McNamara et al 2013 ERJ Letter to Editor

Question: We wanted to compare the safety and effectiveness of water-based exercise (but not swimming) training in people with chronic obstructive pulmonary disease (COPD) versus no exercise or a different kind of exercise in terms of exercise capacity and quality of life.

Background: Land-based exercise training (such as walking or cycling) improves exercise capacity and quality of life in people with COPD. Water-based exercise training is an alternative mode of physical exercise training that may appeal to the older population, those who are unable to complete land-based exercise programmes and people with COPD who also have other physical and medical conditions. We did not include swimming interventions. Study characteristics: Five studies were identified up to August 2013. These studies included a total of 176 participants, with 71 people participating in water-based exercise training, 54 people participating in land-based exercise training and 51 people completing no exercise training. The average age of participants ranged from 57 to 73 years. The water-based exercise training programmes varied from four to 12 weeks in duration with attendance two to three times a week for between 35 and 90 minutes. The water-based exercises were designed to be as similar as possible to the exercises conducted in the land-based exercise sessions. The most common types of exercises were walking and cycling-type movements in the water, as well as strength training, most often using floats to increase the intensity.

Key results: Participants who completed a water-based exercise training programme could walk an average of 371 metres farther than those who completed no exercise training and 313 metres farther than those who completed land-based exercise training. Quality of life also improved in participants who completed water-based exercise training, and significantly better quality of life was reported in these participants compared with those who completed no exercise training. Little information was provided to show whether these effects last for a long time after training has ceased. The effect that severity of COPD may have on benefits of water-based exercise training needs further examination. Two studies reported on adverse events; one minor adverse event was documented (from 20 people participating in water-based exercise training).

Keywords: Water-based exercise training, COPD, Physiology of water immersion

Water-based exercise training for chronic obstructivepulmonary disease (Review)
McNamara RJ, McKeough ZJ, McKenzie DK, Alison JA
This is a reprint of a Cochrane review, prepared and maintaine d by The Cochrane Collaboration and published inThe Cochrane Library
2013, Issue 12
http:www.thecochranelibrary.com
Water-based exercise training for chronic obstructive pul monary disease (Review)
Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

T A B L E O F C O N T E N T S1
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .
6
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
15
ADDITIONAL SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . .
18
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
21
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
29
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Water-based exercise versus no exe rcise, Outcome 1 Exercise capacity (mean change in
metres). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Analysis 1.2. Comparison 1 Water-based exercise versus no exe rcise, Outcome 2 Quality of life (mean change in total
scores). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Analysis 1.3. Comparison 1 Water-based exercise versus no exe rcise, Outcome 3 Quality of life (mean change in individual
domain scores). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Analysis 1.4. Comparison 1 Water-based exercise versus no exe rcise, Outcome 4 Pulmonary function (mean change). 35
Analysis 1.5. Comparison 1 Water-based exercise versus no exe rcise, Outcome 5 Respiratory muscle strength (mean
change). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Analysis 2.1. Comparison 2 Water-based exercise versus land-b ased exercise, Outcome 1 Exercise capacity (mean change in
metres). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Analysis 2.2. Comparison 2 Water-based exercise versus land-b ased exercise, Outcome 2 Quality of life (mean change in
total scores). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Analysis 2.3. Comparison 2 Water-based exercise versus land-b ased exercise, Outcome 3 Quality of life (mean change in
individual domain scores). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Analysis 2.4. Comparison 2 Water-based exercise versus land-b ased exercise, Outcome 4 Pulmonary function (mean
change). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Analysis 2.5. Comparison 2 Water-based exercise versus land-b ased exercise, Outcome 5 Respiratory muscle strength (mean
change). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Analysis 2.6. Comparison 2 Water-based exercise versus land-b ased exercise, Outcome 6 Body composition (mean change
in kilograms). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Analysis 2.7. Comparison 2 Water-based exercise versus land-b ased exercise, Outcome 7 Attendance (mean number). 44
44
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
47
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
48
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
49
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
49
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
49
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
49
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .
i
Water-based exercise training for chronic obstructive pul monary disease (Review)
Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

Intervention Review
Water-based exercise training for chronic obstructive
pulmonary disease
Renae J McNamara1
,2 ,3
, Zoe J McKeough 1
, David K McKenzie 3
, Jennifer A Alison 1
,4
1 Clinical and Rehabilitation Sciences, Faculty of Health Sciences , The University of Sydney, Lidcombe, Australia.2
Department of
Physiotherapy, Prince of Wales Hospital, Randwick, Australi a.3
Department of Respiratory and Sleep Medicine, Prince of Wales
Hospital, Randwick, Australia. 4
Department of Physiotherapy, Royal Prince Alfred Hospital, Camperdown, Australia
Contact address: Renae J McNamara,
renae.mcnamara@sesiahs.health.nsw.gov.au.
Editorial group: Cochrane Airways Group.
Publication status and date: New, published in Issue 12, 2013.
Review content assessed as up-to-date: 13 August 2013.
Citation: McNamara RJ, McKeough ZJ, McKenzie DK, Alison JA. Water-based ex ercise training for chronic obstructive pulmonary
disease. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD008290. DOI: 10.100214651858. CD008290.pub2.
Copyright 2013 The Cochrane Collaboration. Published by Jo hn Wiley & Sons, Ltd.
A B S T R A C T
Background
Land-based exercise training improves exercise capacity and qua lity of life in people with chronic obstructive pulmonary disease
(COPD). Water-based exercise training is an alternative mode of physical exercise training that may appeal to the older population
attending pulmonary rehabilitation programmes, those who are unable to complete land-based exercise programmes and peop le with
COPD with comorbid physical and medical conditions.
Objectives
To assess the effects of water-based exercise training in peopl e with COPD.
Search methods
A search of the Cochrane Airways Group Specialised Register of t rials, which is derived from systematic searches of bibliographic
databases, including the Cochrane Central Register of Contro lled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED
and PsycINFO, was conducted (from inception to August 2013). Hands earching was done to identify further qualifying studies from
reference lists of relevant studies.
Selection criteria
Review authors included randomised or quasi-randomised contr olled trials in which water-based exercise training of at leastfour weeks
duration was compared with no exercise training or any other fo rm of exercise training in people with COPD. Swimming was exclu ded.
Data collection and analysis
We used standard methodological procedures expected by The Coch rane Collaboration.
Main results
Five studies were included with a total of 176 participants (71 p eople participated in water-based exercise training and 54 in land-
based exercise training; 51 completed no exercise training). Al l studies compared supervised water-based exercise training versus land-
based exercise training andor no exercise training in people with COPD (with average forced expiratory volume in one second (F EV
1)
%predicted ranging from 39% to 62%). Sample sizes ranged from 1 1 to 53 participants. The exercise training programmes lastedfrom
1
Water-based exercise training for chronic obstructive pul monary disease (Review)
Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

four to 12 weeks, and the mean age of participants ranged from 57 to 73 years. A moderate risk of bias was due to lack of reporting of
randomisation, allocation and blinding procedures in some st udies, as well as small sample sizes.
Compared with no exercise, water-based exercise training impr oved the six-minute walk distance (mean difference (MD) 62 metres ;
95% condence interval (CI) 44 to 80 metres; three studies; 99 pa rticipants; moderate quality evidence), the incremental shuttle walk
distance (MD 50 metres; 95% CI 20 to 80 metres; one study; 30 part icipants; high quality evidence) and the endurance shuttle walk
distance (MD 371 metres; 95% CI 121 to 621 metres; one study; 30 p articipants; high quality evidence). Quality of life was also
improved after water-based exercise training compared with no exercise (standardised mean difference (SMD) -0.97, 95% CI -0.37 t o -
1.57; two studies; 49 participants; low quality evidence). Com pared with land-based exercise training, water-based exercisetraining did
not signicantly change the six-minute walk distance (MD 11 metre s; 95% CI -11 to 33 metres; three studies; 62 participants; moderate
quality evidence) or the incremental shuttle walk distance (MD 9 metres; 95% CI -15 to 34 metres; two studies; 59 participants; low
quality evidence). However, the endurance shuttle walk distan ce improved following water-based exercise training compared w ith land-
based exercise training (MD 313 metres; 95% CI 232 to 394 metres ; two studies; 59 participants; moderate quality evidence). No
signicant differences were found between water-based exercis e training and land-based exercise training for quality of life, as measured
by the St Georges Respiratory Questionnaire or by three of f our domains of the Chronic Respiratory Disease Questionnai re (CRDQ);
however, the fatigue domain of the CRDQ showed a statisticall y signicant difference in favour of water-based exercise (MD -3.0 0;
95% CI -5.26 to -0.74; one study; 30 participants). Only one study reported long-term outcomes after water-based exercise training
for quality of life and body composition, and no signicant chan ge was observed between baseline results and six-month follow-up
results. One minor adverse event was reported for water-base d exercise training (based on reporting from two studies; 20 pa rticipants).
Impact of disease severity could not be examined because data we re insufcient.
Authors conclusions
There is limited quality evidence that water-based exercise tr aining is safe and improves exercise capacity and quality of lif e in people
with COPD immediately after training. There is limited qual ity evidence that water-based exercise training offers advantages over land-
based exercise training in improving endurance exercise capacit y, but we remain uncertain as to whether it leads to better quality of life.
Little evidence exists examining the long-term effect of water -based exercise training.
P L A I N L A N G U A G E S U M M A R Y
Water-based exercise training for people with chronic obst ructive pulmonary disease
Question: We wanted to compare the safety and effectiveness of water-base d exercise (but not swimming) training in people with
chronic obstructive pulmonary disease (COPD) versus no exercis e or a different kind of exercise in terms of exercise capacity andquality
of life.
Background: Land-based exercise training (such as walking or cycling) improve s exercise capacity and quality of life in people with
COPD. Water-based exercise training is an alternative mode of physical exercise training that may appeal to the older population,
those who are unable to complete land-based exercise programme s and people with COPD who also have other physical and medical
conditions. We did not include swimming interventions.
Study characteristics: Five studies were identied up to August 2013. These studies included a total of 176 participants, with 71
people participating in water-based exercise training, 54 peo ple participating in land-based exercise training and 51 peopl e completing
no exercise training. The average age of participants ranged f rom 57 to 73 years. The water-based exercise training programm es varied
from four to 12 weeks in duration with attendance two to three t imes a week for between 35 and 90 minutes. The water-based exer cises
were designed to be as similar as possible to the exercises cond ucted in the land-based exercise sessions. The most common types of
exercises were walking and cycling-type movements in the water, as well as strength training, most often using oats to increase the
intensity.
Key results: Participants who completed a water-based exercise training pro gramme could walk an average of 371 metres farther than
those who completed no exercise training and 313 metres farthe r than those who completed land-based exercise training. Quality of
life also improved in participants who completed water-based e xercise training, and signicantly better quality of life wasreported in
these participants compared with those who completed no exercis e training. Little information was provided to show whetherthese
effects last for a long time after training has ceased. The effe ct that severity of COPD may have on benets of water-based exer cise
training needs further examination. Two studies reported o n adverse events; one minor adverse event was documented (from 20 people
participating in water-based exercise training).
2
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Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

Quality of the evidence:The quality of evidence contributing to these results was gene rally low to moderate. This was mainly a result
of poor study design and not enough data.
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Water-based exercise training for chronic obstructive pul monary disease (Review)
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S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N
Explanation

Water-based exercise training compared with no exercise training for people with chronic obstructive pulmonary disease (COP D)Patient or population:people with COPD
Settings: pulmonary rehabilitation centres
Intervention: water-based exercise training
Comparison: no exercise trainingOutcomes
Illustrative comparative risks* (95% CI)
No. of participants
(studies)
Quality of the evidence (GRADE)
Comments
Assumed risk
Corresponding risk
No exercise training
Water-based exercise train-
ing
Exercise capacity - func-
tional
Six-minute walk test (mean
distance change in metres)
Mean change in six-minute
walk distance ranged across
control groups from -39 me-
tres to -16 metres
Mean change in six-minute
walk distance in the interven-
tion groups was 62 metres
higher (44 metres to 80 me-
tres higher)
99
(three)

moderate 1
Exercise capacity - peak
Incremental shuttle walk test
(mean distance change in me-
tres)
Mean change in incremental
shuttle walk distance in the
control group was -1 metre
Mean change in incremental
shuttle walk distance in the in-
tervention group was 50 me-
tres higher (20 metres to 80
metres higher)
30
(one)
high
Exercise capacity - en-
durance
Endurance shuttle walk test
(mean distance change in me-
tres)
Mean change in endurance
shuttle walk distance in the
control group was -50 metres
Mean change in endurance
shuttle walk distance in the in-
tervention group was 371 me-
tres higher (121 metres to 621
metres higher)
30(one)
high
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Water-based exercise training for chronic obstructive pul monary disease (Review)
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Quality of life
St Georges Respiratory Ques-
tionnaire (total score)
Lower value post intervention
is favourable, indicating im-
provement in QoL
Mean change in St Georges
Respiratory Questionnaire to-
tal score in the control group
was +6 points
Mean change in St Georges
Respiratory Questionnaire to-
tal score in the intervention
group was 10 points lower (1
point to 19 points lower)
19(one)

low 2
*The basis for the
assumed risk(e.g. the median control group risk across studies) is provided i n footnotes. Thecorresponding risk (and its 95% confidence interval) is based on the
assumed risk in the comparison group and the relative effectof the intervention (and its 95% CI).
CI: Confidence interval.GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the est imate of effect.
Moderate quality: Further research is likely to have an important impact on our conf idence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our c onfidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.1
Two studies showed limitations in design; selection and performan ce bias unknown.
2 Study showed limitations in design (selection and performance bi as unknown).
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Water-based exercise training for chronic obstructive pul monary disease (Review)
Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

B A C K G R O U N D
Description of the condition
Chronic obstructive pulmonary disease (COPD) is a progressive
disease state characterised by airow limitation that is not f ully
reversible (
McKenzie 2007). COPD is a major cause of morbid-
ity, mortality and healthcare costs worldwide (
Chapman 2006).
People with COPD frequently experience breathlessness both at
rest and on exertion, which limits their physical functioning a nd
quality of life.
One of the most effective strategies for the management of COP D
is land-based exercise training as part of integrated pulmona ry re-
habilitation. Land-based exercise training improves exercis e capac-
ity and quality of life (
Lacasse 2006), and reduces admissions to
hospital (
Ries 2007) and length of stay (Golmohammadi 2004).
However, land-based training is not always possible. COPD is
prevalent in the older population (
Cockram 2006), which includes
a high proportion of physical co-morbidities (
Fabbri 2008) that
may preclude the elderly from participating in land-based trai n-
ing. This, combined with a high rate of non-completion of pul-
monary rehabilitation programmes (
Garrod 2006), means that it
is important to explore alternative exercise options to enab le peo-
ple with COPD to complete some form of exercise training.
Description of the intervention
In the past, water-based exercise had been thought unsafe for
people with COPD because of potential increases in cardiac and
respiratory work as a consequence of increased venous return
and increased chest wall pressure resulting from water immers ion
(
Arborelius 1972). However, recent data have shown that a single
head out of water exercise session in water can be performed saf ely
without adverse events and with maintenance of oxygen satura -
tion even in those with severe disease (
Perk 1996). It is important
to note that swimming is not considered in this review because o f
associated submersion of the head in water.
How the intervention might work
As a result of evidence that head out of water immersion and ex-
ercise in water are safe, water-based exercise can be considered a s
an alternative means of exercise training for people with COP D.
It is hypothesised that when individuals complete a water-bas ed
exercise training programme of similar intensity and durati on as
land-based exercise training programmes that have previousl y been
shown to be effective, exercise capacity and quality of life may
improve to a similar degree. The unique properties of water, in-
cluding buoyancy to support body weight and reduce mechanical
impact on the body, water turbulence and resistance to increased
muscle work when moving the body and limbs through the water, and warm water temperature, which may improve blood ow to
muscles, may enable a higher intensity and duration of exercis
e,
especially in people who have difculty completing a land-based
exercise training programme. These features of the water env iron-
ment may mean that water-based exercise training is more suita ble
for people with comorbid conditions such as musculoskeletal or
orthopaedic conditions.
Why it is important to do this review
Thus far, a systematic review of studies of water-based exerci se
training for people with COPD has not been conducted.
It is important to perform this review to evaluate the safety of wa-
ter-based exercise training in people with COPD and to determi ne
the effect of water-based training on exercise capacity and quali ty
of life as described in the available literature.
O B J E C T I V E S
To assess the effects of water-based exercise training in peopl e with
COPD.
M E T H O D S
Criteria for considering studies for this review
Types of studies
Randomised or quasi-randomised controlled trials in which wat er-
based exercise training of at least four weeks duration was co m-
pared with no exercise training or any other form of exercise tr ain-
ing in people with COPD.
Types of participants
Adults with a clinical diagnosis of COPD based on the investi-
gators denition. The COPD should be stable (i.e. optimal an d
stable respiratory medications with no exacerbation or hospi tal
admission within the previous month), and supplemental oxyg en
may be used.
Types of interventions
Studies examining water-based exercise training, supervise d or un-
supervised, were included if they included a comparison with no
exercise training, a land-based exercise training programme o r a
sham water-based treatment. Trials in which water-based train ing
was combined with another training intervention (e.g. land-ba sed
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Water-based exercise training for chronic obstructive pul monary disease (Review)
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exercise training) were eligible for inclusion provided morethan
50% of the training incorporated water-based exercise trainin g.
Swimming interventions were excluded.
Types of outcome measures
Primary outcomes
Exercise capacity (functional or maximal), measured during
formal exercise tests or eld exercise tests. Quality of life, measured by generic or respiratory-specic
quality of life questionnaires.
Secondary outcomes
Pulmonary function.
Respiratory muscle strength.
Upper and lower limb strength.
Oxygen saturation.
Symptoms.
Level of activity.
Psychological status.
Self managementself efcacy.
Healthcare utilisation.
Cost-effectiveness.
Adverse events.
Withdrawal.
Body composition.
Attendance.
Exercise training mode preference.
Arterial blood gases.
Search methods for identication of studies
Electronic searches
We identied trials from the Cochrane Airways Group Specialis ed
Register of trials, which is derived from systematic searches of
bibliographic databases including the Cochrane Central Regi s-
ter of Controlled Trials (CENTRAL), MEDLINE, EMBASE,
CINAHL, AMED and PsycINFO, and we performed hand-
searching of respiratory journals and meeting abstracts (plea se see
Appendix 1for further details).
All records added to the Specialised Register and coded as COPD
were searched using the following terms: water* or aqua* or ba th
or pool or hydrotherap* or hydro-therap* or immers*.
We also conducted a search of ClinicalTrials.gov using the same
terms. All databases were searched from their inception to Aug ust
2013, and no restriction regarding language of publication wa s
imposed. Searching other resources
We handsearched reference lists of all relevant studies to loo
k for
additional qualifying studies. Authors of identied and po tentially
eligible trials were contacted and were asked to identify furt her
published and unpublished studies.
Data collection and analysis
Selection of studies
Studies identied through the literature searches were inde pen-
dently coded by two review authors (RJM and ZJM) for inclusion
upon examination of titles and abstracts. Studies were catego rised
as follows. Include: Study categorically meets all review criteria.
Unclear: Study appears to meet some review criteria, but
insufcient information is available to categorically determ ine
relevance. Exclude: Study does not categorically meet all review
criteria.
The two review authors then used a full-text copy of each study
in the rst two categories to determine study inclusion. Disag ree-
ments were resolved by consensus, and when any disagreement
could not be resolved, we consulted a third review author (JAA). A
full record of decisions was kept, and simple agreement and kap pa
statistics were calculated.
Data extraction and management
Two review authors (RJM and ZJM) independently extracted data
using a standard checklist before the primary review author (RJ M)
entered them into
Review Manager (RevMan), and the second
review author (ZJM) conducted random checks on accuracy. Dis-
agreements were resolved by consensus. When two or more de-
tailed reports described ndings of the same study, data were ex-
tracted separately and then collated. Data collected included cha r-
acteristics of included studies (methods, participants, interv en-
tions, outcomes) and results of the included studies. We record ed
the specic details of exercise training (intensity, frequency , dura-
tion, type). Authors of included studies were contacted and were
asked to provide missing data.
Assessment of risk of bias in included studies
Two review authors (RJM and ZJM) independently assessed the
internal validity of included studies using The Cochrane Coll ab-
orations Risk of bias assessment tool (
Higgins 2011) (includ-
ing randomisation sequence generation; allocation concealmen t;
blinding of participants, assessors and outcome assessments ; com-
pleteness of outcome data; selective outcome reporting and any
other possible sources of bias). Each item for each study was judg ed
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Water-based exercise training for chronic obstructive pul monary disease (Review)
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as having high, low or unclear risk of bias. Disagreements were
resolved by consensus. Study authors were contacted to seek clar -
ication in cases where quality was unclear.
Measures of treatment effect
The mean change from baseline with standard deviation (SD)
for each group was recorded or calculated from available data for
continuous variables. The mean difference (MD) for outcomes
measured using the same measurement tool and the standardis ed
mean difference (SMD) for outcomes measured with different
measuring tools, as well as 95% condence intervals (95% CIs),
were calculated using RevMan 5.2. A pooled quantitative analy sis
was performed when trials were clinically homogeneous.
Unit of analysis issues
One study used a randomised cross-over trial design. Only the
data from the rst arm of this trial were incorporated in this r e-
view, given that a signicant period of treatment interaction was
found in the study. Another study used a semi-randomised desi gn
methodology whereby participants were randomly assigned to the
two intervention groups, but the control (no intervention gro up)
was not randomly assigned. Data from this non-randomised com-
parison control group were not used in this review.
Dealing with missing data
The original study investigators were contacted for further i nfor-
mation when data were missing or could not be interpreted in th e
presented form.
Assessment of heterogeneity
Heterogeneity was assessed using the I 2
statistic to measure the
proportion of variability resulting from between-trial dif ferences.
Assessment of reporting biases
We planned to create a funnel plot to test for publication bias a nd
small-study effects if we had been able to pool ten or more trial s.Data synthesis
A xed-effect model was used in the analysis.
Subgroup analysis and investigation of heterogeneity
One subgroup analysis was specied a priori to explore possib
le
sources of heterogeneity. Severity of lung disease: forced expiratory volume in one
second (FEV 1) less than 40% predicted.
The small number of studies precluded this subgroup analysis . If
in future updates, more studies are included, subgroup analy sis
will be performed.
Sensitivity analysis
A sensitivity analysis was not conducted because of the small nu m-
ber of studies. If more studies are included in future review u p-
dates, a sensitivity analysis will be performed to analyse t he effects
of allocation concealment and intention-to-treat analysis on re -
sults.
R E S U L T S
Description of studies
See
Characteristics of included studiesandCharacteristics of
excluded studies
.
Results of the search
A total of 88 citations were identied by searching the databas es.
Six additional studies were identied upon handsearching of ref-
erence lists and completion of further searches by the review au -
thors. From study titles and abstracts of references in this li st,
we identied and retrieved 26 papers for closer inspection. St udy
evaluation revealed that ve studies (represented by a total of 12
citations) met the inclusion criteria for this review. A ow dia gram
of the search results is provided in
Figure 1. Of the 26 studies anal-
ysed, the review authors agreed on 25 articles (96%) with kappa =
0.90, indicating excellent agreement. Disagreement was reso lved
by consultation with the third review author (JAA).
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Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

Figure 1. Study ow diagram.
Included studies
Five studies (a total of 176 participants) met the inclusion criteria
for this review. Full details can be found in the
Characteristics
of included studies
table. One study was published in abstract
form only; however, we were able to obtain unpublished data f rom
the trialists (
OBrien 2004). Three studies were randomised con-
trolled trials (
de Souto Araujo 2012;McNamara 2013;Ozdemir
2010
), one study was a semi-randomised controlled trial (Wadell
2004
) and the remaining study was a randomised cross-over trial
(
OBrien 2004). Only data from the rst arm of the cross-over
trial and only data from the randomised intervention groups in the
semi-randomised controlled trial were used in analyses. All s tud-
ies compared supervised water-based exercise training versus land-
based exercise training andor no exercise training in people with
COPD (average FEV 1% predicted ranging from 39% to 62%).
It is important to note that the
McNamara 2013study speci-
cally recruited people with COPD who had concurrent physical
co-morbidities such as obesity or musculoskeletal or orthopaed ic
conditions. Sample sizes ranged from 11 to 53 participants. Th e
mean ages of participants ranged from 57 to 73 years. The lengt h
of the exercise training programmes varied from four to 12 wee ks;
programmes consisted of two to three sessions per week, and ea ch
session lasted from 35 to 90 minutes. The water-based exercise training sessions were designed to be as similar as possible
to
the land-based exercise training sessions (
de Souto Araujo 2012;
McNamara 2013;OBrien 2004;Wadell 2004). Upper limb and
or lower limb endurance exercise training, strength training and
use of weights or oats were described by all studies (for addit ional
details, see
Table 1). All studies measured exercise capacity; the test
most commonly performed was the six-minute walk test (
de Souto
Araujo 2012
;McNamara 2013;OBrien 2004;Ozdemir 2010).
Quality of life was assessed in all ve studies by the Chronic Respi-
ratory Disease Questionnaire (
McNamara 2013;Ozdemir 2010)
or the St Georges Respiratory Questionnaire (
de Souto Araujo
2012
;OBrien 2004;Wadell 2004).
Excluded studies
Fourteen studies were excluded from this review upon evalua-
tion against the inclusion and exclusion criteria. The most com-
mon reason for exclusion of studies was that they were not ran-
domised controlled trials (n = 11). Full details can be found in th e
Characteristics of excluded studiestable.
Risk of bias in included studies
An overview of risk of bias is illustrated in
Figure 2andFigure 3.
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Figure 2. Risk of bias graph: review authors judgements about each risk of bias item presented as
percentages across all included studies.
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Figure 3. Risk of bias summary: review authors judgements about each risk of bias item for each included
study.
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Allocation
All studies reported random allocation to groups; however, the
amount of information provided was highly variable. Random i-
sation for sequence generation was reported by two studies (
McNamara 2013;Ozdemir 2010). The remaining three studies
provided insufcient information (
de Souto Araujo 2012;OBrien
2004
) or did not conduct random sequence generation for the
control (no exercise) group (
Wadell 2004). Allocation sequence
concealment with the use of sealed envelopes was reported by tw o
studies (
McNamara 2013;OBrien 2004). Information regarding
concealment of allocation sequence was insufcient in the remain -
ing studies (
de Souto Araujo 2012;Ozdemir 2010;Wadell 2004).
Blinding
Participant and personnel blinding was not possible in any of the
studies because of the physical nature of the intervention. Us e
of a blinded assessor to measure outcomes was reported in two
studies (
McNamara 2013;OBrien 2004). Adequate assessment
of assessor blinding in the three remaining studies could not be
determined because sufcient information was lacking.
Incomplete outcome data
Four studies reported dropouts and losses to follow-up (
de Souto
Araujo 2012
;McNamara 2013;OBrien 2004;Wadell 2004). The
single remaining study did not report dropouts or losses to f ollow-
up (
Ozdemir 2010).
Selective reporting
All studies documented outcome measures, which were reported i n
the prespecied methods (see
Characteristics of included studies). Effects of interventions
See:
Summary of ndings for the main comparison
Summary
of ndings (water exercise vs no exercise)
;Summary of ndings
2 Summary of ndings (water exercise vs land exercise)
TheData and analysestables summarise the results of the meta-
analyses for the two comparison pairs analysed in this review : (1)
water-based exercise versus no exercise; and (2) water-based exe r-
cise versus land-based exercise. Meta-analyses are presented f or all
of the primary outcomes and for the two comparison pairs (regard -
less of the number of studies providing data), and for secondar y
outcomes only when sufcient data were available from at least
two studies.
Summary of ndings for the main comparisonand
Summary of ndings 2summarise the quality of the evidence. For
exercise capacity tests and tests of pulmonary function, positi ve
values reect an improvement. For quality of life measuremen t
tools, negative values reect benet.
Exercise capacity-functional
Four studies used the six-minute walk test to measure func-
tional exercise capacity (
de Souto Araujo 2012;McNamara 2013;
OBrien 2004;Ozdemir 2010). Results from three trials could
be combined in a meta-analysis comparing water-based exercise
(n = 48) versus no exercise (n = 51) (
de Souto Araujo 2012;
McNamara 2013;Ozdemir 2010), and results from three trials
could be combined in a meta-analysis comparing water-based ex-
ercise (n = 28) versus land-based exercise (n = 34) (
de Souto Araujo
2012
;McNamara 2013;OBrien 2004). When compared with no
exercise, water-based exercise resulted in a mean difference cha nge
in distance walked of 62 metres (95% CI 44 to 80 metres;
Figure
4
). When compared with land-based exercise, water-based exercise
resulted in a non-signicant mean difference change in distance
walked of 11 metres (95% CI -11 to 33 metres;
Figure 5).
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Figure 4. Forest plot of comparison: 1 Water-based exerciseversus no exercise, outcome: 1.1 Exercise
capacity (mean change in metres).
Figure 5. Forest plot of comparison: 2 Water-based exercise versus land-based exercise, outcome: 2.1
Exercise capacity (mean change in metres).
Exercise capacity-peak
Two studies used the incremental shuttle walking test (
McNamara
2013
;Wadell 2004). The mean difference for change in distance
walked of 50 metres (95% CI 20 to 80 metres) favoured water- based exercise (one study; n = 15) over no exercise (one study; n =
15) (
Figure 4). No signicant difference was found between water-
based exercise (two studies; n = 30) and land-based exercise (two
studies; n = 29) (MD 9 metres; 95% CI -15 to 34 metres) and
high statistical heterogeneity was noted (I 2
= 78%) (
Figure 5).
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Exercise capacity-endurance
Two studies used the endurance shuttle walk test (
McNamara
2013
;Wadell 2004). The mean difference for change in distance
walked was signicant at 371 metres (95% CI 121 to 621 metres)
in favour of water-based exercise (one study; n = 15) over no
exercise (one study; n = 15) (
Figure 4) and 313 metres (95% CI
232 to 394 metres) in favour of water-based exercise (two studie s;
n = 30) over land-based exercise (two studies; n = 29) (
Figure 5).
Quality of life
Health-related quality of life was measured in all studies; h owever,
insufcient data were available for all studies to enable poo ling of
results in a meta-analysis. The potential impact of the fact tha t
one study (
Ozdemir 2010) did not contribute data to the syn-
thesis is most likely small. In the water-based exercise versu s no
exercise comparison, data could be pooled from two studies (n =
23 water-based exercise; n = 26 no exercise). The Chronic Res- piratory Disease Questionnaire (CRDQ) was used by
McNamara
2013
, and the St Georges Respiratory Questionnare (SGRQ) was
used by
de Souto Araujo 2012. A standardised mean difference
of -0.97 (95% CI -0.37 to -1.57) favoured water-based exercise (
Figure 6). In the water-based exercise versus land-based exercise
comparison, data were available from three studies that used the
SGRQ (
de Souto Araujo 2012;OBrien 2004;Wadell 2004) and
from one study that used the CRDQ (
McNamara 2013) (n = 42
water-based exercise and n = 47 land-based exercise). A standard-
ised mean change in total scores of -0.14 (95% CI -0.57 to 0.28;
Analysis 2.2) indicated no signicant difference in total quality of
life. Moderate to substantial heterogeneity was noted (I 2
= 53%).
No signicant differences between groups were reported for th ree
of three domains of the SGRQ and for three of four domains of
the CRDQ; however the fatigue domain of the CRDQ showed a
statistically signicant difference in favour of water-based e xercise
(MD -3.00, 95% CI -5.26 to -0.74;
Analysis 2.3).
Figure 6. Forest plot of comparison: 1 Water-based exercise versus no exercise, outcome: 1.2 Quality of life
(mean change in total scores).
Pulmonary function
In the comparison of water-based exercise versus no exercise, a
mean difference change of 6.3% (95% CI 3.4 to 9.2) for FEV 1%
predicted favoured water-based exercise when the results of tw o
studies were combined (
de Souto Araujo 2012;McNamara 2013)
(n = 23 water-based exercise; n = 26 no exercise). A weighted
mean difference change of 3.8% (95% CI 0.3 to 7.4) for FVC
% predicted was also found to favour water-based exercise when
the results of three studies were combined (
de Souto Araujo 2012;
McNamara 2013;Ozdemir 2010) (n = 48 water-based exercise; n
= 51 no exercise). No statistically signicant effects on pulmona ry
function were found when water-based exercise was compared
with land-based exercise.
Respiratory muscle strength Two studies reported measures of respiratory muscle strengt
h (
de
Souto Araujo 2012
;McNamara 2013). All measures of respiratory
muscle strength were seen to improve signicantly when water-
based exercise (n = 23) was compared with no exercise (n = 26);
however signicant heterogeneity was noted between the stud ies.
The mean difference change for maximal inspiratory pressure w as
14 cm H 2O (95% CI 5 to 22) and 20% predicted (95% CI 9 to
30) in favour of water-based exercise. Maximal expiratory pre ssure
also improved signicantly after water-based exercise (mean di f-
ference change of 14 cm H 2O, 95% CI 5 to 23; 15% predicted,
95% CI 5 to 26). No statistically signicant effects on respirato ry
muscle strength were found when water-based exercise (n = 23)
was compared with land-based exercise (n = 28).
Adverse events
Two studies provided information regarding adverse events (
McNamara 2013;OBrien 2004) upon completion of water-based
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exercise (n = 20). No adverse events were reported in the study by
OBrien 2004. One minor adverse event (an accidental skin tear
from a ngernail scratch during the session in a water-based ex-
ercise group participant) was reported in the study by
McNamara
2013
.
Body composition
Measurement of body weight (kg) was reported by two studies (
McNamara 2013;Wadell 2004). Upon completion of water-based
exercise (n = 30), participants had a mean weight loss of 1.29 kg
(95% CI -2.65 to 0.07) compared with land-based exercise (n =
29). This mean weight loss did not reach statistical signicance.
Attendance
Exercise session attendance was reported by two studies (
McNamara 2013;OBrien 2004). No signicant difference was
observed in the number of exercise sessions attended between wa-
ter-based exercise training and land-based exercise training (S MD
0.44, 95% CI -0.18 to 1.07). Preference
Two studies examined participants preferences for the exerci
se
training environment upon completion of the training study p e-
riod (
McNamara 2013;OBrien 2004). Of 41 participants who
completed exercise training (i.e. water-based or land-based tra in-
ing), 49% (n = 20) reported that they would prefer exercise train -
ing in water, and 37% (n = 15) reported their preference for exer -
cise training on land. Fifteen percent (n = 6) reported no prefer -
ence for either environment for exercise training.
Long-term effects
One study reported long-term effects of water-based exercise tr ain-
ing six months after completion of a 12-week training programm e
(
Wadell 2004). For outcome measures for which data were re-
ported (quality of life and body composition), no signicant
change was observed between baseline results and results obt ained
six months post water-based exercise training.
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A D D I T I O N A L S U M M A R Y O F F I N D I N G S
Explanation

Water-based exercise training compared with land-based exercise training for people with chronic obstructive pulmonary disease (COPD)Patient or population:people with COPD
Settings: pulmonary rehabilitation centres
Intervention: water-based exercise training
Comparison: land-based exercise trainingOutcomes
Illustrative comparative risks* (95% CI)
No. of participants
(studies)
Quality of the evidence (GRADE)
Comments
Assumed risk
Corresponding risk
Land-based exercise training
Water-based exercise train-
ing
Exercise capacity - func-
tional
Six-minute walk test (mean
distance change in metres)
Mean change in six-minute
walk distance ranged across
control groups from 14 metres
to 43 metres
Mean change in six-minute
walk distance in the interven-
tion groups was 11 metres
higher (11 metres lower to 33
metres higher)
62
(three)

moderate 1
Exercise capacity - peak
Incremental shuttle walk test
(mean distance change in me-
tres)
Mean change in incremental
shuttle walk distance ranged
across control groups from 13
metres to 37 metres
Mean change in incremen-
tal shuttle walk distance in
the intervention groups was
nine metres higher (15 metres
lower to 34 metres higher)
59
(two)

low 2
Exercise capacity - en-
durance
Endurance shuttle walk test
(mean distance change in me-
tres)
Mean change in endurance
shuttle walk distance ranged
across control groups from 33
metres to 117 metres
Mean change in endurance
shuttle walk distance in the
intervention groups was 313
metres higher (232 metres to
394 metres higher)
59
(two)

moderate 2
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Quality of life
St Georges Respiratory Ques-
tionnaire (SGRQ; total score)
Lower value post intervention
is favourable, indicating im-
provement in QoL
Mean change in SGRQ total
score ranged across control
groups from -1 points to -16
points
Mean change in SGRQ to-
tal score in the intervention
groups was 0.3 points higher
(4 points lower to 5 points
higher)
60(three)

low 3
Body composition
Weight (mean change in kilo-
grams)
Mean change in body weight
ranged across control groups
from -0.2 kilograms to +1.3
kilograms
The mean change in body
weight in the intervention
groups was 1.3 kilograms
lower (2.7 kilograms lower to
0.1 kilograms higher)
59
(two)

moderate 2
*The basis for the
assumed risk(e.g. the median control group risk across studies) is provided i n footnotes. Thecorresponding risk (and its 95% confidence interval) is based on the
assumed risk in the comparison group and the relative effectof the intervention (and its 95% CI).
CI: Confidence interval.GRADE Working Group grades of evidence.
High quality: Further research is very unlikely to change our confidence in the est imate of effect.
Moderate quality: Further research is likely to have an important impact on our conf idence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our c onfidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.1
Two studies showed limitations in design; selection and performan ce bias unknown in two studies and one study, respectively.
2 One study had selection bias.
3 All studies showed limitations in design; selection bias present in one study and unknown in two remaining studies; performance and
detection bias unknown in all three studies.
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D I S C U S S I O N
Summary of main results
Five studies comparing water-based exercise training versus no ex-
ercise or land-based exercise training in people with COPD were
identied for this review. Water exercise resulted in signi cant im-
provement in functional exercise capacity, peak exercise capacity ,
endurance exercise capacity and health-related quality of life w hen
compared with no exercise. When compared with land exercise,
water exercise elicited signicantly greater improvement in e n-
durance exercise capacity. To date, data are insufcient for conclu -
sions to be drawn regarding the long-term effects of water-base d
exercise training in COPD.
Overall completeness and applicability of
evidence
Signicant mean improvements in functional, peak and enduran ce
exercise capacity following water exercise compared with no exer -
cise and in endurance exercise capacity following water-based ex-
ercise compared with land-based exercise surpassed the minimum
clinically important differences (MCIDs) that have been report ed
in the literature. The mean improvement in the six-minute wal k
test of 62 metres compared with no exercise is greater than any o f
the previously recorded MCIDs of 25 metres (
Holland 2010), 35
metres (
Puhan 2008) and 54 metres (Redelmeier 1997) in peo-
ple with COPD. The 50 metres mean improvement in incremen-
tal shuttle walk distance when water-based exercise training w as
compared with no exercise is greater than the 47.5 metres MCID
reported by
Singh 2008. Finally, improvement of 371 metres and
313 metres in the endurance shuttle walk test compared with no
exercise and land exercise, respectively, clearly exceeded the M CID
of 60 to 115 metres (
Pepin 2011). The reason for the greater re-
sponse in endurance walking capacity following water exercise i s
unclear; however, it is likely that a greater training stimul us is de-
livered in the water environment, where every motion in ever y
direction of movement is resisted by the hydrostatic pressur e of
the water and the effect of water turbulence (
Becker 2009). This
greater endurance capacity may be better reected in an endurance
exercise test such as the endurance shuttle walk test rather tha n
the six-minute walk test or the incremental shuttle walk test, in
which the participant would have to walk faster rather than lon ger
to demonstrate improvement.
Several components of health-related quality of life signica ntly
improved upon completion of water-based exercise training com-
pared with no exercise training. Signicant changes were record ed
by one study using the CRDQ (for total score, dyspnoea and fa-
tigue subscores) (
McNamara 2013) and by another study using
the SGRQ (including total score and impact subscore) (
de Souto
Araujo 2012
). However, no signicant change in CRDQ emo-
tional function and mastery subscores or in SGRQ symptom and activity subscores were found. When water-based exercise traini
ng
was compared with land-based exercise training, the only signi f-
icant change in quality of life favouring water-based exercise w as
seen in the CRDQ fatigue subscore. But this conclusion is based
on the ndings of only one study (
McNamara 2013). It is impor-
tant to note that most of the studies included in this review di d not
state their primary outcome measure, and only two studies calcu -
lated appropriate sample sizes, which were based on an exercis e ca-
pacity outcome - not on quality of life (
McNamara 2013;Wadell
2004
). Therefore, based on the information provided, none of
the studies in this review were adequately powered to determ ine a
signicant change in quality of life outcomes. Future studies w ill
require sufcient sample sizes so it can be adequately determi ned
whether water-based exercise training changes quality of life .
The studies in this review included COPD participants with an
average FEV 1% predicted ranging from 39% (
de Souto Araujo
2012
) to 62% (McNamara 2013). This classies the participants as
Global Initiative for Chronic Obstructive Lung Disease (GOLD )
stage II (moderate) and III (severe); thus the results of this re view
may not apply to people with COPD GOLD stage I (mild) or
IV (very severe). Furthermore, it should be noted that recruit-
ment of participants for the
McNamara 2013study specically
targeted people with COPD with physical comorbid conditions
that limited their ability to exercise on land (such as obesity, mus-
culoskeletal conditions of the lumbar spine and lower limbs an d
orthopaedic conditions such as joint replacements with limite d
range of motion). Because of heavy weighting of this study in ma ny
of the meta-analyses, the overall results of this review are h eavily
inuenced by this subgroup of people with COPD with physi-
cal comorbid conditions who may respond better to water-based
exercise training because of the treatment effect of their phys ical
comorbidity in the water environment.
Based on data from two studies (n = 20; GOLD stage II), water-
based exercise was found to be safe for people with COPD, with
only one minor adverse event reported. Future studies shoul d re-
port adverse events to further conrm the safety of water-base d
exercise training.
All studies in this review prescribed for both exercise traini ng
groups endurance exercise training or a combination of enduran ce
and strength exercise training. The four studies that include d com-
parisons of water-based exercise versus land-based exercise pr e-
scribed the water-based exercise training programme to match
as closely as possible the land-based exercise training progra mme
by using similar intensity, frequency and muscle groups train ed
(
de Souto Araujo 2012;McNamara 2013;OBrien 2004;Wadell
2004
). This methodological feature gives assurance that the wa-
ter exercise programmes adhered as closely as possible to curre nt
guidelines regarding exercise prescription in pulmonary reh abili-
tation (
Nici 2006), especially given the difference in exercise train-
ing mediums.
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Water-based exercise training for chronic obstructive pul monary disease (Review)
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Quality of the evidence
The quality of evidence for the primary outcomes in this review
ranged from low to moderate. Interpretation of the ndings of
this review should be considered carefully because of potentia l
sources of bias, especially the small sample size of each study. Lack
of adequate randomisation in one study and unreported or poo r
random sequence generation, allocation concealment and blindi ng
of outcome assessors are signicant limitations.
Potential biases in the review process
Although the authors of all included studies were contacted to
provide additional information and results, some informat ion was
not supplied, and this limited the data that could be included i n
some meta-analyses.
Agreements and disagreements with other
studies or reviews
One previous review has examined the effect of water-based exe r-
cise training in people with COPD (
McNamara 2011); however
only one study was identied and reviewed. The inclusion of v e
studies in this current review (including the study previously ex-
amined in
McNamara 2011) is a major strength.
A U T H O R S C O N C L U S I O N S
Implications for practice
There is limited quality evidence that water-based exercise tr aining
is safe for people with COPD (GOLD stage II) and improves exer- cise capacity and health-related quality of life immediately fo
llow-
ing training for people with COPD GOLD stage II and III when
compared with no training. There is limited quality evidence t hat
water-based exercise training offers advantages over land-ba sed ex-
ercise training in improving endurance exercise capacity, but we
remain uncertain as to whether it leads to better quality of li fe. It
is, therefore, appropriate to offer people with GOLD stage I I and
III COPD a water-based exercise training programme, especiall y
when they have concurrent physical co-morbidities, or when the
alternative is no exercise training.
Implications for research
More high-quality randomised controlled trials are required to
further conrm exercise capacity and health-related quality of l ife
outcomes following water-based exercise training in people wi th
COPD. In particular, larger studies need to be conducted to de-
termine whether disease severity affects the benets of wate r-based
exercise training and whether water exercise results in long-t erm ef-
fects. Study methodology in future trials needs to be rigorou s with
adequate sample sizes, randomisation, allocation concealmen t and
blinding of outcome assessors, and this information must be r e-
ported in publications.
A C K N O W L E D G E M E N T S
We thank the staff of the Cochrane Airways Group and the Aus-
tralian Cochrane Airways Group Network for their guidance in
completing this review. Thank you also to the Australian Cochr ane
Airways Group Network for providing a scholarship to enable r e-
view completion.
Anne Holland was the Editor for this review and commented
critically on the review.
R E F E R E N C E S
References to studies included in this review
de Souto Araujo 2012 published and unpublished data
de Souto Araujo ZT, de Miranda Silva Nogueira PA,
Cabral EE, de Paula dos Santos L, da Silva IS, Ferreira GM.
Effectiveness of low-intensity aquatic exercise on COPD: a
randomized clinical trial. Respiratory Medicine2012;106:
153543.
McNamara 2013 published and unpublished data
McNamara RJ, Alison JA, McKenzie DK, McKeough ZJ.
Water-based exercise improves exercise capacity in people
with COPD with physical co-morbid conditions Abstract.
Respirology 2010;15(Suppl.1) :A24.
McNamara RJ, Alison JA, McKenzie DK, McKeough
ZJ. Water-based exercise in people with COPD with physical comorbid conditions: a randomised controlled
trial Abstract. European Respiratory Society 20th Annual
Congress; September 18-22; Barcelona. 2010.

McNamara RJ, McKeough ZJ, McKenzie DK, Alison JA.
Water-based exercise in COPD with physical comorbidities:
a randomised controlled trial. European Respiratory Journal
2013; 41:128491.
OBrien 2004 published and unpublished data
OBrien M, Harris B, Williams M. The effects of
water versus land-based exercise for patients with
chronic obstructive pulmonary disease - a pilot study
Abstract. Australian Journal of Physiotherapy 2004;50(3)
(esupplement):A10.
19
Water-based exercise training for chronic obstructive pul monary disease (Review)
Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

Ozdemir 2010published data only (unpublished sought but not used)
Ozdemir EP, Solak O, Fidan F, Demirdal US, Evcik
D, Unlu M, et al.The effect of water-based pulmonary
rehabilitation on anxiety and quality of life in chronic
pulmonary obstructive disease patients. Turkiye Klinikleri
Journal of Medical Sciences 2010;30(3):8807.
Wadell 2004 published and unpublished data
Wadell K. Physical training in patients with chronic
obstructive pulmonary disease Dissertation. PhD thesis
2004.
Wadell K, Henriksson-Larsen K, Lundgren R, Sundelin
G. Group training in patients with COPD - long term
effects after decreased training frequency. Disability and
Rehabilitation 2005;27(10):57181.
Wadell K, Lundgren R, Henriksson-Larsen K, Sundelin
G. Training in water and on land in patients with COPD
- short and long term perspective Abstract. European
Respiratory Journal 2004;24(Suppl 48) :666s.
Wadell K, Sundelin G, Henriksson-Larsen K, Lundgren
R . High intensity physical group training in water -
an effective training modality for patients with COPD.
Respiratory Medicine 2004;98(5):42838.
Wadell K, Sundelin G, Henriksson-Larsn K, Lundgren R.
Physical training in water is effective in patients with COPD
- a randomised controlled study Abstract. European
Respiratory Journal 2002;20(Suppl 38) :68s.
Wadell K, Sundelin G, Lundgren R, Henriksson-Larsen K,
Lindstrom B. Muscle performance in patients with chronic
obstructive pulmonary disease - effects of a physical training
programme. Advances in Physiotherapy 2005;7(2):519.
References to studies excluded from this review
Kurabayashi 1997 published data only
Kurabayashi H, Kubota K, Machida I, Tamura K, Take
H, Shirakura T. Effective physical therapy for chronic
obstructive pulmonary disease: pilot study of exercise in ho t
spring water. American Journal of Physical Medicine and
Rehabilitation 1997;76(3):2047.
Kurabayashi 1998 published data only
Kurabayashi H, Machida I, Handa H, Akiba T, Kubota
K. Comparison of three protocols or breathing exercises
during immersion in 38C water for chronic obstructive
pulmonary disease. American Journal of Physical Medicine
and Rehabilitation 1998;77(2):1458.
Kurabayashi 2000 published data only
Kurabayashi H, Machida I, Tamura K, Iwai F, Tamura
J, Kubota K. Breathing out into water during subtotal
immersion: a therapy for chronic pulmonary emphysema.
American Journal of Physical Medicine and Rehabilitation
2000; 79(2):1503.
Kurabyashi 1997 published data only
Kurabayashi H, Kubota K, Tamura J. Physical therapy in
a pool as rehabilitation for chronic obstructive pulmonary
disease in the elderly. Japanese Journal of Geriatrics 1997;34:
8038. Lopez Varela 2006
published data only
Lopez Varela M, Anido T, Cuello A, Pena S. Pulmonary
rehabilitation outcomes in COPD patients including water
training. European Respiratory Journal 2006;28(Suppl 50):
554s.
Lopez Varela 2008 published data only
Lopez Varela MV, Anido T, Cuello A, Pens S, da Rosa
A. Water and land training PR in COPD patients. Are
benets different in men and women? Abstract. European
Respiratory Society Annual Congress, Berlin, Germany, Oct
4-8. 2008:578s.
Lotshaw 2001 published data only
Lotshaw A, Hart M, Bokovoy J, Millard M. Water based
pulmonary rehabilitation is an effective program for exerci se
training in COPD patients. American Journal of Critical
Care Medicine 2001;163:A968.
Lotshaw 2002 published and unpublished data
Lotshaw A, Duncan C, Hart M, Millard M. Land and
water-based pulmonary rehabilitation: a comparison of
physical performance and quality of life in patients with
COPD. American Journal of Respiratory and Critical Care
Medicine 2002;165(8(Suppl)):A16.
Lotshaw 2003 published and unpublished data
Lotshaw A, Duncan C, Hart M, Millard M. Land and
water-based pulmonary rehabilitation; a comparison of
physical performance and quality of life in patients with
COPD. First National COPD Conference; November 14-
15; Arlington, Virginia. 2003:Abstract no. 1143.
Lotshaw 2007 published data only
Lotshaw AM, Thompson M, Sadowsky S, Hart MK,
Millard MW. Quality of life and physical performance in
land- and water-based pulmonary rehabilitation. Journal of
Cardiopulmonary Rehabilitation and Prevention 2007;27:
24751.
Millard 1999 published data only
Millard MW, Hart M, Lotshaw AM, Kraft C. The effect
of water immersion on subjects with COPD during peak
lower extremity exercise on treadmill. American Journal of
Critical Care Medicine 1999;3:A313.
Mitsunobu 2004 published data only
Mitsunobu F, Hosaki Y, Ashida K, Iwagaki N, Nagita T,
Fujii M, et al.Five-year observation of the effects of spa
therapy for patients with pulmonary emphysema, evaluated
by %low attenuation area (%LAA) of the lungs on high-
resolution CT, %DLco and %residual volume (RV). Journal
of the Japanese Association of Physical Medicine, Balneolo gy
and Climatology 2004;67(3):14854.
Perk 1996 published data only
Perk J, Perk L, Boden C. Cardiorespiratory adaptation of
COPD patients to physical training on land and in water.
European Respiratory Journal 1996;9:24852.
Rae 2009 published data only
Rae S, White P. Swimming pool-based exercise as pulmonary
rehabilitation for COPD patients in primary care: feasibilit y
20
Water-based exercise training for chronic obstructive pul monary disease (Review)
Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

and acceptability.Primary Care Respiratory Journal 2009;18
(2):904.
Additional references
Arborelius 1972 Arborelius M, Balludin UI, Lilja B, Lundergren CEG.
Hemodynamic changes in man during immersion with
head above water. Aerospace Medicine 1972;43:5928.
Becker 2009 Becker BE. Aquatic therapy: scientic foundations and
clinical rehabilitation applications. Physical Medicine and
Rehabilitation 2009;1:85972.
Chapman 2006 Chapman KR, Mannino DM, Soriano JB, Vermeire PA,
Buist AS, Thun MJ, et al.Epidemiology and costs of chronic
obstructive pulmonary disease. European Respiratory Journal
2006; 27:188207.
Cockram 2006 Cockram J, Cecins N, Jenkins S. Maintaining exercise
capacity and quality of life following pulmonary
rehabilitation. Respirology2006;11:98104.
Fabbri 2008 Fabbri LM, Luppi F, Beghe B, Rabe KF. Complex chronic
comorbidities of COPD. European Respiratory Journal 2008;
31 :20412.
Garrod 2006 Garrod R, Marshall J, Barley E, Jones PW. Predictors of
success and failure in pulmonary rehabilitation. European
Respiratory Journal 2006;27(4):78894.
Golmohammadi 2004 Golmohammadi K, Jacobs P, Sin DD. Economic evaluation
of a community-based pulmonary rehabilitation program
for chronic obstructive pulmonary disease. Lung2004; 182:
18796.
Higgins 2011 Higgins JPT, Green S (editors). Cochrane Handbook
for Systematic Reviews of Interventions Version 5.2.0.
Chichester: John Wiley & Sons, 2011.
Holland 2010 Holland AE, Hill CJ, Rasekaba T, Lee A, Naughton MT,
McDonald CF. Updating the minimal important difference
for six-minute walk distance in patients with chronic
obstructive pulmonary disease. Archives of Physical Medicine
and Rehabilitation 2010;91:2215.
Lacasse 2006 Lacasse Y, Goldstein RS, Lasserson TJ, Martin S. Pulmonary
rehabilitation for chronic obstructive pulmonary disease.
Cochrane Database of Systematic Reviews 2006, Issue 3.
DOI: 10.100214651858.CD003793.pub2 McKenzie 2007
McKenzie DK, Frith PA, Burdon JG, Town GI. The
COPD-X Plan: Australian and New Zealand Guidelines
for the management of Chronic Obstructive Pulmonary
Disease 2003. Medical Journal of Australia 2003;178:S739.
McNamara 2011 McNamara RJ, Alison JA, McKeough ZJ. Water-based
exercise in chronic obstructive pulmonary disease. Physical
Therapy Reviews 2011;16(1):2530.
Nici 2006 Nici L, Donner C, Wouters E, Zuwallack R, Ambrosino
N, Bourbeau J, et al.American Thoracic SocietyEuropean
Respiratory Society statement on pulmonary rehabilitation.
American Journal of Respiratory and Critical Care Medicine
2006; 173:1390413.
Pepin 2011 Pepin V, Laviolette L, Brouillard C, Sewell L, Singh SJ,
Revill SM, et al.Signicance of changes in endurance shuttle
walking performance. Thorax2011;66:11520.
Puhan 2008 Puhan MA, Mador MJ, Held U, Goldstein R, Guyatt GH,
Schunemann HJ. Interpretation of treatment changes in 6-
minute walk distance in patients with COPD. European
Respiratory Journal 2008;32:63743.
Redelmeier 1997 Redelmeier DA, Bayoumi AM, Goldstein RS, Guyatt GH.
Interpreting small differences in functional status: the six
minute walk test in chronic lung disease patients. American
Journal of Respiratory and Critical Care Medicine 1997;155:
127882.
Review Manager (RevMan) The Nordic Cochrane Centre, The Cochrane Collaboration.
Review Manager (RevMan). 5.2. Copenhagen: The Nordic
Cochrane Centre, The Cochrane Collaboration, 2012.
Ries 2007 Ries AL, Bauldoff GS, Carlin BW, Casaburi R, Emery CF,
Mahler DA, et al.Pulmonary rehabilitation: joint ACCP
AACVPR evidence-based clinical practice guidelines. Chest
2007; 131:442.
Singh 2008 Singh SJ, Jones PW, Evans R, Morgan MD. Minimum
clinically important improvement for the incremental
shuttle walking test. Thorax2008;63:7757.
References to other published versions of this review
McNamara 2010 McNamara RJ, McKeough ZJ, McKenzie DK, Alison
JA. Water-based exercise training for chronic obstructive
pulmonary disease. Cochrane Database of Systematic Reviews
2010, Issue 1. DOI: 10.100214651858.CD008290
Indicates the major publication for the study
21
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Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

C H A R A C T E R I S T I C S O F S T U D I E S
Characteristics of included studiesordered by study ID
de Souto Araujo 2012
MethodsRandomised controlled trial
ParticipantsCOPD, n = 32
Land-based exercise training, n = 13, eight male, age mean (SD) 5 7 (8) years, FEV
139
(11) % predicted
Water-based exercise training, n = 8, four male, age mean (SD) 62 (10) years, FEV
144
(10) % predicted
No exercise training, n = 11, eight male, age mean (SD) 71 (10) yea rs, FEV
145 (13) %
predicted
InterventionsLand-based exercise training: eight-week exercise programme, three times a week, 90
minutes, consisting of continuous exercise for upper and lower limbs (callisthenic activi-
ties with the respiratory cycle) for 15 minutes without weight s; unsupported upper limb
exercises using weights (initial weight 50% of maximum load an d increased weekly) and
diagonal movements for two minutes with equal rest periods; lower limb cycling for 30
minutes (intensity determined by Borg dyspnoea and perceived effort score of 5); 15
minutes of cool-down exercise for muscle groups used during the s ession
Water-based exercise training: eight-week exercise programme , three times a week, 90
minutes, consisting of continuous warm-up exercises for upper a nd lower limbs (callis-
thenic activities with the respiratory cycle) for 15 minutes wi thout weights; unsupported
upper limb exercises using two diagonal movements and weight s for two minutes with
an equal rest period (initial weight 50% of maximum load and in creased weekly); lower
limb training using oats positioned between the legs and pe rforming bicycling move-
ments for 30 minutes (intensity determined by Borg dyspnoea a nd perceived effort score
of 5); 15 minutes of cool-down exercise for muscle groups used duri ng the session
No exercise training: no exercise training
OutcomesSpirometry
Respiratory muscle strength
Six-minute walk test
BODE (body mass, airway obstruction, dyspnoea, exercise capacit y) index
St Georges Respiratory Questionnaire
All measured before and after intervention period
Notes
Risk of bias
BiasAuthors judgementSupport for judgement
Random sequence generation (selection
bias)Unclear riskInsufcient information provided; randomly assigned
Allocation concealment (selection bias)Unclear riskNot specied
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de Souto Araujo 2012(Continued)
Blinding of participants and personnel
(performance bias)
All outcomesHigh riskNot possible to blind participants or personnel because
of the physical nature of the intervention
Blinding of outcome assessment (detection
bias)
All outcomesUnclear riskNot specied
Incomplete outcome data (attrition bias)All outcomesHigh riskTen dropouts with no reporting of data
Selective reporting (reporting bias)Low riskStudy protocol documented in methods and prespecied
outcomes reported in prespecied methods
McNamara 2013
MethodsRandomised controlled trial
ParticipantsCOPD with physical comorbid conditions, n = 53
Land-based exercise training, n = 20, 10 male, age mean (SD) 73 (7) years, FEV
162
(15) % predicted
Water-based exercise training, n = 18, ve male, age mean (SD) 72 (10) years, FEV
160
(10) % predicted
No exercise training, n = 15, seven male, age mean (SD) 70 (9) year s, FEV
155 (20) %
predicted
InterventionsLand-based exercise training: eight-week outpatient exercise programme, three times a
week, 60 minutes, supervised sessions consisting of upper li mb endurance exercise and
lower limb endurance exercise (walking and cycling) in a gym with i nitial intensity at
80% of walking speed on initial six-minute walk test either ov er-ground or on a treadmill,
and progressed to maintain an intensity rating of three to v e on the modied category
ratio 0 to 10 dyspnoea and rating of perceived exertion scales
Water-based exercise training: eight-week outpatient exercis e programme, three times
a week, 60 minutes, supervised sessions consisting of exercis es in hydrotherapy pool
matched as closely as possible for intensity, duration and mus cle groups trained to the
land-based training exercises, and progressed by increasing w ater turbulence, speed and
range of motion (specic exercise programme detailed in main pu blication)
No exercise training: usual medical care, no exercise training, requested not to alter
exercise level over study period
OutcomesSpirometry
Respiratory muscle strength
Six-minute walk test
Incremental shuttle walk test
Endurance shuttle walk test
Chronic Respiratory Disease Questionnaire
Hospital Anxiety and Depression Scale
All measured before and after intervention period
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McNamara 2013(Continued)
NotesSupported by the Physiotherapy Research Foundation
Risk of bias
BiasAuthors judgementSupport for judgement
Random sequence generation (selection
bias)Low riskComputer-generated random number sequence
Allocation concealment (selection bias)Low riskSequentially numbered, opaque, sealed envelopes
Blinding of participants and personnel
(performance bias)
All outcomesHigh riskNot possible to blind participants or personnel because
of the physical nature of the intervention
Blinding of outcome assessment (detection
bias)
All outcomesLow riskData collected by investigator blinded to treatment allo-
cation
Incomplete outcome data (attrition bias)All outcomesHigh riskNo missing outcome data for participants who completed
the study; information about participants withdrawing
from the study provided but not included in intention-
to-treat analysis
Selective reporting (reporting bias)Low riskStudy protocol documented in methods and prespecied
outcomes reported in prespecied methods
OBrien 2004
MethodsRandomised cross-over trial
ParticipantsCOPD, n = 11
Land followed by water training, n = 6, four male, age mean (SD) 63 (23) years, FEV
1
61 (18) % predicted
Water followed by land training, n = 5, four male, age mean (SD) 71 (11) years, FEV
1
58 (32) % predicted
InterventionsLand-based exercise training: six weeks, twice a week, 45 minut es, supervised in gym,
including warm-up of walking and stretches, aerobic training a nd strength and resistance
training using free weights, at an intensity of three to four on the modied Borg rating
of perceived exertion scale
Water-based exercise training: six weeks, twice a week, 45 minu tes, supervised in hy-
drotherapy pool using similar muscle groups to ensure standa rdisation to land-based
exercise programme and using properties of water to provide r esistance, at an intensity
of three to four on the modied Borg rating of perceived exerti on scale
Both groups were also encouraged to complete a 20-minute home wa lking programme
twice per week with distance calculated at 80% of the average spee d of the baseline six-
minute walk test
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OBrien 2004(Continued)
OutcomesSpirometry
Six-minute walk test
St Georges Respiratory Questionnaire
All measured before and after each six-week intervention peri od
NotesAbstract: full text copy of thesis was obtained
Only data from the rst arm of the cross-over trial were used
Risk of bias
BiasAuthors judgementSupport for judgement
Random sequence generation (selection
bias)Unclear riskInsufcient information provided
Subjects were randomly assigned into two groups
Allocation concealment (selection bias)Low riskRandomisation was conducted via the sealed envelope
method, with envelopes created previously, by investiga-
tors other than the principal, who was blinded to the ran-
domisation process
Blinding of participants and personnel
(performance bias)
All outcomesHigh riskNot possible to blind participants or personnel because
of the physical nature of the intervention
Blinding of outcome assessment (detection
bias)All outcomesLow riskData collected by investigator blinded to treatment allo-
cation
Incomplete outcome data (attrition bias)All outcomesHigh riskOne dropout with no reporting of data
Selective reporting (reporting bias)Low riskStudy protocol documented in methods and prespecied
outcomes reported in prespecied methods
Ozdemir 2010
MethodsRandomised controlled trial
ParticipantsCOPD, n = 50
Water-based exercise training, n = 25, all male, age mean (SD) 61 (9) years, FEV
155
(16) % predicted
No exercise training, n = 25, all male, age mean (SD) 64 (9) years, FEV
154 (20) %
predicted
InterventionsWater-based exercise training: four weeks, three times a week , 35 minutes, supervised
in an aquatic centre with a warm-up, stretches and strengthenin g exercises for shoulder
girdle and upper extremity muscles utilising oatation devi ces for resistance
No exercise training: medical therapy only
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Ozdemir 2010(Continued)
OutcomesSpirometry
Arterial blood gases
Six-minute walk test
Chronic Respiratory Disease Questionnaire
Hospital Anxiety and Depression Scale
All measured before and after intervention period
Notes
Risk of bias
BiasAuthors judgementSupport for judgement
Random sequence generation (selection
bias)Low riskRandomly assigned according to table of random num-
bers
Allocation concealment (selection bias)Unclear riskNot specied
Blinding of participants and personnel
(performance bias)
All outcomesHigh riskNot possible to blind participants or personnel because
of the physical nature of the intervention
Blinding of outcome assessment (detection
bias)All outcomesUnclear riskNot specied
Incomplete outcome data (attrition bias)All outcomesUnclear riskNot specied
Selective reporting (reporting bias)Low riskStudy protocol documented in methods and prespecied
outcomes reported in prespecied methods
Wadell 2004
MethodsSemi-randomised controlled trial
ParticipantsCOPD, n = 43
Land-based exercise training, n = 15, ve male, age mean (SD) 65 (7 ) years, FEV
153
(12) % predicted
Water-based exercise training, n = 15, four male, age mean (SD) 6 5 (4) years, FEV
156
(11) % predicted
No exercise training, n = 13, seven male, age mean (SD) 63 (7) year s, FEV
149 (12) %
predicted
InterventionsLand-based exercise training: 12 week outpatient group progr amme, three times a week,
45 minutes, supervised, intensity guided by music to achieve a mean heart rate of 80% to
100% of peak heart rate according to maximal cycle ergometer test and a Borg dyspnoea
score of 5 and rating of perceived exertion score of 15, including warm-up and exibility
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Wadell 2004(Continued)
exercises, followed by four minutes of endurance exercises and three minutes of strength
exercises (repeated three times while focusing on the legs, arm s and torso each time) and
nally exibility, stretching and cool-down exercises
Water-based exercise training: as per land-based exercise trai ning but in water
No exercise training: no intervention
OutcomesSpirometry
Incremental shuttle walk test
Endurance shuttle walk test
Incremental cycle ergometer test
St Georges Respiratory Questionnaire
Short Form-36 questionnaire
All measured before and after intervention period
NotesSupported by the Swedish Heart and Lung Foundation, the Nati onal Patient Federation
for Heart and Lung Diseases in Sweden and the Swedish Vardal F oundation
Data from the control group were not used because of the non-rand omised nature of
the group
Risk of bias
BiasAuthors judgementSupport for judgement
Random sequence generation (selection
bias)High riskRandomly assigned on the basis of distance living
away from study location
Allocation concealment (selection bias)Unclear riskNot specied
Blinding of participants and personnel
(performance bias)
All outcomesHigh riskNot possible to blind participants or personnel be-
cause of the physical nature of the intervention
Blinding of outcome assessment (detection
bias)All outcomesUnclear riskNot specied
Incomplete outcome data (attrition bias)All outcomesLow riskIntention-to-treat analysis
Selective reporting (reporting bias)Low riskStudy protocol documented in methods and pre-
specied outcomes reported in prespecied meth-
ods
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Characteristics of excluded studiesordered by study ID
StudyReason for exclusion
Kurabayashi 1997Not a randomised controlled trial; no physical exercise traini ng
Kurabayashi 1998Not a randomised controlled trial; no physical exercise training
Kurabayashi 2000No physical exercise training
Kurabyashi 1997Not a randomised controlled trial; no physical exercise training
Lopez Varela 2006Abstract; randomisation not stated; author of study did not respond to review authors request for clarication;
no full text published
Lopez Varela 2008Water-based exercise training combined with land-based exercis e training in 50:50 ratio (i.e. water-based exercise
training not greater than 50%)
Lotshaw 2001Not a randomised controlled trial
Lotshaw 2002Not a randomised controlled trial
Lotshaw 2003Not a randomised controlled trial
Lotshaw 2007Not a randomised controlled trial
Millard 1999Not a randomised controlled trial
Mitsunobu 2004Not a randomised controlled trial
Perk 1996Not a randomised controlled trial
Rae 2009Not a randomised controlled trial
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D A T A A N D A N A L Y S E S
Comparison 1. Water-based exercise versus no exercise
Outcome or subgroup titleNo. of
studies No. of
participants Statistical method Effect size
1 Exercise capacity (mean change
in metres)3 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Functional - six-minute
walk test3 99 Mean Difference (IV, Fixed, 95% CI) 62.09 44.34, 79.85
1.2 Peak - incremental shuttle
walk test1 30 Mean Difference (IV, Fixed, 95% CI) 50.0 19.93, 80.07
1.3 Endurance - endurance
shuttle walk test1 30 Mean Difference (IV, Fixed, 95% CI) 371.0 120.83, 621. 17
2 Quality of life (mean change intotal scores)2 49 Std. Mean Difference (IV, Fixed, 95% CI) -0.97 -1.57, -0.37
3 Quality of life (mean change inindividual domain scores)2 Mean Difference (IV, Fixed, 95% CI) Subtotals only
3.1 Chronic Respiratory
Disease Questionnaire - total
score1 30 Mean Difference (IV, Fixed, 95% CI) -10.00 -20.60, -3. 40
3.2 Chronic Respiratory
Disease Questionnaire -
dyspnoea score1 30 Mean Difference (IV, Fixed, 95% CI) -3.0 -5.73, -0.27
3.3 Chronic Respiratory
Disease Questionnaire -
emotional function score1 30 Mean Difference (IV, Fixed, 95% CI) -2.0 -5.24, 1.24
3.4 Chronic Respiratory
Disease Questionnaire - fatigue
score1 30 Mean Difference (IV, Fixed, 95% CI) -5.0 -7.53, -2.47
3.5 Chronic Respiratory
Disease Questionnaire -
mastery score1 30 Mean Difference (IV, Fixed, 95% CI) -2.0 -4.26, 0.26
3.6 St Georges Respiratory
Questionnaire - total score1 19 Mean Difference (IV, Fixed, 95% CI) -10.0 -19.29, -0.71
3.7 St Georges Respiratory
Questionnaire - symptom score1 19 Mean Difference (IV, Fixed, 95% CI) 2.0 -13.49, 17.49
3.8 St Georges Respiratory
Questionnaire - activity score1 19 Mean Difference (IV, Fixed, 95% CI) -13.00 -26.18, 0. 18
3.9 St Georges Respiratory
Questionnaire - impact score1 19 Mean Difference (IV, Fixed, 95% CI) -13.0 -21.59, -4.41
4 Pulmonary function (mean change)3 Mean Difference (IV, Fixed, 95% CI) Subtotals only
4.1 FEV 1(% predicted)2 49 Mean Difference (IV, Fixed, 95% CI) 6.32 3.43, 9.22
4.2 FVC (% predicted)3 99 Mean Difference (IV, Fixed, 95% CI) 3.82 0.25, 7.39
4.3 FEV
1FVC ratio (%)3 99 Mean Difference (IV, Fixed, 95% CI) 2.79 -0.74, 6.33
5 Respiratory muscle strength
(mean change)2 Mean Difference (IV, Fixed, 95% CI) Subtotals only
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5.1 MIP (cm H2O)2 49 Mean Difference (IV, Fixed, 95% CI) 13.83 5.30, 22.35
5.2 MIP (% predicted)2 49 Mean Difference (IV, Fixed, 95% CI) 19.80 9.36, 30.24
5.3 MEP (cm H
2O)2 49 Mean Difference (IV, Fixed, 95% CI) 14.25 5.23, 23.27
5.4 MEP (% predicted)2 49 Mean Difference (IV, Fixed, 95% CI) 15.22 4.85, 25.59
Comparison 2. Water-based exercise versus land-based exercise
Outcome or subgroup title No. of
studies No. of
participants Statistical method Effect size
1 Exercise capacity (mean change
in metres)4 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Functional - six-minute
walk test3 62 Mean Difference (IV, Fixed, 95% CI) 10.85 -10.82, 32. 51
1.2 Peak - incremental shuttle
walk test2 59 Mean Difference (IV, Fixed, 95% CI) 9.36 -15.22, 33.95
1.3 Endurance - endurance
shuttle walk test2 59 Mean Difference (IV, Fixed, 95% CI) 313.17 232.35, 393.99
2 Quality of life (mean change intotal scores)4 89 Std. Mean Difference (IV, Fixed, 95% CI) -0.15 -0.58, 0.28
3 Quality of life (mean change inindividual domain scores)4 Mean Difference (IV, Fixed, 95% CI) Subtotals only
3.1 Chronic Respiratory
Disease Questionnaire - total
score1 30 Mean Difference (IV, Fixed, 95% CI) -8.0 -16.38, 0.38
3.2 Chronic Respiratory
Disease Questionnaire -
dyspnoea score1 30 Mean Difference (IV, Fixed, 95% CI) -2.0 -4.73, 0.73
3.3 Chronic Respiratory
Disease Questionnaire -
emotional function score1 30 Mean Difference (IV, Fixed, 95% CI) -2.0 -5.24, 1.24
3.4 Chronic Respiratory
Disease Questionnaire - fatigue
score1 30 Mean Difference (IV, Fixed, 95% CI) -3.0 -5.26, -0.74
3.5 Chronic Respiratory
Disease Questionnaire -
mastery score1 30 Mean Difference (IV, Fixed, 95% CI) -1.0 -3.26, 1.26
3.6 St Georges Respiratory
Questionnaire - total score3 60 Mean Difference (IV, Fixed, 95% CI) 0.31 -4.14, 4.75
3.7 St Georges Respiratory
Questionnaire - symptom score3 59 Mean Difference (IV, Fixed, 95% CI) 7.84 -3.06, 18.74
3.8 St Georges Respiratory
Questionnaire - activity score3 59 Mean Difference (IV, Fixed, 95% CI) -2.82 -7.67, 2.04
3.9 St Georges Respiratory
Questionnaire - impact score3 59 Mean Difference (IV, Fixed, 95% CI) -0.49 -4.44, 3.45
4 Pulmonary function (mean change)3 Mean Difference (IV, Fixed, 95% CI) Subtotals only
4.1 FEV 1(litres)2 41 Mean Difference (IV, Fixed, 95% CI) 0.08 -0.04, 0.19
4.2 FEV
1(% predicted)3 62 Mean Difference (IV, Fixed, 95% CI) 0.21 -2.88, 3.31
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4.3 FVC (litres)2 41 Mean Difference (IV, Fixed, 95% CI) 0.12 -0.04, 0.28
4.4 FVC (% predicted)2 51 Mean Difference (IV, Fixed, 95% CI) 2.89 -4.24, 10.02
4.5 FEV1FVC ratio (%)3 62 Mean Difference (IV, Fixed, 95% CI) 2.22 -1.89, 6.34
5 Respiratory muscle strength
(mean change)2 Mean Difference (IV, Fixed, 95% CI) Subtotals only
5.1 MIP (cm H 2O)2 51 Mean Difference (IV, Fixed, 95% CI) 0.06 -7.21, 7.34
5.2 MIP (% predicted)2 51 Mean Difference (IV, Fixed, 95% CI) 3.40 -5.77, 12.58
5.3 MEP (cm H
2O)2 51 Mean Difference (IV, Fixed, 95% CI) -6.80 -16.42, 2.83
5.4 MEP (% predicted)2 51 Mean Difference (IV, Fixed, 95% CI) -3.88 -13.88, 6.12
6 Body composition (mean change
in kilograms)2 59 Mean Difference (IV, Fixed, 95% CI) -1.29 -2.65, 0.07
7 Attendance (mean number)2 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
7.1 Attendance at supervised
exercise sessions2 41 Std. Mean Difference (IV, Fixed, 95% CI) 0.44 -0.18, 1.07
Analysis 1.1. Comparison 1 Water-based exercise versus no e xercise, Outcome 1 Exercise capacity (mean
change in metres).
Review: Water-based exercise training for chronic obstruc tive pulmonar y disease
Comparison: 1 Water-based exercise versus no exercise
Outcome: 1 Exercise capacity (mean change in metres)
Study or subgroup Water-based exercise No exercise Mean
Difference Weight Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Functional - six-minute walk test de Souto Araujo 2012 8 56 (51) 11 -33 (40)
17.4 % 89.00 46.48, 131.52
McNamara 2013 15 48 (39) 15 -16 (31)
49.6 % 64.00 38.79, 89.21
Ozdemir 2010 25 6 (50) 25 -39 (61)
33.0 % 45.00 14.08, 75.92
Subtotal (95% CI) 48 51
100.0 % 62.09 44.34, 79.85
Heterogeneity: Chi 2
= 2.73, df = 2 (P = 0.25); I 2
=27%
Test for overall effect: Z = 6.85 (P 0.00001)
2 Peak - incremental shuttle walk test McNamara 2013 15 49 (43) 15 -1 (41)
100.0 % 50.00 19.93, 80.07
Subtotal (95% CI) 15 15
100.0 % 50.00 19.93, 80.07
Heterogeneity: not applicable
Test for overall effect: Z = 3.26 (P = 0.0011)
3 Endurance - endurance shuttle walk test McNamara 2013 15 321 (356) 15 -50 (343)
100.0 % 371.00 120.83, 621.17
Subtotal (95% CI) 15 15
100.0 % 371.00 120.83, 621.17
Heterogeneity: not applicable
Test for overall effect: Z = 2.91 (P = 0.0037)
Test for subgroup differences: Chi 2
= 6.41, df = 2 (P = 0.04), I 2
=69%
-1000 -500 0 500 1000
Favours no exercise Favours water exercise
31
Water-based exercise training for chronic obstructive pul monary disease (Review)
Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

Analysis 1.2. Comparison 1 Water-based exercise versus no exercise, Outcome 2 Quality of life (mean
change in total scores).
Review: Water-based exercise training for chronic obstruc tive pulmonar y disease
Comparison: 1 Water-based exercise versus no exercise
Outcome: 2 Quality of life (mean change in total scores)
Study or subgroup Water-based exercise No exercise Std.
Mean
Difference Weight Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
de Souto Araujo 2012 8 -4 (11) 11 6 (9)38.0 % -0.97 -1.94, 0.01
McNamara 2013 15 -12 (15) 15 0 (8)
62.0 % -0.97 -1.73, -0.21
Total (95% CI) 23 26
100.0 % -0.97 -1.57, -0.37
Heterogeneity: Chi 2
= 0.00, df = 1 (P = 1.00); I 2
=0.0%
Test for overall effect: Z = 3.17 (P = 0.0015)
Test for subgroup differences: Not applicable
-2 -1 0 1 2
Favours water exercise Favours no exercise
32
Water-based exercise training for chronic obstructive pul monary disease (Review)
Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

Analysis 1.3. Comparison 1 Water-based exercise versus no exercise, Outcome 3 Quality of life (mean
change in individual domain scores).
Review: Water-based exercise training for chronic obstruc tive pulmonar y disease
Comparison: 1 Water-based exercise versus no exercise
Outcome: 3 Quality of life (mean change in individual domain scores)
Study or subgroup Water-based exercise No exercise Mean
Difference Weight Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Chronic Respirator y Disease Questionnaire - total score McNamara 2013 15 -12 (15) 15 0 (8)
100.0 % -12.00 -20.60, -3.40
Subtotal (95% CI) 15 15
100.0 % -12.00 -20.60, -3.40
Heterogeneity: not applicable
Test for overall effect: Z = 2.73 (P = 0.0063)
2 Chronic Respirator y Disease Questionnaire - dyspnoea sco re
McNamara 2013 15 -3 (5) 15 0 (2)
100.0 % -3.00 -5.73, -0.27
Subtotal (95% CI) 15 15
100.0 % -3.00 -5.73, -0.27
Heterogeneity: not applicable
Test for overall effect: Z = 2.16 (P = 0.031)
3 Chronic Respirator y Disease Questionnaire - emotional fun ction score
McNamara 2013 15 -3 (5) 15 -1 (4)
100.0 % -2.00 -5.24, 1.24
Subtotal (95% CI) 15 15
100.0 % -2.00 -5.24, 1.24
Heterogeneity: not applicable
Test for overall effect: Z = 1.21 (P = 0.23)
4 Chronic Respirator y Disease Questionnaire - fatigue score McNamara 2013 15 -4 (4) 15 1 (3)
100.0 % -5.00 -7.53, -2.47
Subtotal (95% CI) 15 15
100.0 % -5.00 -7.53, -2.47
Heterogeneity: not applicable
Test for overall effect: Z = 3.87 (P = 0.00011)
5 Chronic Respirator y Disease Questionnaire - master y scor e
McNamara 2013 15 -2 (4) 15 0 (2)
100.0 % -2.00 -4.26, 0.26
Subtotal (95% CI) 15 15
100.0 % -2.00 -4.26, 0.26
Heterogeneity: not applicable
Test for overall effect: Z = 1.73 (P = 0.083)
6 St Georges Respirator y Questionnaire - total score de Souto Araujo 2012 8 -4 (11) 11 6 (9)
100.0 % -10.00 -19.29, -0.71
Subtotal (95% CI) 8 11
100.0 % -10.00 -19.29, -0.71
Heterogeneity: not applicable
Test for overall effect: Z = 2.11 (P = 0.035)
7 St Georges Respirator y Questionnaire - symptom score de Souto Araujo 2012 8 6 (21) 11 4 (9)
100.0 % 2.00 -13.49, 17.49
-50 -25 0 25 50
Favours water exercise Favours no exercise (Continued . . .)
33
Water-based exercise training for chronic obstructive pul monary disease (Review)
Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

(. . . Continued )
Study or subgroup Water-based exercise No exercise Mean
Difference Weight Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Subtotal (95% CI) 8 11100.0 % 2.00 -13.49, 17.49
Heterogeneity: not applicable
Test for overall effect: Z = 0.25 (P = 0.80)
8 St Georges Respirator y Questionnaire - activity score de Souto Araujo 2012 8 -9 (17) 11 4 (10)
100.0 % -13.00 -26.18, 0.18
Subtotal (95% CI) 8 11
100.0 % -13.00 -26.18, 0.18
Heterogeneity: not applicable
Test for overall effect: Z = 1.93 (P = 0.053)
9 St Georges Respirator y Questionnaire - impact score de Souto Araujo 2012 8 -5 (9) 11 8 (10)
100.0 % -13.00 -21.59, -4.41
Subtotal (95% CI) 8 11
100.0 % -13.00 -21.59, -4.41
Heterogeneity: not applicable
Test for overall effect: Z = 2.97 (P = 0.0030)
Test for subgroup differences: Chi 2
= 16.75, df = 8 (P = 0.03), I 2
=52%
-50 -25 0 25 50
Favours water exercise Favours no exercise
34
Water-based exercise training for chronic obstructive pul monary disease (Review)
Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

Analysis 1.4. Comparison 1 Water-based exercise versus no exercise, Outcome 4 Pulmonary function
(mean change).
Review: Water-based exercise training for chronic obstruc tive pulmonar y disease
Comparison: 1 Water-based exercise versus no exercise
Outcome: 4 Pulmonar y function (mean change)
Study or subgroup Water-based exercise No exercise Mean
Difference Weight Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 FEV 1(% predicted)
de Souto Araujo 2012 8 4.4 (3.8) 11 -2.4 (3.5)
74.8 % 6.80 3.45, 10.15
McNamara 2013 15 8.4 (7.7) 15 3.5 (8.4)
25.2 % 4.90 -0.87, 10.67
Subtotal (95% CI) 23 26
100.0 % 6.32 3.43, 9.22
Heterogeneity: Chi 2
= 0.31, df = 1 (P = 0.58); I 2
=0.0%
Test for overall effect: Z = 4.28 (P = 0.000019)
2 FVC (% predicted) de Souto Araujo 2012 8 4.5 (20.6) 11 -3.6 (9.1)
5.5 % 8.10 -7.15, 23.35
McNamara 2013 15 6.3 (10.3) 15 0.9 (7.5)
30.6 % 5.40 -1.05, 11.85
Ozdemir 2010 25 -0.5 (7.1) 25 -3.2 (8.9)
63.9 % 2.70 -1.76, 7.16
Subtotal (95% CI) 48 51
100.0 % 3.82 0.25, 7.39
Heterogeneity: Chi 2
= 0.78, df = 2 (P = 0.68); I 2
=0.0%
Test for overall effect: Z = 2.10 (P = 0.036)
3 FEV 1FVC ratio (%)
de Souto Araujo 2012 8 4.4 (12.1) 11 -4.1 (4)
16.5 % 8.50 -0.21, 17.21
McNamara 2013 15 3.6 (7.1) 15 2.3 (6.1)
55.7 % 1.30 -3.44, 6.04
Ozdemir 2010 25 0.5 (6) 25 -1.9 (16)
27.8 % 2.40 -4.30, 9.10
Subtotal (95% CI) 48 51
100.0 % 2.79 -0.74, 6.33
Heterogeneity: Chi 2
= 2.04, df = 2 (P = 0.36); I 2
=2%
Test for overall effect: Z = 1.55 (P = 0.12)
Test for subgroup differences: Chi 2
= 2.54, df = 2 (P = 0.28), I 2
=21%
-50 -25 0 25 50
Favours no exercise Favours water exercise
35
Water-based exercise training for chronic obstructive pul monary disease (Review)
Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

Analysis 1.5. Comparison 1 Water-based exercise versus no exercise, Outcome 5 Respiratory muscle
strength (mean change).
Review: Water-based exercise training for chronic obstruc tive pulmonar y disease
Comparison: 1 Water-based exercise versus no exercise
Outcome: 5 Respirator y muscle strength (mean change)
Study or subgroup Water-based exercise No exercise Mean
Difference Weight Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 MIP (cm H 2O)
de Souto Araujo 2012 8 33 (30) 11 -14 (20)
12.7 % 47.00 23.09, 70.91
McNamara 2013 15 7 (10) 15 -2 (15)
87.3 % 9.00 -0.12, 18.12
Subtotal (95% CI) 23 26
100.0 % 13.83 5.30, 22.35
Heterogeneity: Chi 2
= 8.47, df = 1 (P = 0.004); I 2
=88%
Test for overall effect: Z = 3.18 (P = 0.0015)
2 MIP (% predicted) de Souto Araujo 2012 8 32 (31) 11 -14 (20)
18.1 % 46.00 21.48, 70.52
McNamara 2013 15 11 (14) 15 -3 (18)
81.9 % 14.00 2.46, 25.54
Subtotal (95% CI) 23 26
100.0 % 19.80 9.36, 30.24
Heterogeneity: Chi 2
= 5.36, df = 1 (P = 0.02); I 2
=81%
Test for overall effect: Z = 3.72 (P = 0.00020)
3 MEP (cm H 2O)
de Souto Araujo 2012 8 17 (13) 11 -5 (14)
54.4 % 22.00 9.77, 34.23
McNamara 2013 15 2 (16) 15 -3 (21)
45.6 % 5.00 -8.36, 18.36
Subtotal (95% CI) 23 26
100.0 % 14.25 5.23, 23.27
Heterogeneity: Chi 2
= 3.38, df = 1 (P = 0.07); I 2
=70%
Test for overall effect: Z = 3.10 (P = 0.0020)
4 MEP (% predicted)
de Souto Araujo 2012 8 18 (14) 11 -5 (14)
66.2 % 23.00 10.25, 35.75
McNamara 2013 15 5 (20) 15 5 (29)
33.8 % 0.0 -17.83, 17.83
Subtotal (95% CI) 23 26
100.0 % 15.22 4.85, 25.59
Heterogeneity: Chi 2
= 4.23, df = 1 (P = 0.04); I 2
=76%
Test for overall effect: Z = 2.88 (P = 0.0040)
Test for subgroup differences: Chi 2
= 0.88, df = 3 (P = 0.83), I 2
=0.0%
-100 -50 0 50 100
Favours no exercise Favours water exercise
36
Water-based exercise training for chronic obstructive pul monary disease (Review)
Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

Analysis 2.1. Comparison 2 Water-based exercise versus land-based exercise, Outcome 1 Exercise capacity
(mean change in metres).
Review: Water-based exercise training for chronic obstruc tive pulmonar y disease
Comparison: 2 Water-based exercise versus land-based exer cise
Outcome: 1 Exercise capacity (mean change in metres)
Study or subgroup Water-based exercise Land-based exercis eMean
Difference Weight Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Functional - six-minute walk test de Souto Araujo 2012 8 56 (51) 13 22 (53)
22.6 % 34.00 -11.60, 79.60
McNamara 2013 15 48 (39) 15 43 (37)
63.4 % 5.00 -22.21, 32.21
OBrien 2004 5 14 (55) 6 14 (40)
14.0 % 0.0 -57.87, 57.87
Subtotal (95% CI) 28 34
100.0 % 10.85 -10.82, 32.51
Heterogeneity: Chi 2
= 1.30, df = 2 (P = 0.52); I 2
=0.0%
Test for overall effect: Z = 0.98 (P = 0.33)
2 Peak - incremental shuttle walk test McNamara 2013 15 49 (43) 15 13 (53)
50.7 % 36.00 1.46, 70.54
Wadell 2004 15 19 (66) 14 37 (20)
49.3 % -18.00 -53.00, 17.00
Subtotal (95% CI) 30 29
100.0 % 9.36 -15.22, 33.95
Heterogeneity: Chi 2
= 4.63, df = 1 (P = 0.03); I 2
=78%
Test for overall effect: Z = 0.75 (P = 0.46)
3 Endurance - endurance shuttle walk test
McNamara 2013 15 321 (356) 15 117 (216)
14.7 % 204.00 -6.73, 414.73
Wadell 2004 15 365 (164) 14 33 (53)
85.3 % 332.00 244.49, 419.51
Subtotal (95% CI) 30 29
100.0 % 313.17 232.35, 393.99
Heterogeneity: Chi 2
= 1.21, df = 1 (P = 0.27); I 2
=17%
Test for overall effect: Z = 7.59 (P 0.00001)
Test for subgroup differences: Chi 2
= 51.89, df = 2 (P = 0.00), I 2
=96%
-500 -250 0 250 500
Favours land exercise Favours water exercise
37
Water-based exercise training for chronic obstructive pul monary disease (Review)
Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

Analysis 2.2. Comparison 2 Water-based exercise versus land-based exercise, Outcome 2 Quality of life
(mean change in total scores).
Review: Water-based exercise training for chronic obstruc tive pulmonar y disease
Comparison: 2 Water-based exercise versus land-based exer cise
Outcome: 2 Quality of life (mean change in total scores)
Study or subgroup Water-based exercise Land-based exercis eStd.
Mean
Difference Weight Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
de Souto Araujo 2012 8 -4 (11) 13 -16 (15)21.5 % 0.84 -0.08, 1.77
McNamara 2013 15 -12 (15) 15 -4 (7)
33.7 % -0.67 -1.40, 0.07
OBrien 2004 5 -4 (6) 6 -2 (4)
12.7 % -0.37 -1.57, 0.84
Wadell 2004 14 -3 (11) 13 -1 (10)
32.1 % -0.18 -0.94, 0.57
Total (95% CI) 42 47
100.0 % -0.15 -0.58, 0.28
Heterogeneity: Chi 2
= 6.43, df = 3 (P = 0.09); I 2
=53%
Test for overall effect: Z = 0.68 (P = 0.50)
Test for subgroup differences: Not applicable
-2 -1 0 1 2
Favours water exercise Favours land exercise
38
Water-based exercise training for chronic obstructive pul monary disease (Review)
Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

Analysis 2.3. Comparison 2 Water-based exercise versus land-based exercise, Outcome 3 Quality of life
(mean change in individual domain scores).
Review: Water-based exercise training for chronic obstruc tive pulmonar y disease
Comparison: 2 Water-based exercise versus land-based exer cise
Outcome: 3 Quality of life (mean change in individual domain scores)
Study or subgroup Water-based exercise Land-based exercis eMean
Difference Weight Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Chronic Respirator y Disease Questionnaire - total score McNamara 2013 15 -12 (15) 15 -4 (7)
100.0 % -8.00 -16.38, 0.38
Subtotal (95% CI) 15 15
100.0 % -8.00 -16.38, 0.38
Heterogeneity: not applicable
Test for overall effect: Z = 1.87 (P = 0.061)
2 Chronic Respirator y Disease Questionnaire - dyspnoea sco re
McNamara 2013 15 -3 (5) 15 -1 (2)
100.0 % -2.00 -4.73, 0.73
Subtotal (95% CI) 15 15
100.0 % -2.00 -4.73, 0.73
Heterogeneity: not applicable
Test for overall effect: Z = 1.44 (P = 0.15)
3 Chronic Respirator y Disease Questionnaire - emotional fun ction score
McNamara 2013 15 -3 (5) 15 -1 (4)
100.0 % -2.00 -5.24, 1.24
Subtotal (95% CI) 15 15
100.0 % -2.00 -5.24, 1.24
Heterogeneity: not applicable
Test for overall effect: Z = 1.21 (P = 0.23)
4 Chronic Respirator y Disease Questionnaire - fatigue score McNamara 2013 15 -4 (4) 15 -1 (2)
100.0 % -3.00 -5.26, -0.74
Subtotal (95% CI) 15 15
100.0 % -3.00 -5.26, -0.74
Heterogeneity: not applicable
Test for overall effect: Z = 2.60 (P = 0.0094)
5 Chronic Respirator y Disease Questionnaire - master y scor e
McNamara 2013 15 -2 (4) 15 -1 (2)
100.0 % -1.00 -3.26, 1.26
Subtotal (95% CI) 15 15
100.0 % -1.00 -3.26, 1.26
Heterogeneity: not applicable
Test for overall effect: Z = 0.87 (P = 0.39)
6 St Georges Respirator y Questionnaire - total score de Souto Araujo 2012 8 -4 (11) 14 -16 (15)
16.5 % 12.00 1.05, 22.95
OBrien 2004 5 -4 (6) 6 -2 (4)
52.1 % -2.00 -8.16, 4.16
Wadell 2004 14 -3 (11) 13 -1 (10)
31.5 % -2.00 -9.92, 5.92
Subtotal (95% CI) 27 33
100.0 % 0.31 -4.14, 4.75
Heterogeneity: Chi 2
= 5.25, df = 2 (P = 0.07); I 2
=62%
-50 -25 0 25 50
Favours water exercise Favours land exercise (Continued . . .)
39
Water-based exercise training for chronic obstructive pul monary disease (Review)
Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

(. . . Continued )
Study or subgroup Water-based exercise Land-based exercis eMean
Difference Weight Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Test for overall effect: Z = 0.13 (P = 0.89)
7 St Georges Respirator y Questionnaire - symptom score de Souto Araujo 2012 8 6 (21) 13 -16 (18)
38.7 % 22.00 4.46, 39.54
OBrien 2004 5 -2 (22) 6 1 (16)
22.2 % -3.00 -26.15, 20.15
Wadell 2004 14 0 (26) 13 0 (20)
39.1 % 0.0 -17.43, 17.43
Subtotal (95% CI) 27 32
100.0 % 7.84 -3.06, 18.74
Heterogeneity: Chi 2
= 4.12, df = 2 (P = 0.13); I 2
=52%
Test for overall effect: Z = 1.41 (P = 0.16)
8 St Georges Respirator y Questionnaire - activity score de Souto Araujo 2012 8 -9 (17) 13 -21 (21)
8.8 % 12.00 -4.40, 28.40
OBrien 2004 5 -1 (3) 6 1 (9)
40.1 % -2.00 -9.67, 5.67
Wadell 2004 14 -5 (9) 13 1 (9)
51.1 % -6.00 -12.79, 0.79
Subtotal (95% CI) 27 32
100.0 % -2.82 -7.67, 2.04
Heterogeneity: Chi 2
= 4.02, df = 2 (P = 0.13); I 2
=50%
Test for overall effect: Z = 1.14 (P = 0.26)
9 St Georges Respirator y Questionnaire - impact score de Souto Araujo 2012 8 -5 (9) 13 -13 (16)
13.6 % 8.00 -2.70, 18.70
OBrien 2004 5 -6 (5) 6 -4 (2)
71.5 % -2.00 -6.67, 2.67
Wadell 2004 14 -3 (13) 13 -2 (14)
14.9 % -1.00 -11.21, 9.21
Subtotal (95% CI) 27 32
100.0 % -0.49 -4.44, 3.45
Heterogeneity: Chi 2
= 2.83, df = 2 (P = 0.24); I 2
=29%
Test for overall effect: Z = 0.24 (P = 0.81)
Test for subgroup differences: Chi 2
= 8.15, df = 8 (P = 0.42), I 2
=2%
-50 -25 0 25 50
Favours water exercise Favours land exercise
40
Water-based exercise training for chronic obstructive pul monary disease (Review)
Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

Analysis 2.4. Comparison 2 Water-based exercise versus land-based exercise, Outcome 4 Pulmonary
function (mean change).
Review: Water-based exercise training for chronic obstruc tive pulmonar y disease
Comparison: 2 Water-based exercise versus land-based exer cise
Outcome: 4 Pulmonar y function (mean change)
Study or subgroup Water-based exercise Land-based exercis eMean
Difference Weight Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 FEV 1(litres)
McNamara 2013 15 0.14 (0.15) 15 0.07 (0.24)
65.9 % 0.07 -0.07, 0.21
OBrien 2004 5 0.04 (0.06) 6 -0.05 (0.24)
34.1 % 0.09 -0.11, 0.29
Subtotal (95% CI) 20 21
100.0 % 0.08 -0.04, 0.19
Heterogeneity: Chi 2
= 0.03, df = 1 (P = 0.87); I 2
=0.0%
Test for overall effect: Z = 1.29 (P = 0.20)
2 FEV 1(% predicted)
de Souto Araujo 2012 8 4.4 (3.8) 13 6.5 (5.2)
64.0 % -2.10 -5.96, 1.76
McNamara 2013 15 8.4 (7.73) 15 3 (9.95)
23.5 % 5.40 -0.98, 11.78
OBrien 2004 5 1.55 (2.26) 6 -0.78 (10.66)
12.5 % 2.33 -6.43, 11.09
Subtotal (95% CI) 28 34
100.0 % 0.21 -2.88, 3.31
Heterogeneity: Chi 2
= 4.14, df = 2 (P = 0.13); I 2
=52%
Test for overall effect: Z = 0.14 (P = 0.89)
3 FVC (litres) McNamara 2013 15 0.16 (0.23) 15 0.04 (0.3)
71.5 % 0.12 -0.07, 0.31
OBrien 2004 5 0.08 (0.26) 6 -0.03 (0.25)
28.5 % 0.11 -0.19, 0.41
Subtotal (95% CI) 20 21
100.0 % 0.12 -0.04, 0.28
Heterogeneity: Chi 2
= 0.00, df = 1 (P = 0.96); I 2
=0.0%
Test for overall effect: Z = 1.42 (P = 0.16)
4 FVC (% predicted)
de Souto Araujo 2012 8 4.5 (20.6) 13 6.1 (13.3)
19.9 % -1.60 -17.60, 14.40
McNamara 2013 15 6.3 (10.3) 15 2.3 (11.9)
80.1 % 4.00 -3.96, 11.96
Subtotal (95% CI) 23 28
100.0 % 2.89 -4.24, 10.02
Heterogeneity: Chi 2
= 0.38, df = 1 (P = 0.54); I 2
=0.0%
Test for overall effect: Z = 0.79 (P = 0.43)
5 FEV 1FVC ratio (%)
de Souto Araujo 2012 8 4.4 (12.1) 13 3.5 (13.6)
13.5 % 0.90 -10.28, 12.08
McNamara 2013 15 3.6 (7.13) 15 0.87 (6.55)
70.4 % 2.73 -2.17, 7.63
OBrien 2004 5 1.08 (6.89) 6 -0.04 (10.37)
16.1 % 1.12 -9.14, 11.38
-20 -10 0 10 20
Favours land exercise Favours water exercise (Continued . . .)
41
Water-based exercise training for chronic obstructive pul monary disease (Review)
Copyright 2013 The Cochrane Collaboration. Published by J ohn Wiley & Sons, Ltd.

(. . . Continued )
Study or subgroup Water-based exercise Land-based exercis eMean
Difference Weight Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
Subtotal (95% CI) 28 34100.0 % 2.22 -1.89, 6.34
Heterogeneity: Chi 2
= 0.14, df = 2 (P = 0.93); I 2
=0.0%
Test for overall effect: Z = 1.06 (P = 0.29)
Test for subgroup differences: Chi 2
= 1.79, df = 4 (P = 0.77), I 2
=0.0%
-20 -10 0 10 20
Favours land exercise Favours water exercise
Analysis 2.5. Comparison 2 Water-based exercise versus lan d-based exercise, Outcome 5 Respiratory
muscle strength (mean change).
Review: Water-based exercise training for chronic obstruc tive pulmonar y disease
Comparison: 2 Water-based exercise versus land-based exer cise
Outcome: 5 Respirator y muscle strength (mean change)
Study or subgroup Water-based exercise Land-based exercis eMean
Difference Weight Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 MIP (cm H 2O)
de Souto Araujo 2012 8 33 (30) 13 32 (36)
6.5 % 1.00 -27.55, 29.55
McNamara 2013 15 7 (10) 15 7 (11)
93.5 % 0.0 -7.52, 7.52
Subtotal (95% CI) 23 28
100.0 % 0.06 -7.21, 7.34
Heterogeneity: Chi 2
= 0.00, df = 1 (P = 0.95); I 2
=0.0%
Test for overall effect: Z = 0.02 (P = 0.99)
2 MIP (% predicted)
de Souto Araujo 2012 8 32 (31) 13 34 (36)
10.0 % -2.00 -31.06, 27.06
McNamara 2013 15 11 (14) 15 7 (13)
90.0 % 4.00 -5.67, 13.67
Subtotal (95% CI) 23 28
100.0 % 3.40 -5.77, 12.58
Heterogeneity: Chi 2
= 0.15, df = 1 (P = 0.70); I 2
=0.0%
Test for overall effect: Z = 0.73 (P = 0.47)
3 MEP (cm H 2O)
de Souto Araujo 2012 8 17 (13) 13 27 (36)
20.0 % -10.00 -31.54, 11.54
-50 -25 0 25 50
Favours land exercise Favours water exercise (Continued . . .)
42
Water-based exercise training for chronic obstructive pul monary disease (Review)
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(. . . Continued )
Study or subgroup Water-based exercise Land-based exercis eMean
Difference Weight Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
McNamara 2013 15 2 (16) 15 8 (14)80.0 % -6.00 -16.76, 4.76
Subtotal (95% CI) 23 28
100.0 % -6.80 -16.42, 2.83
Heterogeneity: Chi 2
= 0.11, df = 1 (P = 0.74); I 2
=0.0%
Test for overall effect: Z = 1.38 (P = 0.17)
4 MEP (% predicted) de Souto Araujo 2012 8 18 (14) 13 25 (35)
21.9 % -7.00 -28.36, 14.36
McNamara 2013 15 5 (20) 15 8 (10)
78.1 % -3.00 -14.32, 8.32
Subtotal (95% CI) 23 28
100.0 % -3.88 -13.88, 6.12
Heterogeneity: Chi 2
= 0.11, df = 1 (P = 0.75); I 2
=0.0%
Test for overall effect: Z = 0.76 (P = 0.45)
Test for subgroup differences: Chi 2
= 2.65, df = 3 (P = 0.45), I 2
=0.0%
-50 -25 0 25 50
Favours land exercise Favours water exercise
Analysis 2.6. Comparison 2 Water-based exercise versus lan d-based exercise, Outcome 6 Body
composition (mean change in kilograms).
Review: Water-based exercise training for chronic obstruc tive pulmonar y disease
Comparison: 2 Water-based exercise versus land-based exer cise
Outcome: 6 Body composition (mean change in kilograms)
Study or subgroup Water-based exercise Land-based exercis eMean
Difference Weight Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
McNamara 2013 15 -1.9 (3.2) 15 -0.2 (3.4)33.2 % -1.70 -4.06, 0.66
Wadell 2004 15 0.2 (2.01) 14 1.29 (2.52)
66.8 % -1.09 -2.76, 0.58
Total (95% CI) 30 29
100.0 % -1.29 -2.65, 0.07
Heterogeneity: Chi 2
= 0.17, df = 1 (P = 0.68); I 2
=0.0%
Test for overall effect: Z = 1.86 (P = 0.063)
Test for subgroup differences: Not applicable
-10 -5 0 5 10
Favours water exercise Favours land exercise
43
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Analysis 2.7. Comparison 2 Water-based exercise versus land-based exercise, Outcome 7 Attendance
(mean number).
Review: Water-based exercise training for chronic obstruc tive pulmonar y disease
Comparison: 2 Water-based exercise versus land-based exer cise
Outcome: 7 Attendance (mean number)
Study or subgroup Water-based exercise Land-based exercis eStd.
Mean
Difference Weight Std.
Mean
Difference
N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI
1 Attendance at super vised exercise sessions McNamara 2013 15 21 (2) 15 19 (4)
72.3 % 0.62 -0.12, 1.35
OBrien 2004 5 10 (1) 6 10 (1)
27.7 % 0.0 -1.19, 1.19
Subtotal (95% CI) 20 21
100.0 % 0.44 -0.18, 1.07
Heterogeneity: Chi 2
= 0.75, df = 1 (P = 0.39); I 2
=0.0%
Test for overall effect: Z = 1.40 (P = 0.16)
Test for subgroup differences: Not applicable
-2 -1 0 1 2
Favours land exercise Favours water exercise
A D D I T I O N A L T A B L E S
Table 1. Intervention characteristics
StudyWater-based exerciseLand-based exerciseOther comparison
group
Description In-
tensityFrequencyDescription In-
tensityFrequency
de Souto Araujo
2012Continuous warm-
up exercises for up-
per and lower limbs
(callisthenic activi-
ties with the res-
piratory cycle) forEight weeks, three
times a week, 90
minutesContinuous exercise
for upper and lower
limbs (callisthenic
activities with the
respiratory cycle) for
15 minutes withoutSame as water-based
exerciseNo exercise training
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Table 1. Intervention characteristics(Continued)
15 minutes without
weights;
unsupported upper
limb exercises using
two diagonal move-
ments and weights
for two min-
utes with an equal
rest period (initial
weight 50% of max-
imum load and in-
creased weekly)
; lower limb train-
ing using oats posi-
tioned between the
legs and perform-
ing bicycling move-
ments for 30 min-
utes (intensity de-
termined by Borg
dyspnoea and per-
ceived effort score of
5); 15 minutes of
cool-down exercise
for muscle groups
used during the ses-
sionweights;
unsupported upper
limb exercises us-
ing weights (initial
weight 50% of max-
imum load and in-
creased weekly)
and diagonal move-
ments for two min-
utes with equal rest
periods; lower limb
cycling for 30 min-
utes (intensity de-
termined by Borg
dyspnoea and per-
ceived effort score of
ve); 15 minutes of
cool-down exercise
for muscle groups
used during the ses-
sion
McNamara 2013Supervised sessions
consisting of exer-
cises in hydrother-
apy pool matched
as closely as possi-
ble for intensity, du-
ration
and muscle groups
trained to the land-
based training exer-
cises, and progressed
by increasing water
turbulence, speed
and range of mo-
tion (specic exer-
cise programme de-
tailed in main pub-
lication)Eight weeks, three
times a week, 60
minutesSupervised sessions
consisting of up-
per limb endurance
exercise and lower
limb endurance ex-
ercise (walking and
cycling) in a gym
with initial intensity
at 80% of walking
speed on initial six-
minute walk test ei-
ther over-ground or
on a treadmill, and
progressed to main-
tain an intensity rat-
ing of three to ve
on the modied cat-
egory ratio 0 to 10
dyspnoea and rat-
ing of perceived ex-
ertion scalesSame as water-based
exerciseUsual medical care,
no exercise training,
requested not to al-
ter exercise level over
study period
45
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Table 1. Intervention characteristics(Continued)
OBrien 2004Supervised in hy-
drotherapy pool us-
ing similar muscle
groups to ensure
standardisation to
land-based exercise
programme and us-
ing properties of wa-
ter to provide resis-
tance, at an intensity
of three to four on
the modied Borg
rating of perceived
exertion scaleSix weeks, two times
a week, 45 minutesSupervised
warm-up of walk-
ing and stretches,
aerobic training and
strength and resis-
tance training using
free weights, at an
intensity of three to
four on the mod-
ied Borg rating
of perceived exer-
tion scaleSame as water-based
exercise-
Ozdemir 2010Supervised in an
aquatic centre with a
warm-up, stretches
and strengthening
exercises for shoul-
der girdle and up-
per extremity mus-
cles utilising oata-
tion devices for re-
sistanceFour weeks, three
times a week, 35
minutes--Medical therapy
only
Wadell 2004As per land-based
exercise training but
in water12
weeks, three times a
week, 45 minutesSupervised,
intensity guided by
music to achieve a
mean heart rate of
80% to 100% of
peak heart rate ac-
cording to maximal
cycle ergometer test
and a Borg dysp-
noea score of 5 and
rating of perceived
exertion score of 15,
including warm-up
and exibility exer-
cises, followed
by four minutes of
endurance exercises
and three minutes of
strength exer-
cises (repeated three
times while focus-
ing on the legs, armsSame as water-based
exerciseNo intervention
46
Water-based exercise training for chronic obstructive pul monary disease (Review)
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Table 1. Intervention characteristics(Continued)
and torso each time)
and nally exibil-
ity, stretching and
cool-down exercises
A P P E N D I C E S
Appendix 1. Sources and search methods for the Cochrane Airways Gr oup Specialised Register
(CAGR)
Electronic searches: core databases
DatabaseFrequency of search
CENTRAL ( The Cochrane Library )Monthly
MEDLINE (Ovid)Weekly
EMBASE (Ovid)Weekly
PsycINFO (Ovid)Monthly
CINAHL (EBSCO)Monthly
AMED (EBSCO)Monthly
Handsearches: core respiratory conference abstracts
ConferenceYears searched
American Academy of Allergy, Asthma and Immunology (AAAAI)2001 onwards
American Thoracic Society (ATS)2001 onwards
Asia Pacic Society of Respirology (APSR)2004 onwards
47
Water-based exercise training for chronic obstructive pul monary disease (Review)
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(Continued)
British Thoracic Society Winter Meeting (BTS)2000 onwards
Chest Meeting2003 onwards
European Respiratory Society (ERS)1992, 1994, 2000 onwards
International Primary Care Respiratory Group Congress (IPC RG)2002 onwards
Thoracic Society of Australia and New Zealand (TSANZ)1999 onwards
MEDLINE search strategy used to identify trials for the CAGR
COPD search
1. Lung Diseases, Obstructive
2. exp Pulmonary Disease, Chronic Obstructive
3. emphysema$.mp.
4. (chronic$ adj3 bronchiti$).mp.
5. (obstruct$ adj3 (pulmonary or lung$ or airway$ or airow$ or b ronch$ or respirat$)).mp.
6. COPD.mp.
7. COAD.mp.
8. COBD.mp.
9. AECB.mp.
10. or1-9
Filter to identify RCTs
1. exp clinical trial publication type
2. (randomised or randomised).ab,ti.
3. placebo.ab,ti.
4. dt.fs.
5. randomly.ab,ti.
6. trial.ab,ti.
7. groups.ab,ti.
8. or1-7
9. Animals
10. Humans
11. 9 not (9 and 10)
12. 8 not 11
The MEDLINE strategy and the RCT lter are adapted to identif y trials in other electronic databases.
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Water-based exercise training for chronic obstructive pul monary disease (Review)
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H I S T O R Y
Protocol rst published: Issue 1, 2010
Review rst published: Issue 12, 2013
DateEventDescription
25 November 2009AmendedConicts of interest statement added.
C O N T R I B U T I O N S O F A U T H O R S
RJM: protocol initiation, development and writing; search for and retrieval of studies; study screening, quality appraisal and data
extraction; author contact; data entry and analysis; manuscrip t writing.
ZJM: protocol development; study screening, quality apprais al and data extraction; data entry review; manuscript review.
DKM: protocol development; manuscript review.
JAA: protocol development; study quality appraisal; manuscr ipt review.
D E C L A R A T I O N S O F I N T E R E S T
The review authors (RJM, ZJM, DKM and JAA) conducted one of the in cluded studies before commencing this review (
McNamara
2013
).
S O U R C E S O F S U P P O R T
Internal sources No sources of support supplied
External sources Australian Cochrane Airways Group Network Scholarship, Aust ralia.
D I F F E R E N C E S B E T W E E N P R O T O C O L A N D R E V I E W
Types of interventions: The criterion trials where water-ba sed training was combined with another training interventio n were included
provided 50% or more of the training was water-based was chang ed to a criterion whereby trials where water-based training was
combined with another training intervention were included pr ovided the water-based exercise training accounted forgreater than 50%
of the total training period.
Types of outcome measures-secondary outcomes: Additional outco mes reported in trials (but not prespecied for this review) were
included in the secondary outcome measures list in this review f or future updates. These include body composition, attendance,
preference for exercise training mode and arterial blood gase s.
Subgroup analysis: This analysis could not be performed for d isease severity, as we did not identify any trials with data presented
according to disease severity.
Sensitivity analysis: This was not performed and funnel plo ts were not constructed because of the small number of included st udies. If
in future updates more studies are included, these analyses w ill be performed.
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Water-based exercise training for chronic obstructive pul monary disease (Review)
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