set on water temperature but to be considered as hydrotherapy, some form of exercise had to be conducted in pool water. This document is organized by medical condition. An overall summary of findings is presented for each condition. The conclusions of major published systematic reviews are presented where appropriate. The results of all identified randomized controlled trials are presented individually such that the reader can draw their own conclusions. This review does not address issues relating to balneotherapy (spa hot tub ormineral spring treatment typically above 34oC with no exercise), aqua-fitness for obesity, pregnancy or in healthy people, labour pools, water immersion, baths, sitz baths, whirlpools or other water based interventions that do not require a pool.

 

 

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Evidence-based systematic review of the effectiveness of hydrotherapy in
acute and chronic medical conditions.
Dr. Gordon Doig,
Senior Lecturer in Intensive Care,
University of Sydney
www.EvidenceBased.net

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2008 Gordon S. Doig. All rights reserved. This publication is protected by copyright. No
part of it may be reproduced for commercial purposes or distributed electronically without
prior written permission of the publisher. Reproduction for personal or educational use is
acceptable.
Dr. Gordon Doig,
Senior Lecturer in Intensive Care,
Northern Clinical School,
University of Sydney,
Sydney, NSW
gdoig@med.usyd.edu.au
ISBN: 978-0-9756039-2-5
Title: Evidence-based systematic review of the effectiveness of hydrotherapy in acute and
chronic medical conditions.
Edition: First
AuthorContributor: Doig, Gordon S;
Date of Publication: 31 July 2008
Format: WEB
Size: 297x210
No. of Pages: 36
Publisher: EvidenceBased.net, Sydney, NSW, Australia

Evidence-based systematic review of the effectiveness of hydrotherapy
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Download this entire document from: www.EvidenceBased.netfiles Introduction ...................................................................................................................................................... 5
Search strategy. ............................................................................................................................................... 5
1) search for systematic reviews.................................................................................................................... 5
2) search for recent RCTs.............................................................................................................................. 5
Economic evaluation ....................................................................................................................................... 6
Summary of findings ...................................................................................................................................... 6
Economic evaluation in Osteoarthritis............................................................................................................ 6
Economic evaluation in Fibromyalgia ........................................................................................................... 6
Neurologic or Musculoskeletal Disease (Meta-analysis of trials conducted in hipknee osteoarthritis,
rheumatoid arthritis, fibromyalgia, multiple sclerosis and lower back pain) ............................................ 7
Summary of findings ...................................................................................................................................... 7
Hip and Knee Osteoarthritis ........................................................................................................................... 7
Summary of findings ...................................................................................................................................... 7
Systematic Review of RCTs .......................................................................................................................... 8
RCTs comparing water exercise to land exercise ......................................................................................... 8
RCTs comparing water exercise to electro-acupuncture ............................................................................... 9
RCTs comparing water exercise to Tai Chi ................................................................................................. 10
RCTs comparing water exercise to no exercise .......................................................................................... 10
Mixed osteoarthritis and rheumatoid arthritis populations ......................................................................11
Summary of findings .................................................................................................................................... 11
RCT evidence .............................................................................................................................................. 12
Juvenile idiopathic arthritis .......................................................................................................................... 12
Summary of findings .................................................................................................................................... 12
RCT evidence .............................................................................................................................................. 13
Rheumatoid arthritis...................................................................................................................................... 13
Summary of findings .................................................................................................................................... 13
RCTs comparing water to land-based exercise ........................................................................................... 13
RCTs comparing water-based exercise to no intervention ..........................................................................14
Fibromyalgia .................................................................................................................................................. 15
Summary of findings ............................................................................................................
........................ 15
RCT evidence: Hydrotherapy vs exercise control group ............................................................................. 15
RCT evidence: Hydrotherapy vs sedentary control group ...........................................................................16
RCT evidence: Hydrotherapy vs balneotherapy .......................................................................................... 18
RCT evidence: Hydrotherapy and sleep ...................................................................................................... 18
Multiple Sclerosis .......................................................................................................................................... 19
Low back pain and leg pain .......................................................................................................................... 19
Summary of findings .................................................................................................................................... 19
Systematic review of land-based exercise................................................................................................... 19
RCT evidence: hydrotherapy vs land based exercise ................................................................................. 19
RCT evidence: hydrotherapy vs no exercise ............................................................................................... 20
RCT evidence: hydrotherapy vs hydrotherapy ............................................................................................ 20
Ankylosing Spondylitis ................................................................................................................................. 20
Summary of findings .................................................................................................................................... 21
RCT evidence .............................................................................................................................................. 21
Neuromotor impairments.............................................................................................................................. 23
Summary of findings .................................................................................................................................... 23
Brain Injury ..................................................................................................................................................... 23
Summary of findings .................................................................................................................................... 23
RCT evidence .............................................................................................................................................. 23
Older patients with chronic heart failure .................................................................................................... 24
RCT evidence .............................................................................................................................................. 24
Chronic Obstructive Pulmonary Disease .................................................................................................... 24
Summary of findings .................................................................................................................................... 24
RCT evidence .............................................................................................................................................. 24
Varicose veins................................................................................................................................................ 25
Cruciate ligament repairs ............................................................................................................................. 25
Summary of findings .................................................................................................................................... 25
RCT evidence .............................................................................................................................................. 25

Evidence-based systematic review of the effectiveness of hydrotherapy
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Download this entire document from: www.EvidenceBased.netfiles Fracture of Proximal Humerus ..................................................................................................................... 25
Summary of findings .................................................................................................................................... 25
Total hip arthroplasty .................................................................................................................................... 26
Stroke.............................................................................................................................................................. 26
Normal, healthy pregnant women and preventingreducing back pain ................................................... 27
Summary of findings .................................................................................................................................... 27
RCT evidence .............................................................................................................................................. 27
Coronary artery disease............................................................................................................................... 27
Summary of findings .................................................................................................................................... 27
RCT evidence .............................................................................................................................................. 27
Indications for which RCTs were NOT available: ....................................................................................... 28
Spinal cord injury, cerebral palsy, Guillain-Barre Syndrome, Post-Polio Syndrome, Chronic Regional Pain
Syndrome, Rett Syndrome, Autism, Spinal Muscular Atrophy or Breast cancer lymphodema. .................. 29
Topics and papers identified in the search but NOT included in this review ......................................... 29
Methods paper ............................................................................................................................................. 29
Crenobalneotherapy balneotherapy (hot mineral spring spas above 34C, no exercises performed in hot
spa) .............................................................................................................................................................. 29
Labour (bath immersions or labour pool) ..................................................................................................... 29
Burns Wound Debridement........................................................................................................................ 29
Heatstroke (requires local cooling baths equipment)................................................................................... 29
Neuroedocrine disorders of females ............................................................................................................ 30
Bluebottle stings ........................................................................................................................................... 30
Pressure ulcer healing ................................................................................................................................. 30
Normal healthy vollyball players .................................................................................................................. 30
Normal pregnant women.............................................................................................................................. 30
Healthy college aged women ....................................................................................................................... 30
Well elderly................................................................................................................................................... 30
Stretching for Ankylosing Spondylitis ........................................................................................................... 30
Post menopausal sedentary healthy women ............................................................................................... 30
Post menopausal healthy women with osteoporosis ................................................................................
... 31
Obese healthy women ................................................................................................................................. 31
Reference List ................................................................................................................................................ 32

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Introduction
The purpose of this systematic review was to identify and summarise the evidence
from randomised controlled trials supporting the use of hydrotherapy (aquatic exercise,
pool therapy) in acute and chronic medical conditions. For the purposes of this review, no
limits were set on water temperature but to be considered as hydrotherapy, some form of
exercise had to be conducted in pool water.
This document is organised by medical condition. An overall summary of findings is
presented for each condition. The conclusions of major published systematic reviews are
presented where appropriate. The results of all identified randomised controlled trials are
presented individually such that the reader can draw their own conclusions.
This review does not address issues relating to balneotherapy (spa hot tub or
mineral spring treatment typically above 34
oC with no exercise), aqua-fitness for obesity,
pregnancy or in healthy people, labour pools, water immersion, baths, sitz baths, whirl
pools or other water based interventions that do not require a pool.
Search strategy.
Medline was searched using Pubmed up to 29 July 2008.
1) search for systematic reviews
((hydrotherapyMeSH Terms OR hydrotherapyText Word) OR aquatic exerciseAll
Fields OR pool therapyAll Fields) AND systematicsb
On 29 July 2008, this search identified 41 potentially eligible papers.
2) search for recent RCTs
((hydrotherapyMeSH Terms OR hydrotherapyText Word) OR aquatic exerciseAll
Fields OR pool therapyAll Fields) AND (randomized controlled trialPublication Type
OR (randomizedTitleAbstract AND controlledTitleAbstract AND trialTitleAbstract))
On 29 July 2008, this search identified 73 potentially eligible papers.
The reference lists of retrieved reviews (1-13) and additional unpublished reviews
(14), were searched by hand.
Conference abstracts were not eligible for consideration in this review. Abstracts do
not present enough detailed information regarding study methods and results to allow
reliable appraisal and interpretation.

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Economic evaluation
The best economic evaluations are driven by the results of a randomised controlled
trial. If a well designed randomised controlled trial establishes a difference in clinical
outcomes, comprehensive costing can be undertaken to determine the true costs
associated with the observed improvement in outcome. Two papers were identified that
based economic evaluations of hydrotherapy upon RCTs (15;16).
Summary of findings
Hydrotherapy may cost in excess of US$50,000 per quality adjusted life year
gained. US$50,000 per quality adjusted life year is commonly accepted as a threshold for
interventions considered to be prohibitively expensive (15).
Economic evaluation in Osteoarthritis
This economic analysis (15) randomised 249 participants with arthritis to the
treatment or control groups using a stratified randomisation process.
Persons in the treatment group were directed to an Arthritis Foundation certified
aquatic class. The aquatic program, run by certified instructors, is held in pools with a
temperature of 85 F to 92 F. Participants engage in gentle upper- and lower-body
activities to help increase joint flexibility and range of motion, and maintain muscle
strength. Treatment group participants were asked to attend class at least twice weekly for
the 20-week study period.
Participants in the control group were asked to follow their usual pattern of activities
and to abstain from new exercise programs for the duration of the study.
Using non-active controls not receiving additional land-based exercises would tend
to over-estimate the benefits of aquatic exercise.
A significant mean difference between groups was found for the participant-specific
Current Health Desirability Rating score with the treatment group reporting a higher mean
rating after class, whereas the mean rating for the control group declined. Treatment group
scores were also significantly improved for the disability measure of the Health
Assessment Questionnaire and the physical domain score of the Perceived Quality of Life
scale.
Based on the observed magnitudes of clinical benefit, the authors calculated the
cost-effectiveness of hydrotherapy for arthritis in excess of US$50,000 per additional
quality adjusted life-year gained.
A subgroup analysis of this trial (12) focussed on the incremental cost-effectiveness
in patients older than 60 (17). This 106 patient subgroup selected from the original 249
patient trial appeared to have a larger greater treatment effect, as measured by the
Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index.
Due to the larger treatment effect seen in this subgroup analysis, the incremental
cost-effectiveness ratio for patients over 60 was calculated to range from 3838 to 5951
per quality-adjusted life-year (QALY) gained in comparison to usual care.
It is important to note that the authors report uncertainty inherent in the data meant
that the latter had wide 95% confidence intervals such that it was not possible to determine
a ceiling valuation (with 95% confidence) for comparison with competing approaches. Due
to this issue, the overall costs of this program may be prohibitively expensive.
Economic evaluation in Fibromyalgia
Costs to the health care system and to society were considered in this study (16) of
included 33 participants, randomly assigned to a hydrotherapy group (n
= 17) or a control

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group (n = 16). The intervention in the experimental group consisted of a 1-hour,
supervised, water-based exercise sessions, three times per week for 8 months. Each
QALY gained in association with the exercise programme cost an additional 3,947QALY
(95% CI: 1,782 to 47,000) for a health care perspective and 7,878QALY (3,559 to
93,818) from a societal perspective.
The upper limit of 47,000 per additional QALY marks this intervention as
potentially prohibitively expensive.
Neurologic or Musculoskeletal Disease (Meta-analysis of trials conducted in
hipknee osteoarthritis, rheumatoid arthritis, fibromyalgia, multiple sclerosis and
lower back pain)
A comprehensive systematic review published in 2008 by Hall et al (13)
investigated the effects of hydrotherapy across different medical conditions. This
systematic review conducted an extensive literature search that included 18 electronic
databases. It identified 19 relevant RCTs which have been reviewed and are reported
individually by medical condition in this document.
Summary of findings
Comparing hydrotherapy to no intervention, pooling trials across medical conditions
Hall et al found a small post treatment pain relief effect in favour of hydrotherapy (P=0.04;
standardised mean difference SMD, -0.17; 95% confidence interval CI, -0.33 to -0.01).
Hall et al cautions the reader that it was not possible to draw a firm conclusion about this
effect because of the lack of consistency of evidence across studies.
Pain-relieving effects were found to be similar between aquatic and land based
exercise (P=0.56; SMD=0.11; 95% CI, -0.27 to 0.50).
Overall, Hall et al conclude, there is sound evidence that there are no differences
in pain-relieving effects between aquatic and land exercise.
Hip and Knee Osteoarthritis
Two thorough, recent systematic reviews (2;11) were identified. They included three
RCTs (18;19;20). Ten additional RCTs (21-30) were identified by the primary search. All
thirteen RCTs were retrieved and reviewed.
Summary of findings
A systematic overview published in 2008 by Dziedzic et al (11) reviewed all other
systematic reviews on the topic and concluded that there is strong evidence for the
effectiveness of therapeutic land-based exercise for patients with osteoarthritis. Bartels
et al (2) conducted a review of clinical trials noted there is a lack of high-quality studies of
hydrotherapy in this condition.
The presence of strong evidence supporting land exercise establishes land
exercise as the appropriate comparison group against which to evaluate the incremental
benefits of hydrotherapy.
Of the thirteen RCTs reviewed, six (18;19;22;28-30) RCTs compared water
exercise to land exercise and failed to find a significant difference between water and land
exercise. One trial compared water exercise to electro-acupuncture (20) and concluded
electro-acupuncture and hydrotherapy, both in combination with patient education, induce
long-lasting effects, shown by reduced pain and ache and by increased functional activity
and quality of life, as demonstrated by differences in the pre- and post-treatment
assessments. A second trial compared hydrotherapy to Tai Chi (21) and concluded,
Access to either hydrotherapy or Tai Chi classes can provide large and sustained

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improvements in physical function for many older, sedentary individuals with chronic hip or
knee osteoarthritis.
Because of multiple study groups in certain RCTs, nine papers provide a
comparison of hydrotherapy to no exercise control groups (19-21;23-28). Eight of the nine
papers demonstrate some form of benefit in the hydrotherapy group compared to no
exercise controls. One paper only showed benefit to land-based exercise compared to the
no exercise controls. Land based exercise (18;19;22;28), electro-acupuncture (20) and Tai
Chi (21) have all been demonstrated to have a positive effect compared to no exercise
controls.
Hydrotherapy has not been shown to be superior to land-based exercise, electro-
acupuncture or Tai Chi.
Systematic Review of RCTs
A comprehensive review of the literature was conducted by Bartels et al (2) in
2007.
Compared to no exercise controls, patients with combined knee and hip
osteoarthritis demonstrated 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) immediately after exercise. There was no evidence of effect on
walking ability or stiffness and no differences at 6 month follow-up with regards to pain,
function, stiffness, mental health or quality of life.
This systematic review identified only one trial that compared aquatic exercise with
land-based exercise. Immediately after treatment, there was a large reduction in pain in
favour of hydrotherapy (SMD 0.86,95%CI 0.25 to 1.47; 22% relative percent
improvement), but no evidence of effect on stiffness or walking ability.
RCTs comparing water exercise to land exercise
In 2008, Lund et al (28) randomised 79 patients with knee osteoarthritis to: 1)
aquatic exercise (n = 27), 2) land-based exercise (n = 25) or 3) control (n = 27).
Both the aquatic and land-based exercise programs consisted of the following parts:
warm-up, strengtheningendurance exercise, balance exercise and stretching exercise.
Each session lasted 50 min, comprising 10 min warm-up, 20 min resistance exercises, 10
min balance and stabilising exercises, 5 min lower limb stretches and 5 min cool-down
period. Both exercise interventions were carried out for 8 weeks with 2 sessions per week.
No effect was observed immediately after exercise cessation (8 weeks). At 3-month
follow-up a reduction in VAS pain was observed only in the land-based exercise group
compared with control (8.1 mm, 95% confidence interval 15.4 to 0.4; p = 0. 039).
There were no differences between groups for Knee Injury and Osteoarthritis Outcome
Score questionnaire. There were no improvements following aquatic exercise.
Only land-based exercise showed some improvement in pain and muscle strength
compared with the control group, while no clinical benefits were detectable after aquatic
exercise compared with the control group.
Sylvester
(29) randomised 14 patients with hip osteoarthritis to: 1) hydrotherapy or:
2) short wave diathermy and exercises. Both groups performed hip and walking exercises
for 30 mins twice a week for six weeks.
There were no significant differences between the groups prior to treatment.
Following treatment, pain had decreased significantly (p 0.02) in both groups.
After treatment, there were no significant differences between the two groups with
regards to pain, functional ability, life satisfaction, gait and range of motion .

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Wyatt et al (30) randomised 46 subjects between the ages of 45 and 70 years with
knee osteoarthritis to: 1) aquatic exercise or 2) land exercise.
Both exercise groups performed knee exercises 3 times a week for 6wk. The
aquatic exercise was conducted in a 1.5m therapeutic pool at 32.2C.
Both exercise groups showed a significant (p 0.05) increase in all measurements
between pre- and posttests.
There were no significant differences between the aquatic exercise group and the
land-based exercise group pertaining to knee ROM, thigh girth, and time for a 1-mile walk.
Subjective pain levels were significantly less in the aquatic group when compared
with the land-based group.
Green et al (18) randomised 47 subjects with OA of the hip to: 1) a regimen of
home exercises or 2) twice weekly hydrotherapy for 6 weeks in addition to home
exercises. There was an improvement seen in both subjective and objective measures in
both groups however there were no significant differences between the two groups.
Foley et al (19) randomised participants into one of three groups: 1) hydrotherapy
(n = 35), 2) gym (n = 35), or 3) control (n = 35). The two exercising groups had three
exercise sessions a week for six weeks. At six weeks an independent physiotherapist
unaware of the treatment allocation performed all outcome assessments (muscle strength
dynamometry, six minute walk test, WOMAC OA Index, total drugs, SF-12 quality of life,
Adelaide Activities Profile, and the Arthritis Self-Efficacy Scale). Functional gains were
achieved with both exercise programmes compared with the control group.
Silva et al (22) randomly assigned 64 subjects with osteoarthritis of the knee to one
of two groups that performed exercises for 18 weeks: a water-based exercise group and a
land-based exercise group. The outcome measures included a visual analog scale (VAS)
for pain in the previous week, the Western Ontario and McMaster Universities
Osteoarthritis Index (WOMAC), pain during gait assessed by a VAS at rest and
immediately following a 50-foot (15.24-m) walk test (50FWT), walking time measured at
fast and comfortable paces during the 50FWT, and the Lequesne Index. Measurements
were recorded by a blinded investigator at baseline and at 9 and 18 weeks after initiating
the intervention.
Based on inspection of the 95% confidence intervals presented in Table 3, 4 and 5
in the publication (22), there were no significant differences between groups in outcomes
measured at 9 and 18 weeks.
RCTs comparing water exercise to electro-acupuncture
Stener-Victorin et al (20) randomised 45 patients, aged 4286 years, with
radiographic changes consistent with osteoarthritis in the hip, pain related to motion, pain
on load, and ache to; 1) electro-acupuncture or, 2) hydrotherapy, both in combination with
patient education, or 3) patient education alone.
Electro-acupuncture and hydrotherapy, both in combination with patient education,
induced long-lasting effects, shown by reduced pain and ache and by increased functional
activity and quality of life, as demonstrated by differences in the pre- and post-treatment
assessments however there were no differences between the electro-acupuncture and
hydrotherapy groups.

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RCTs comparing water exercise to Tai Chi
Fransen et al (21) randomly allocated participants to 12 weeks of hydrotherapy
classes (n=55), Tai Chi classes (n=56), or a waiting list control group (n=41).
The authors report changes over time but do not report comparisons between
groups. Direct inspection of the 95% confidence intervals calculated around the estimates
of change fail to show any difference between hydrotherapy and Tai Chi.
Overall, the authors conclude: Access to either hydrotherapy or Tai Chi classes
can provide large and sustained improvements in physical function for many older,
sedentary individuals with chronic hip or knee osteoarthritis.
N.B. - Some sources reference the Fransen et al (21) paper as: Nairn F,
Winstanley J, et al. Hydrotherapy and Tai Chi provide clinical improvements for older
people with arthritis. Arthritis Care Res 2007; :407-414. Both references lead to the
same paper.
RCTs comparing water exercise to no exercise
Wang et al (23) randomised 38 participants from community sources to a 12 week
aquatic programme or a non-exercise control condition. The 12-week aquatic programme
consists of warm up, flexibility and strength training, and cool down. The exercises are
divided into six sections, as shown in Table 1. The 50-minutes class focuses on joints in
the trunk, shoulders, elbows, wrists, fingers, hip, knees, ankles and toes, and emphasizes
muscle groups of upper and lower limbs.
Control participants were asked to continue their physical activity as usual and
offered an opportunity to participate in the aquatic programme at the end of the trial.
The aquatic exercise group responded to exercise. A more appropriate and relevant
control group would have been dry land exercise of the same duration, intensity and
frequency.
Belza et al (24) randomised 249 adults with osteoarthritis to: 1) a 20-week Arthritis
Foundation Aquatic exercise Program (n=125) or 2) a wait-list control group (n=124).
Participants in the control group were asked to follow their usual pattern of activities and
abstain from starting new exercise programs for the duration of the study, after which they
were invited to attend an AFAP free of charge.
Participants allocated to receive exercise responded to exercise. This trial does not
provide an objective comparison between water based exercises and the appropriate
comparator group, gentle land based exercises. No inferences can be drawn regarding the
added value of conducting the exercises in water.
Hinman et al (25) randomised 71 volunteers with symptomatic hip OA or knee OA
to: 1) an aquatic physical therapy group (n=36), or; 2) a wait-list control group (n=35).
The aquatic physical therapy program comprised functional weight bearing and
progressive exercises provided twice weekly (4560 minutes each) for 6 weeks. An
experienced aquatic physical therapist individually instructed participants in the
hydrotherapy pool (water temperature_34C), with a maximum of 6 participants per
session. Quality of movement was emphasised, and the therapist palpated the lower-limb
musculature to ensure appropriate contraction throughout the exercises.
The control group did not receive any additional physical therapy over the 6-week
trial; however, these participants were offered the intervention following the 6-week
assessment to minimise dropouts from this group. Control participants were instructed to
continue with their usual daily activities and medication regimen and not commence any
new exercise programs or treatments for their OA affected joints.

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The findings demonstrated that a 6-week, twice-weekly exercise program leads to
reduced pain and joint stiffness as well as improved physical function, hip muscle strength,
and quality of life in people with OA. Due to the lack of an active control group, it is difficult
to draw inferences from these results.
Suomi et al (26) randomised women with lower extremity arthritis to: 1) an aquatic
exercise group (n = 14) or; 2) no-exercise control group (n = 10).
Arthritis Foundation Aquatic Program (AFAP) classes were conducted in three 45-
minute training sessions weekly for 6 weeks following AFAP guidelines. The instructor for
all AFAP classes was a graduate adapted physical education student certified as an AFAP
instructor, with 2 years of AFAP teaching experience.
Control subjects were asked to refrain from engaging in any organized physical
activity program or beginning any new physical activity during the duration of the
investigation.
The women with arthritis who followed an aquatic exercise program for 6 weeks
significantly reduced their total sway area and their sway in the medial-lateral direction
under the full vision condition; they also reduced their total sway area and their sagittal and
medial-lateral sway in the no-vision condition.
The authors found these results difficult to explain: studies performed to date have
not found significant relationships between attributes of arthritis and increased postural
sway. The association of increased postural sway with age, however, is well established.
In the present study, the subjects in the exercise group were significantly older than
subjects in the control group.
The authors speculate that the increased levels of sway in the medial-lateral
direction under both visual conditions were likely a function of the difference in ages
between the two groups rather than being attributable to the impact of the intervention on
the effects of arthritis.
Soumi et al (27) randomised women to participate in: 1) a pool exercise group
(n=20) or; 2) a no exercise control group (n=10).
The pool exercise group received the Arthritis Foundation Aquatic Program three
times a week for six weeks in a pool heated to between 85-87
oF.
The control group received no intervention and were asked to refrain from taking up
any additional exercise during the study period.
Three patients randomised to the pool exercise group dropped out and outcomes
are not reported for these patients.
The intervention group, which received more exercise than the control group
responded to exercise. Hip abduction isometric strength and range of motion were
increased significantly in the exercise group however there were no changes over time in
shoulder abduction isometric strength or range of motion.
Mixed osteoarthritis and rheumatoid arthritis populations
There were three RCTs (31-33) conducted that enrolled mixed patient groups.
Outcomes were not adequately described such that effects could be attributed to either
condition.
Summary of findings
One study reported a difference in self-reported pain compared to a no exercise
control group. No trials reported differences between land and water based exercise with

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regards to functional outcomes, quality of life measures, activities of daily living or joint
range of motion.
RCT evidence
In 1989, Minor et al (33) randomised a mixed group of RA and OA patients to: 1)
aquatic exercise (n=47) or; 2) land-based walking exercise (n=36) or 3) control (n=32).
Both aquatic and land exercise groups exercised at 60-80% of their maximal heart
rate for 60 minutes, three times a week for 12 weeks.
The control group performed non-aerobic range of motion exercises.
The aquatics and walking exercise groups showed significant improvement over the
control group in aerobic capacity, 50-foot walking time, depression, anxiety, and physical
activity after the 12-week exercise program.
There were no significant differences between the aquatic and land-based exercise
groups.
In 2003, Suomi et al (31) randomised a volunteer sample of 30 men and women
with arthritis (osteoarthritis, n=22; rheumatoid arthritis, n=8), to 8 weeks of: 1) an aquatic
exercise (n=10); 2) on-land exercise (n=10); 3) or control group (n=10).
Participants received the National Arthritis Foundation (NAF) aquatic and on-land
exercise programs on functional fitness and perceived ability to perform activities of daily
living (ADL) measures in older adults with arthritis.
Control patients received no intervention.
Based on inspection of the 95% confidence intervals around the post-intervention
outcomes, there appear to be no differences between land or water based exercise
groups. Both NAF exercise programs appeared to be effective in improving functional
physical fitness and perceived ability to perform ADL measures in older adults with arthritis
compared to no intervention controls.
In 1995, Ahern et al (32) randomised 30 patients with rheumatoid arthritis or
osteoarthritis who had just completed a four day course of hydrotherapy to receive: 1)
hydrotherapy for six more weeks (n=22) or; 2) no intervention control group (n=8).
Hydrotherapy consisted of two group sessions per week for six weeks.
The control group received no intervention.
Self-reported pain was significantly improved in the water exercise group compared
to the no exercise controls however this did not translate to a difference in self-reported
function (illness Behaviour Questionnaire, the Stanford Health Assessment Questionnaire
or the Frenchay Activities Index), quality of life (Zung self-rating depression scale) or target
joint range of motion between groups.
Juvenile idiopathic arthritis
There was one well conducted RCT on this topic (34).
Summary of findings
This trial was commissioned by the National Health Service Research &
Development Health Technology Assessment (HTA) Programme. The authors concluded
that there appears to be no evidence to justify the costs of building pools or initiating new
services specifically for use in this disease.

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RCT evidence
In 2005 Epps et al (34) conducted a clinical trial commissioned by the National
Health Service Research & Development Health Technology Assessment (HTA)
Programme.
This multicentre randomised controlled, partially blinded, trial allocated 100 patients
to a control arm receiving land-based physiotherapy only (land group) compared to 100
patients in an intervention arm receiving a combination of hydrotherapy and land-based
physiotherapy (combined group).
Disease improvement was defined as a decrease of 30% or more in any three of six
core set variables without a 30% increase in more than one of the remaining three
variables. This primary outcome measure was assessed at 2 months following completion
of the intervention.
Two months after intervention 47% patients in the combined group and 61%
patients in the land group had improved disease with 11% and 5% with worsened disease,
respectively. The analysis showed no significant differences in mean costs and QALYs
between the two groups.
The trailists state that there appears to be no evidence to justify the costs of
building pools or initiating new services specifically for use in this disease.
Rheumatoid arthritis
A systematic review (4) conducted in 2004 identified only one clinical trial in this
population (35). Four additional clinical trials were identified by the primary search (36-39).
Although the paper by Stenstrom et al (35) has been reported as a randomised
trial in many other reviews, this paper is not a randomised trial. Patients were allowed to
choose whether they participated in a 4 year water exercise program or not. If a particular
patient declined an invitation to participate in a 4 year water exercise program, they were
allowed to remain at home and served as no exercise controls. Because factors such as
the patients current fitness level or their current ability to participate in exercise activities
may have influenced their decision to choose exercise or control, it is difficult to attribute
any differences in outcomes between the two groups to the intervention under study. This
is not a randomised controlled trial and cannot be considered in this review.
Summary of findings
Two trials compared hydrotherapy to land-based exercise and failed to find any long
term differences in quality of life, health status, pain or functional scores.
One trial, published in 2005, compared a 12 week period of twice weekly pool
exercises to no exercise and found the pool exercise group improved in most measures of
exercise tolerance however there were no differences between groups with regards
maximal aerobic capacity or the physical domains of the SF-36.
One trial compared 12 weeks of aquatic exercise to no exercise and found
significant improvements in measures of pain.
RCTs comparing water to land-based exercise
In 2007 Eversden et al (36) randomised 115 patients with rheumatoid arthritis to: 1)
a weekly 30-minute session of hydrotherapy or; 2) similar exercises on land for 6 weeks.
The exercise content in each group was similar and exercises were tailored to each
individual's ability. Participants warmed up by mobilising and stretching. The core
exercises were repeated each week and focussed on joint mobility, muscle strength and
functional activities.

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Eleven patients allocated land exercise failed to complete the six week course
compared with four patients allocated to hydrotherapy (p = 0.09).
Significantly more patients treated with hydrotherapy reported feeling much better
or very much better than the patients treated with land exercise (87% vs 47.5%, p 0.001
Fisher's exact test) immediately on completion of the treatment programme.
This perceived benefit was not reflected by differences between groups in 10-metre
walk times, functional scores, repeatable quality of life measures (Health Assessment
Questionnaire, EuroQual Visual Analog Scale), measures of health status (EuroQual 5D
utility score), or pain measured by a Visual Analog Scale.
In 1998, Sanford-Smith et al (37) randomised 24 subjects to receive 1)
aquaerobics or 2) home exercises.
The aquaerobics program received group sessions three times a week for 10
weeks. Each 1 hour session was conducted in a hydrotherapy pool heated to 36
oC and
consisted of a 15 minute warm up, 20-25 minutes of aerobics with a target of 70%
maximum heart rate and 15 minute cool down.
Control group participants received a 10 week program including range of motion
and isometric strength exercises.
Both groups demonstrated improvements over time in response to exercise using
measures that are considered to be general indicators of disease severity active joint
count, erythrocyte sedimentation rate, the Stanford Health Assessment Questionnaire or
self limiting maximal exercise (stress) test.
There were no differences between groups with regards to any outcome.
RCTs comparing water-based exercise to no exercise
Published in 2005, Bilberg et al (38) conducted a trial involving 46 patients with
chronic RA who were randomly assigned to: 1) exercise in a temperate pool twice a week
for 12 weeks (n=20) or; 2) no additional exercise (n=23).
The treatment group exercised twice a week for 12 weeks in groups of eight or nine
patients in a temperate pool. Each session was 45 min long and of moderate aerobic
intensity. It comprised exercises for aerobic capacity, dynamic (eccentric and concentric)
and static muscle strength, and muscle endurance in the upper and lower extremities,
flexibility, coordination and relaxation. The pace of the exercises was guided by music.
The sessions were led by two alternating physiotherapists, who gave individual
instructions to each patient if needed.
The control group received no additional interventions.
The primary study outcomes, aerobic capacity, estimated using a submaximum
ergometer cycle, and the physical component of the SF-36 did not differ between groups.
At six month follow-up, the group randomised to receive additional exercises
demonstrated improvements in measures of exercise tolerance: the chair test and the
shoulder endurance test, with 10 of the 13 demonstrating significant improvement.
Since the control group did not receive additional exercises, it is impossible to
determine whether the improvements observed in the intervention group are attributable to
a general increase in exercise level in the intervention group or the fact the exercises were
conducted in water.
In 1996, Rintala et al (39) randomised 34 patients with rheumatoid arthritis to: 1)
aquatic exercise (n=18) or; 2) control (n=16).

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The aquatic exercise undertook a routine to improve aerobic power, muscle
strength, endurance, and joint mobility in sessions of 45 to 60 mins twice a week for 12
weeks.
The control group received no additional exercise.
The aquatic exercise group reported a significant reduction in pain compared with
control.
Fibromyalgia
There was one well conducted systematic review of non-pharmacological
interventions for fibromyalgia (5) and one systematic review of all types of exercise (10).
Ten RCTs evaluating the effects of hydrotherapy were identified and retrieved (40-
45; 46;47-49).
Summary of findings
Published in 2008, the review by Busch et al (10) concluded There is moderate
quality evidence that short-term aerobic-only exercise training at ACSM-recommended
levels has medium-size positive effects on global well-being and physical function. The
finding that exercise improves outcome establishes land-based exercise as the relevant
control group against which the incremental benefits hydrotherapy need to be established.
Busch et al were unable to make specific recommendations regarding the role of aquatic
exercise.
Three trials compared hydrotherapy with a land based exercise group (43;45;47).
There were no reported differences between hydrotherapy and land-based exercise with
regards to major outcomes: functional capacity, tender points or depression.
Five trials (40;42;44;46;48) compared water based exercise programs to control
groups that received no additional exercise. Benefits reported by these trials may simply
be attributed to the increased exercise level experienced in the water exercise group.
One trial compared hydrotherapy to balneotherapy (hot spa with no exercises) (49).
The hydrotherapy group received exercise training and demonstrated significantly less
depression.
A final trial compared hydrotherapy with conventional land-based physiotherapy and
attempted to measure the relaxing effects of water-based exercise by measuring sleep
time and quality of life (41). This trial found that there were no significant differences
between the two groups with regards to quality of life or Total Sleep Time but Total Nap
Time was significantly higher in the traditional land-based physiotherapy group post
intervention.
RCT evidence: Hydrotherapy vs exercise control group
In 2006, Assis et al (43) assigned sixty sedentary women with fibromyalgia, ages
1860 years, to: 1) either deep water running (DWR) or; 2) land-based exercises (LBE).
Patients were trained for 15 weeks at their anaerobic threshold. Visual analog scale
(VAS) of pain, Fibromyalgia Impact Questionnaire (FIQ), Beck Depression Inventory (BDI),
Short Form 36 Health Survey (SF-36), and a patients global assessment of response to
therapy (PGART) were measured at baseline, week 8, and week 15. Statistical analysis
included all patients.
There were no significant differences between groups with regards to VAS, PGART,
FIQ total score, SF-36 domains BDI or fitness at the end of the 15 week sessions.
Jentoft et al (47) randomised 34 subjects diagnosed with fibromyalgia to: 1) pool-
based exercise (n=18) or 2) land-based exercise (n=16).

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Pool (34oC water temp) and land-based exercises were designed to be similar with
regards to training intensity and the muscle groups activated. The aim of each program
was to improve cardiovascular capacity with minimal risk of injury.
No between group differences were found with regards to functional capacity,
symptom profile (Fibromyalgia Impact Questionnaire, VAS symptom severity scales, VAS
pain) or self-efficacy (Arthritis Self-Efficacy Scale) after 20 weeks of exercise.
The land exercise group had improved their grip strength after 20 weeks compared
with the pool exercise group (P = 0.02). No between-group differences were found in other
variables.
In 2008, Evcik et al (45) published a 63 patient trial comparing: 1) an aquatic
exercise program (n = 33) with; 2) a home-based exercise program (n = 30).
The aquatic exercise program was undertaken in a swimming pool at 33C. Each
session was conducted in groups of 78 patients, lasted 60 min and was conducted 3
times a week, over 5 weeks.
The control home-based exercise program was also a 60 min program and was
conducted 3 times a week, over 5 weeks.
Both groups demonstrated significant improvements in pain VAS and Beck
Depression Index (BDI) scores over time.
At the end of the trial, pain VAS was significantly lower (P 0.001) in the pool
exercise group however this did not translate to a difference between groups in measures
of functional capacity (measured using the Fibromyalgia Impact Questionnaire), number of
tender points, or BDI scores.
RCT evidence: Hydrotherapy vs sedentary control group
Mannerkorpi et al (44) randomised 58 patients to: 1) 6 months of pool exercise
combined with a 6 session education program for patients with fibromyalgia syndrome or;
2) no intervention control.
The active treatment hydrotherapy patients were instructed to match the pool
exercises to their threshold of pain and fatigue while their education sessions focused on
strategies for coping with symptoms and encouragement of physical activity.
The control patients received no interventions.
Compared to the control group that received no intervention, the authors reported
significant improvements in the Fibromyalgia Impact Questionnaire total score (p = 0.017)
and the 6 min walk test (p 0.0001). Significant differences were also found for physical
function, grip strength, pain severity, social functioning, psychological distress, and quality
of life in patients who received aquatic exercise.
It is difficult to tease out the individual effects of the hydrotherapy and the exercise
promoting education. If the control group had received exercise and or exercise
promoting education, the inferences drawn would have been more robust.
In 2006, Gusi et al (40) randomly assigned 34 women to: 1) a hydrotherapy
exercise group (n=17) to perform 3 weekly sessions of training including aerobic,
proprioceptive, and strengthening exercises during 12 weeks, or; 2) a control group
(n=17).
The hydrotherapy exercise group trained in a waist high warm pool (33C) three
times per week for 12 weeks. Each 1-hour session included 10 minutes of warming up with
slow walks and mobility exercises, 10 minutes of aerobic exercises at 6575% of maximal
heart rate (HRmax), 20 minutes of overall mobility and lower-limb strength exercises (4
sets of 10 repetitions of unilateral flexion and extension of the knee at slow pace with the

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body in a vertical position using water as resistance), another set of 10 minutes of aerobics
at 6575% HRmax, and 10 minutes of cooling down with low-intensity exercises. Heart
rate was monitored with a pulse meter (Polar Accurex Plus; Polar Electro Oy, Kempele,
Finland).
The control group continued to follow normal daily activities, which did not include
any form of exercise related to those in the therapy.
The group receiving exercise was found to improve measures of exercise tolerance.
A more appropriate and relevant control group would have been dry land exercise of the
same duration and frequency.
In 2007, Tomas-Carus et al (42) randomised 34 females with fibromyalgia into two
groups: 1) a hydrotherapy exercise group, who exercised for 60 min in warm water, three
times a week (N = 17); and 2) a control group, who continued their habitual leisure-time
activities (N = 17).
The group receiving exercise was found to improve measures of exercise tolerance.
A more appropriate and relevant control group would have been dry land exercise of the
same duration and frequency.
In 1999, Gowans et al (46) randomised subjects to: 1) an exercise program or; 2)
to serve as waiting list controls.
The exercise program lasted 6 weeks and consisted of 2 exercise classes and 2
multidisciplinary educational sessions per week. Exercise classes were conducted in a
warm, therapeutic pool and were 30 minutes long. Each class consisted of 20 minutes of
walkingjoggingside-steppingarm exercises against water resistance and 5 minutes of
stretching at the beginning and end of each class. Educational sessions were one hour
long and were run in a group setting, immediately prior to pool classes. During educational
sessions, patients were provided with information on exercise, postural correction,
activities of daily living, sleep, relaxation, medication, nutrition, and psychosocial coping
strategies.
Control subjects received no interventions and were evaluated at baseline and 6
weeks following enrolment.
Forty-five subjects (23 intervention subjects, 22 waiting list control subjects) were
randomised however three intervention group subjects were subsequently excluded from
analysis for attending less than 50% of the program.
Six minute walk distance, FIQ Feeling bad days and FIQ morning fatigue were
significantly better in patients who completed the exercise and education program as
compared to control patients. Failure to provide some form of exercise and education to
the control group makes it difficult to draw inferences from these findings.
In 2007, Munguia-Izquierdo et al (48) randomly assigned 60 women to either; 1)
an exercise training group (n = 35) to perform 3 sessions per week of aquatic training
(32C) including mobility, aerobic, strengthening, and relaxation exercises for 16 weeks or;
2) a control group (n = 25).
The exercise group trained in a chest high warm pool (32C) 3 times per week for
16 weeks. Each session included 10 minutes of warm-up with slow walks and mobility
exercises; 10-20 minutes of strength exercises developed at slow pace using water and
aquatic materials as resistance, including a stepped progression during the program; 20-
30 minutes of aerobic exercises developed progressively at intensity sufficient to achieve
50-80% of predicted maximum heart rate (220 age); and 10 minutes of cooling down
with low-intensity and relaxation exercises.

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The control group received no intervention.
Six exercise training group patients and one control patient were excluded from the
final analysis.
At baseline, before the intervention began, the exercise group demonstrated a
significantly lower pain threshold than the control group in 5 tender points (p 0.05).
The authors present the results of changes over time in each group but do not
conduct direct tests between groups. Based on the means and standard deviations
presented in this paper, 95% confidence intervals have been calculated for this report to
allow between group comparisons of major outcomes.
The authors report significant differences over time with regard to pain thresholds
however they admit the exercise group started the trial with significantly lower pain
thresholds at baseline. Due to this confounding, between group comparisons of these
measures could not be re-calculated for this report.
Although there was a significant difference between groups with regards to tender
point count (exercise group 95% CI 8.9 to 12.6 vs control group 95% CI 14.4 to 17.7),
these findings did not translate to differences in global measures of functional capacity
(FIQ score 95% CI 59.35 to 66.84 vs 57.0 to 68.3 in controls) or pain (VAS pain 95% CI
61.5 to 72.2 vs 67.7 to 83.8 for controls). Failure to provide some form of exercise and
education to the control group makes it difficult to draw inferences from these findings.
RCT evidence: Hydrotherapy vs balneotherapy
In 2004, Altan et al (49) randomised 50 female patients to: 1) pool-based exercise
(n=25) or; 2) balneotherapy, applied in the same pool without any exercise (n=25).
The pool-based exercise program was given by a physiotherapist to 25 patients in a
therapeutic pool at 37
oC for 35 min a day three times a week for 12 weeks. The program
included warming (walking back and forth in the pool), activity (jumping in the pool and
active joint motion range and stretching of the neck and the extremities), relaxation (lying
supine on the water and slow swimming), and out-of-pool exercises (bending back and
forth, squatting, and relaxing with deep breaths) for a period of 35 min.
The control balneotherapy sessions lasted 35 min three times a week for 12 weeks
and were conducted in the same pool as the exercise group. Control patients were
instructed not to perform any exercise during the sessions.
Comparison of the two groups on the basis of the post-treatment (weeks 12 and 24)
percent changes and difference in scores relative to pre-treatment (week 0) values failed
to show a significant difference between the groups for any parameter except the Beck
Depression Inventory (P0.01).
A dry land exercise based comparison group was not included in this study.
RCT evidence: Hydrotherapy and sleep
To assess the relaxing effects of water-based exercise, Vitorino et al (41)
randomly assigned 50 outpatients, all female, 3060 years old, diagnosed with
Fibromylagia, to two groups to carry out 3 weeks of treatment with hydrotherapy or
conventional physiotherapy.
The hydrotherapy exercises were composed of the following: (1) warm-up (5 min),
(2) stretching (6 min in the beginning and in the end), (3) aerobic exercises (30 min), and
(4) relaxation (13 min).
Patients in the conventional physiotherapy group were subjected to (1) surface
heating by infrared lamp (10 min); (2) stretching (5 min in the beginning and in the end);
(3) aerobic exercise (30 min); and (4) relaxation (10 min).

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This trial found no significant differences between the two groups with regards to
Total Sleep Time or quality of life however the Total Nap Time was significantly higher in
the physiotherapy group post intervention.
Multiple Sclerosis
In 2001, Sutherland et al (50) randomised 22 people with MS to: 1) hydrotherapy
(n = 11) or; 2) no-special-activity control (n=11)
The hydrotherapy session included water aerobics, water jogging and deep water
running in 45 minute sessions conducted 3 times a week for 10 weeks.
The control group received no additional interventions.
Compared to no exercise controls, hydrotherapy sessions resulted in a significant
reduction in fatigue and pain.
Low back pain and leg pain
Summary of findings
Extensive systematic reviews (11;51) of all exercise interventions concluded that
there is strong evidence to support the use of land based exercise. Land-based exercise
significantly reduces sick days during the first follow-up year. Because of the known strong
effect of exercise, the appropriate control group against which to assess the incremental
benefits of hydrotherapy is land-based exercise.
Four clinical trials were identified (52-55). Only one clinical trial and one pseudo-
randomised trial compared hydrotherapy to land-based exercise. There were no
differences between hydrotherapy and land-based exercise.
One trial compared hydrotherapy to no intervention, and the third compared two
types of hydrotherapy.
Systematic review of land-based exercise
An extensive review by Kool et al (51) investigated whether land-based exercise
alone or as a part of a multidisciplinary treatment reduces sick leave in patients with non-
specific, non-acute, low back pain. The reviewers concluded that there is strong evidence
that land-based exercise significantly reduces sick days during the first follow-up year.
Since land-based exercise is accepted to be effective, it serves as the appropriate
control intervention against which to evaluate the effectiveness of hydrotherapy.
RCT evidence: hydrotherapy vs land based exercise
In 2004, Yozbatiran et al (55) randomised 30 patients to: 1) aquatic exercise
(n=15) or; 2) land-based exercise (n=15).
Both groups followed similar programs, which included warm-up, stretching, a
circuit of 15 progressive exercises, cool down with light stretching and light aerobic
exercise. Sessions were conducted 3 times a week for 4 weeks.
No significant differences were found between the groups with regards to aerobic
fitness, motor fitness (single leg balance test with eyes open or closed), musculoskeletal
fitness, pain reports, Sorensen and Oswestry low back pain disability index scores.

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Sjogren et al (53) sequentially allocated sixty subjects in order of presentation
with chronic low back pain to either: 1) hydrotherapy treatment or; 2) land treatment
groups.
Due to the sequential allocation process, this trial should be regarded as pseudo- or
quasi-randomised. Pseudo-randomised trials may be subject to severe forms of selection
bias and allocation bias, and may over-estimate treatment effects by up to 40%.
Both the land and the hydrotherapy exercise programs consisted of two group
sessions per week for a period of six weeks. Each subject had to participate in the full
twelve sessions over this period. If a session was missed an alternative session was
arranged and if more than two consecutive sessions were missed the subject was
withdrawn from the study.
Twenty-eight subjects from each group attended all treatment and assessment
sessions. Results indicated that both groups improved significantly in functional ability and
in decreasing pain levels. Thoracolumbar mobility did not improve significantly in either
group. Overall there was no significant difference found between the two types of
treatment.
RCT evidence: hydrotherapy vs no exercise
In 1998, McIlveen et al (52) randomised 109 adults with lower back paain (LBP) or
back and leg pain of more than three months duration to either: 1) hydrotherapy or; 2)
control (delayed hydrotherapy) group.
Each hydrotherapy session was led by experienced pool volunteers with additional
training in delivering the prescribed 20 spinal exercises. Ten repetitions of each prescribed
exercise were included during each session. If a subject missed a session, an extra one
was arranged. Any subject who missed more than one session in the four-week period
was withdrawn from the study.
The control group received no intervention during the study period. They were
placed on a waiting list for hydrotherapy.
Forty-five 45 people in the experimental group, and 50 people in the control group
completed the trial.
Significantly more people in the exercise group reported a change in functional
status, as measured by the Oswestry Disability Questionnaire score (p=0.04).
Differences between the experimental and control groups were not significant for
other measures of pain, light touch, reflexes, strength, or for the ranges of flexion,
extension and passice straight leg raise. It is difficult to draw inferences from these results
because the control group did not receive any active intervention.
RCT evidence: hydrotherapy vs hydrotherapy
In 2008, Schrepfer et al (54) randomised 49 patients to: 1) deep water walking or
2) deep water hanging. This study did not identify any significant differences between
hydrotherapy groups. It also did not include a land-based exercise group as a control.
Ankylosing Spondylitis
There were two systematic reviews covering all aspects of exercise (land and
aquatic) in this condition. One could not be included in this review because it is published
in Portuguese (1). The comprehensive Cochrane Collaboration systematic review
conducted by Dagfinrud et al in 2008 was retrieved (7). Because outcomes and
interventions differed between trials to such a degree, the authors of this Cochrane
Collaboration systematic review were not able to conduct a meta-analyses of any specific
intervention.

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Three clinical trials and one economic evaluation on this topic were identified
(56;57-59) and retrieved for individual review.
Summary of findings
The English language abstract (available on PubMed) for the Portuguese language
review concludes that physical exercise is helpful and acknowledges that the research
supporting hydrotherapy looks promising. The authors of the second systematic review,
published in 2008 conclude, we still do not know which particular treatment protocol to be
recommended in the management of AS.
Inferences regarding the true benefits of hydrotherapy are difficult to draw from the
three individual clinical trials. One trial compared an extensive spa resort holiday program
to no holiday and no change in exercise (56). One trial compared an extensive exercise
program, where hydrotherapy was provided after sporting exercises, with a control group
that received a home exercise program (57). The third trial, which included three different
groups, does not present standard errors or standard deviations for study outcomes thus
direct comparisons between groups cannot be made (58).
RCT evidence
van Tubergen et al (56) randomised patients to receive a three week holiday at a
resort spa, where they undertook an extensive five day a week exercise package and
education. Patients randomised to the control group remained at home and did not change
their exercise patterns.
The spa resort holiday package included spa-exercise therapy 5 days a week at
one of two spa resorts. Therapy programs were standardised for both spa resorts and
were performed by trained physiotherapists not involved in the outcome assessment and
analyses of the study. Every morning patients started with 1 hour of physical exercises,
followed by 30 minutes of walking, and postural correction therapy by lying supine on a
bed (initially 14 minutes, but increasing daily by 2 minutes to a final period of 30 minutes a
day). Every other afternoon, the patients in Bad Hofgastein visited the Gasteiner
Heilstollen. The Gasteiner Heilstollen are former mine galleries with a climate
characterised by temperatures from 38.0 to 41.5C, a humidity of 70% to 98%, and
concentrations of radioactive radon in the air. Patients travelled by train to one of the
treatment areas situated 2 kilometers inside the mountain, where they rested (naked) in
the supine position on a bed for 1 hour. After the stay in the Heilstollen, the patients rested
for 30 minutes at room temperature. Instead of visiting the Gasteiner Heilstollen, the
patients in Arcen received a similar thermal treatment by visiting the sauna and the
thermal baths. Either the Heilstollen or the sauna was visited a total of 10 times within a
period of 3 weeks. In the Heilstollen, the radon progeny activity was measured in Working
Level using the Instant Radon Progeny Meter (IRPM, Type TN-IR-21, Thomson & Nielsen,
Canada). For the total 10-hour stay, patients were exposed to a cumulative dose of 0.536
Working Level Month (WLM). The other afternoons were spent with 30 minutes of
intensive hydrotherapy and 30 minutes bathing in thermal water, followed by 1 hour of
sports. Individual therapies were not allowed. During the weekends, patients were
permitted to visit the thermal baths but were instructed not to exercise.
Hydrotherapy was only a small component of the extensive holiday resort package
evaluated. This study cannot serve as a comparison of hydrotherapy (exercise in water) to
simple exercise or control.
An economic evaluation (59) of this spa holiday intervention calculated the costs
per quality-adjusted life year gained for each resort compared to control as 7,465 (95%

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CI 3,29414,686) for the spa resort holiday in Bad Hofgastein, Austria, and 18,575 (95%
CI 3,678114,257) for the spa resort holiday in Arcen, The Netherlands.
Hidding et al (57) randomised 149 patients to: 1) twice weekly group physical
therapy for 9 months plus home exercises or; 2) home exercise.
The group physical therapy sessions were extensive and consisted of 1 hour of
physical training, followed by 1 hour of sporting activities and 1 hour of hydrotherapy.
Hydrotherapy was given in heated water (mean, 31
o C; range, 29o-32o C) to reduce pain
and improve mobility of the spine and peripheral joints after sporting exercises. It is not
reported whether exercises were conducted during hydrotherapy. Group physical therapy
patients were also encouraged to conduct a home exercise program that was directed at
the hip joints, peripheral joints, and the entire spine, for 30 min daily over the entire study
period.
Control patients were encouraged to conduct a home exercise program that was
directed at the hip joints, peripheral joints, and the entire spine, for 30 min daily over the
entire study period.
Compared to individually directed home exercises conducted for 30 minutes a day,
the addition of a twice weekly comprehensive group exercise program for 9 months
resulted in significant improvements in fitness (maximum work capacity by ergometry),
thoracolumbar mobility, and overall global health as assessed by the patients (P 0.05).
Other measures of functional capacity (Sickness Impact Profile, Health Assessment
Questionnaire for the Spondylarthropathies, and Functional Index measures) did not differ
between groups.
Helliwell et al (58) randomised 44 patients with ankylosing spondylitis to receive: 1)
intensive in-patient physiotherapy, which included hydrotherapy (n=15); 2) hydrotherapy
plus home exercises (n=15); or 3) home exercises alone (n=14).
The intensive in-patient treatment consisted of a three-week admission to the Royal
Bath Hospital, Harrogate and involved daily (Monday to Friday) one-hour group exercise
sessions with stretching exercises and aerobics, a hydrotherapy session at least three
times a week, very occasionally supplemented by Vichy massage if back muscle spasm
was a prominent feature. Interferential treatments were given to specific peripheral joints
where pain in those joints hindered full participation in the exercise classes.
The hydrotherapy plus home exercise group received a six-week period of twice-
weekly out-patient hydrotherapy sessions which included exercise for all parts of the body
with emphasis on exercises for the back and neck. Patients in this group were also taught
a home exercise regime to perform twice a day and were given a diary to check
satisfactory compliance with these exercises.
Home exercise patients were instructed in the same home exercise regime as the
hydrotherapy patients and were also given the diary to complete.
Not all patients attended outcome follow-up (at six months 87% of patients in the in-
patient group, 60% of patients in hydrotherapy and exercise groups and 57% of patients in
the home exercise group attended for assessment).
Despite randomisation and stratification, treatment groups differed in their initial
baseline measurements: the hydrotherapy group had better cervical rotation and VAS pain
scores.
Based on ANOVAs, which assess overall differences between all three groups but
do not provide direct comparisons between individual groups, the groups differed
significantly immediately after treatment for the visual analogue scores for pain and

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stiffness (F = 10.88, p = 0.001) and for cervical rotation (F = 3.73, p = 0.03). This
difference was not maintained even at two months after cessation of treatment.
Neuromotor impairments
One comprehensive systematic review published in 2006 by Getz et al (3)
addressed research findings in this condition. It identified 11 articles on the topic: one
randomised control trial, two quasi-experimental studies, one cohort study, two case
control studies and five case reports. The clinical trial (60) was retrieved and appraised
individually.
Summary of findings
The study by Dorval et al (60) has been identified by other reviewers (3) as being
randomised however it used a purposive group allocation process. Dorval et al report
that Conventional aquatic exercise (n = 10) and experimental aquatic exercise(n = 10)
groups were formed according to availability of transportation and mobility. This type of
purposive group allocation may lead to significant biases. Furthermore, this paper
compares two types of aquatic exercise groups.
Despite the positive increase in the subjects scores in both aquatic intervention
groups, the authors conclude that the experimental aquatic programme was not sufficiently
powerful to be significantly different from the conventional aquatic program, in terms of
gains in self-esteem and functional independence. This non-randomised intervention study
does not contain a land-based control group.
Brain Injury
There were two small RCTs on this topic (61;62). Both trials appear very similar and
may represent duplicate reports of the same project in various stages of completion.
Summary of findings
Patients who received additional exercise in the hydrotherapy group responded to
exercise.
The control patients in these small trials (61;62) participated in an 8-week
vocational rehabilitation class, which was based around improving reading and writing
skills post-injury.
Patients enrolled into these trials were above level six (confusedappropriate) on
the Ranchos Los Amigos Scale and were able to undertake a sub-maximal cycle
ergometry test thus they were capable of land-based exercises. A more appropriate
comparison group would have been land-based exercises matched for frequency, duration
and intensity.
RCT evidence
In 2004, Driver et al (62) reported eight participants were assigned to an aquatic
exercise group and eight to a control group.
The aquatic exercise group completed an 8-week exercise programme that
consisted of 24 exercise sessions (three times a week) each lasting 1-hour. Exercise
sessions included both aerobic and resistance training components. Throughout the
programme, participants wore Polar Heart rate monitors to ensure that heart rate was kept
within 5070% of the individuals maximum heart rate. Heart rate was determined using the
Karvonen method.
Each participant was assigned an instructor who worked with the participant
throughout the programme for instructional and safety reasons.

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The control group was assigned an 8-week vocational rehabilitation class. The
vocational class was a reading and writing programme based on improving hand and
creative writing ability post-injury. The vocational rehabilitation class was a typical
programme offered at the rehabilitation centre, although none of the control group had
previously completed the class.
The aquatic exercise group responded to exercise. A more appropriate and relevant
control group would have been dry land exercise of the same duration and frequency.
In 2006, Driver et al (63) reported that eighteen individuals were randomly
assigned to an aquatic exercise (n=9) or control group (n=9).
The aquatic exercise sessions were completed three times a week for 8 weeks and
each session lasted 1-hour. Exercise sessions included both aerobic and resistance
training components. Throughout the programme, participants wore Polar Heart rate
monitors to ensure that heart rate was kept within 5070% of the individuals maximum
heart rate. Heart rate was determined using the Karvonen method.
The control group participated in an 8-week vocational rehabilitation class, which
was based around improving reading and writing skills post-injury.
The aquatic exercise group responded to exercise. A more appropriate and relevant
control group would have been dry land exercise of the same duration and frequency.
Older patients with chronic heart failure
Two RCTs (64;65), one of which is a cross-over trial.
The cross-over RCT by Michalesen et al (65) compared six weeks of home
hydrotherapy followed by six weeks restriction. In this trial, hydrotherapy consisted of
warm baths followed by cold foot and arm pourings washings. Since no exercises were
conducted, the results of this trial are not relevant to this review.
RCT evidence
This small trial by Cider et al (64) compared: 1) 15 patients with heart failure who
received 45 minute hydrotherapy (pool exercises) sessions 3 times a week for 8 weeks to;
2) 10 no exercise control patients.
Cider et al report, The control group was instructed to live their life as normal for 8
weeks and were not allowed to increase their habitual physical activity during this period.
The group receiving exercise was found to improve measures of exercise tolerance.
A more appropriate and relevant control group would have been dry land exercise of the
same duration, intensity and frequency.
Chronic Obstructive Pulmonary Disease
One small RCT (66) has been conducted in this patient population.
Summary of findings
High intensity physical group training undertaken in water may result in higher
activity levels and physical function scores compared to land based training.
RCT evidence
In 2004, Waddell et al (66) reported the results of a trial containing 43 outpatients,
with moderate to severe COPD (27 w16 m), from two local hospitals in northern Sweden.
Patients were randomised to receive high intensity physical group training in water
(water group) or on land (land group) performed for 12 weeks, three times per week, 45
min per session.

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Although there were no differences in overall quality of life measures, the water
group scored significantly higher in the activity scale of the St. Georges Respiratory
Questionnaire and the physical health domain of the SF-36 compared to the land exercise
control group.
The authors conclude that high intensity physical group training in water is of benefit
for patients with COPD.
Varicose veins
Ernst et al conducted a trial (67) in 1991 that involved 61 patients. Patients were
randomised to regular hydrotherapy or control (no intervention). Control patients had better
venous competence but the hydrotherapy patients had smaller leg volumes. No long term
or quality of life measures were reported.
Cruciate ligament repairs
One pseudo randomised trial was identified (68).
Summary of findings
There was a statistically significant difference in a self-reported symptom scale in
favour of hydrotherapy measured at 8 weeks however the clinical importance of the
magnitude of the difference observed is not reported (mean=92.2, SD=4.31 vs 82.4,
SD=12.36, P=0.03).
RCT evidence
This trial by Tovin et al (68) allocated 20 subjects to: 1) land exercise or; 2) water
exercise. Both exercise groups began in the first week post-op and continued for eight
weeks.
This is a methodologically weak pseudo-randomised trial. Allocation concealment
was not maintained.
The analysis is quite complex with attempts to account for measurements taken at
multiple time points. There are no notable differences in measures of joint laxity, peak
torque recovery, range of motion recovery or mid-patella and above mid-patella girth
measurements.
There was a statistically significant difference in a self-reported symptom scale in
favour of hydrotherapy measured at week 8 however the clinical importance of the
magnitude of the difference observed is not reported or discussed (mean=92.2, SD=4.31
vs 82.4, SD=12.36, P=0.03).
Fracture of Proximal Humerus
One systematic review (69) was identified. The review by Hodgson et al concluded
that Electrotherapy or hydrotherapy does not enhance recovery and joint mobilization has
limited evidence of its efficacy. One RCT of hydrotherapy was identified (70).
Summary of findings
Revay et al (70) studied patients with a fractured humerus: two fragment fracture at
the level of the surgical neck or three and four fragment fractures (non-displaced) or with
less than 1cm displacement or more than 45
o angulation. Forty-eight patients were
randomised to: 1) self training or 2) self training combined with treatment in a 33oC
swimming pool.
The authors conclude, Both self training and group training in swimming pools
gave acceptable results. There were no differences between groups after one year. The

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less resource consuming self training group, however, gave better results after two and
three months.
Total hip arthroplasty
In 2003, Gilbey et al (71) randomised 76 patients with end-stage hip arthritis who
were scheduled for a total hip replacement to: 1) an 8-week customised pre-operative
exercise program followed by a 12 week post-surgery exercise program (n=37) or; 2)
control (n=31).
The Exercise Intervention Program consisted of two supervised clinic-based and
two home-based exercise sessions each week for 8 weeks before surgery. Once their
wound had healed, patients continued clinic-based exercise sessions until 12 weeks after
surgery. The clinic exercise session was approximately 1 hour with a 30-minute aerobic
and strength program followed by a 30-minute program of mobility and gait training in the
hydrotherapy pool.
Control subjects received no additional exercise. Both groups received routine in-
hospital physical therapy.
The exercise group responded to exercise. Exercise patients demonstrated
significantly better strength, range of motion and WOMAC scores compared to no-exercise
patients.
Hydrotherapy was only one aspect of the Exercise Intervention Program. The
control group did not receive any intervention. It is difficult to draw inferences regarding
whether the benefits of the Exercise Intervention Program are attributable to land-based
aerobic and strength training or hydrotherapy-based mobility and gait training.
Stroke
In 2004, Chu et al (72) randomised 12 community-dwelling people with stroke who
had mild to moderate residual motor deficits (residual unilateral weakness) to: 1) group
exercise programs for 1 hour, 3 times a week for 8 weeks in chest-deep water at targeted
heart rates or; 2) a control group that performed arm and hand exercises while sitting.
The water-based exercise intervention consisted of 10 minutes of land-based
stretching, 5 minutes of light aerobic warm-up in the water (marching on the spot, single-
and double-legged hopping holding onto the pool edge), 30 minutes of moderate to high
aerobic activities (shallow water walking, running, side stepping) at the target heart rate
prescribed for that week, 5 minutes of a light cool down (marching on the spot), and 10
minutes of gentle stretching in the water.
The main objective of the control program was to improve upper-extremity function.
The water-based exercise group attained significant improvements over the control
group in cardiovascular fitness, maximal workload, gait speed, and paretic lower-extremity
muscle strength. The relatively short program (8wk) of water based exercise resulted in a
22% improvement in cardiovascular fitness in a small group of people with stroke
compared to sedentary control patients.
It is important to note that the eligibility criteria for this study resulted in a patient
population with relatively high function. In preparation for randomisation, all subjects
performed a maximal cycle test, and were required to reach maximal effort as defined by
the ACSM guidelines. The experimental and control groups differed significantly in the
aerobic capacity of the prescribed exercises, with the water exercise group achieving
target heart rates of 50% to 70%, 75%, and 80% heart rate reserve 5 beatsmin (as
determined by the initial maximal exercise test) for weeks 1 to 2, 3 through 5, and 6
through 8, respectively. As demonstrated by the pre-randomisation cycle test performed at
eligibility screening, the control group patients would have been capable of undertaking a

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cycle-based aerobic component to their prescribed exercise class with similar target heart
rate goals.
Normal, healthy pregnant women and preventingreducing back pain
Summary of findings
A comprehensive systematic review of the effects of all types of physical therapy in
pregnancy, including water gymnastics, was conducted in 2003 by Stuge et al (73). These
authors concluded Because of heterogeneity and the varying quality of the studies no
strong evidence exists concerning the effect of physical therapy interventions on the
prevention and treatment of back and pelvic pain related to pregnancy. Future studies
should meet current methodological standards, and interventions to be evaluated should
be based on established theoretical framework.
With regards to the study by Khilstrand et al (74), Stuge et al conclude, Water
gymnastics show less pain intensity and significantly less sick leave compared with no
intervention, but this might be because of an attention effect.
RCT evidence
In 1999, Kihlstrand et al (74) randomised normal healthy women during the
second half of pregnancy to: 1) participate in water-gymnastics (n=129) once a week or; 2)
no intervention control group (n=129).
The water-gymnastics group included ten classes of 1215 women and took place
in a swimming pool with a water temperature of 3234 degrees Celsius. The exercises
were recommended by the Swedish Swimming Society and tested for pregnant women by
physiotherapists. The women were offered water-gymnastics 1720 times (once a week
during the second half of pregnancy). Each training session lasted one hour and included
relaxing exercises. All classes were led by one specially trained midwife. Another specially
trained midwife replaced her during holidays or sickness. Two different exercise programs
were used for all women; one with exercises suitable for earlier pregnancy to be used for
the first ten training sessions, and one with exercises suitable for later pregnancy for the
last ten sessions.
The control group received no additional exercises or attention.
Intensity of backlow back pain increased with advancing pregnancy. There was no
excess risk for urinary or vaginal infections associated in the intervention group. Compared
to no intervention, water gymnastics during the second half of pregnancy significantly
reduced the intensity of backlow back pain. Compared to no intervention, water-
gymnastics decreased the number of women on sick-leave because of backlow back
pain.
Failure to include an active control group makes it difficult to draw inferences from
this study. It is possible the water-gymnastics group benefited from the attention provided
by a group program.
Coronary artery disease
Summary of findings
One small trial compared water exercise to land exercise (75). Both programs were
found to improve overall fitness but there were no differences between water or land
exercise groups.
RCT evidence
In 2007, Volaklis et al (75) examined the effects of combined resistance and
aerobic training on land versus combined resistance and aerobic training in water. Thirty-

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four subjects with coronary artery disease were randomly assigned to: 1) land exercise (n
= 12), 2) water exercise (n = 12), or 3) control (n = 10) groups.
The water exercise program was conducted in a heated pool (depth 1.20 m) at
water temperatures between 28C and 30C and consisted of 2 weekly aerobic sessions
(at 50%-70% of maximal heart rate achieved during symptom limited grade exercise test)
and 2 weekly sessions of resistance training (60%-80% of the maximal number of
repetitions performed in each exercise at baseline). All sessions lasted 60 min and
included a warmup period (10 minutes), the main program (30-40 minutes), and a cool
down period (10 minutes).
The land exercise program consisted of 2 weekly aerobic sessions and 2 weekly
sessions of resistance training. Both aerobic and strength exercise lasted 60 minutes and
included a warm-up period (10 minutes), the main program (30-40 minutes) and a cool
down period (10 minutes). The exercise intensity of the aerobic program was 60% to 80%
of the maximal heart rate achieved during a symptom-limited grade exercise test.
After 4 months of training, analysis of covariance revealed that body weight and
sum of skinfolds were lower for both exercise groups than for the control group. Patients
who trained in water improved exercise time and maximum strength in a similar manner
compared to the patients who trained on land.
Both exercise groups significantly reduced total cholesterol and triglycerides, but
there were no differences among exercise groups.
The results of the present study show that both the water and land exercise
programs were effective at increasing exercise time, muscular strength, body composition,
and improving lipid profile in patients with CAD.
Indications for which RCTs were NOT available:
It is possible to conduct an RCT in virtually all disease conditions, both acute and
chronic.
If there are no established land-based exercise or physiotherapy treatment
interventions, patients may be randomised to water-exercise vs. an appropriately designed
standard care intervention. An appropriately designed standard care intervention could
provide an objective comparison of the benefits of water-exercise against standard care,
controlling for changes over time, the psychological effects of the attention provided in a
group environment andor education.
If there are established benefits from land-based exercise or physiotherapy
treatment interventions, patients may be randomised to water-exercise or land-based
exercise. Such a comparison effectively establishes the benefits of water-exercise against
the known benefits of land-based exercise, controlling for other extraneous factors.
The non-randomised interventional study conducted by Kesiktas et al (76) provides
proof that RCTs can be conducted in all patient populations. This control case matched
study conducted in spinal cord injury patients compared: 1) passive range of motion
exercise twice a day and oral baclofen for 10 weeks to; 2) passive range of motion and
oral baclofen, as well as 20 min of water exercises (at 71 F, full immersion) 3 times per
week. However, because investigators personally selected the group to which patients
would be allocated to, it is not a randomised trial and may be prone to major biases.
Patients could easily have been randomly allocated to treatment groups.
It is beyond the scope of this review to appraise observational or uncontrolled
intervention studies.
Despite an extensive search, RCTs have not been identified in the following patient
groups:

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Spinal cord injury, cerebral palsy, Guillain-Barre Syndrome, Post-Polio Syndrome, Chronic
Regional Pain Syndrome, Rett Syndrome, Autism, Spinal Muscular Atrophy or Breast
cancer lymphodema.
Topics and papers identified in the search but NOT included in this review
Methods paper
1 methods paper (not a clinical topic) not retrieved
Crenobalneotherapy balneotherapy (hot mineral spring spas above 34C, no exercises
performed in hot spa)
2 recent systematic reviews identified, retrieved and reviewed for additional RCTs on
hydrotherapy (12;77).
4 older systematic reviews 2 French language identified, not retrieved.
2 RCTs (78;79) and one systematic review on balneotherapy in RA (80).
Paper by Hall (79) evaluated the effect of tap water baths.
RCT conducted by Altan et al in 2006 (81), compared exercise on land with exercise on
land plus balneotherapy (therapeutic hot spa containing spa water at 39C for 30 min once
a day for 3 weeks hot spa). Both control and balneotherapy patients received instructions
on a land-based exercise programme, which they were requested to repeat once a day for
30 min during the study.
Codish et al (82) studied the efficacy of balneotherapy and climatictherapy
(climatotherapy) at the Dead Sea area in patients with ankylosing spondylitis. The
intervention group received daily treatments consisting of each of the following: 20 minute
applications of mud packs heated to 3940C to the entire body, 20 minute sessions in a
sulfur (mineral) pool at 3637C, and bathing in Dead Sea water (in the sea itself or in an
indoor pool). Participants in the control group received climatotherapy, but were prohibited
from receiving any form of balneotherapy.
Systematic review of adjuvant therapy in subacute back pain (6) identified one trial of
balneotherapy, which was not retrieved (no exercises in water).
Labour (bath immersions or labour pool)
1 narrative (opinion based editorial) review in Labour not retrieved
1 systematic review with a focus on bath tub or labour pool immersion (not exercise in a
pool).
Not able to conduct a meta-analysis trials so each publication was reviewed
independently. No overall conclusion with regards to water immersion could be
reached (83).
One small trial by Benfield et al (84) evaluated the impact of a tub of 37C water for 1 hr
during early labor compared to no tub.
Burns Wound Debridement
2 papers. Requires department specific whirlpools.
Heatstroke (requires local cooling baths equipment)
2 reviews and 1 RCT on heatstroke.

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Neuroedocrine disorders of females
1 Russian language Guideline
Bluebottle stings
1 RCT of cold vs hot water.
Pressure ulcer healing
RCT (85) evaluating the effects of whirlpool baths on pressure ulcer healing.
Normal healthy vollyball players
Population not included (86).
Normal pregnant women
Participants were not randomised to any intervention. Observational studies not included
(87).
Healthy college aged women
Population not included (88).
Well elderly
Population not included (89-91).
Stretching for Ankylosing Spondylitis
This trial by Bulstrode et al (92) does not compare hydrotherapy with another
intervention. It compares a comprehensive exercise intervention with or without stretching
exercises performed on dry land. All patients in this trial received a 15-day intensive
physiotherapy courses. Active exercises were given in the gymnasium and hydrotherapy
pool to strengthen progressively the anti-gravity and postural muscles and to increase
mobility of all the joints of the spine, thorax, hips and shoulders. Stretching exercises were
added on top of this base level intervention.
Post menopausal sedentary healthy women
2003 trial by Ay and Yurtkuran (93) randomised 46 (but the Abstract states 41)
sedentary but healthy women to a controlled aquatic exercise program or sedentary
lifestyle. The normal healthy women randomised to exercise responded to exercise.
Results of this trial are difficult to interpret since an appropriate gentle land based exercise
control group was not provided.
This second trial by Au and Yurtkuran (94) randomised a 62 postmenopausal
healthy sedentary women to into three Groups: 1) aquatic exercise (n = 24); 2) weight
bearing exercise (n = 24), and 3) control groups (n = 23).
The authors conclude: In this longitudinal study, it was determined that a moderate
increase of the regular physical activity, either as aquatic or weight-bearing exercise, is
effective to increase calcaneal BUA by 3.1% and 4.2%, respectively, in sedentary
postmenopausal women. Because BUA is an ultrasound measure that may be correlated
to bone mineral density, this suggests exercise (of either type) may increase BMD of the
calcaneous.

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Post menopausal healthy women with osteoporosis
The purpose of this study by Devereux et al (95)was to assess the effects of a
water-based exercise and self-management program on balance, fear of falling, and
quality of life in community-dwelling women 65 years of age or older with a diagnosis of
osteopenia or osteoporosis.
Fifty women with an average age of 73.3 years (range 65.582.4, SD 3.9) were
randomised to intervention or control groups.
The intervention group received a 10-week water-based exercise and self-
management program compiled by Community Physiotherapy Services and conducted by
a physiotherapist at an aquatic centre twice a week for one hour.
The control group did not receive any instructions and were not encouraged to
change their physical activity, activities of daily living or social habits during the study.
The group randomised to receive exercise at a community aquatic centre reported
significant improvements in quality of life. Due to the lack of a group-based land exercise
control group, it is difficult to draw conclusions from this paper.
Obese healthy women
Paper by Gappmaier et al not included (96).

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