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LITERATURE REVIEW
The Effectiveness of Hydrotherapy in the Management
of Rheumatoid Arthritis: A Systematic Review
Khamis Y. Al-Qubaeissy MD, Francis A. Fatoye PhD, Peter C. Goodwin PhD &
Abebaw M. Yohannes*PhD, MSc, FCCP
Department of Health Professions, Manchester Metropolitan University, Manchester, UK
Abstract
Background. Hydrotherapy is frequently indicated for the rehabilitation of patients with rheumatoid arthritis (RA);
nevertheless, there has been inadequate appraisal of its effectiveness. The potential benefits of hydrotherapy for
patients with RA are to improve and/or maintain functional ability and quality of life.
Objectives. The aim of this systematic review was to evaluate the effectiveness of hydrotherapy in the management
of patients with RA.
Method. AMED, CINAHL, EMBASE, MEDLINE, PubMed, Science Direct and Web of Science were searched between
1988 and May 2011. Keywords used were rheumatoid arthritis, hydrotherapy, aquatic physiotherapy, aqua therapy and
water therapy. Searches were supplemented with hand searches of references of selected articles. Randomized
controlled trials were assessed for their methodological quality using the Physiotherapy Evidence Database (PEDro)
scale. This scale ranks the methodological quality of a study scoring 7 out of 10 as ‘high quality’,5–6as‘moderate
quality’and less than 4 as ‘poor quality’.
Results. Initially, 197 studies were identified. Six studies met the inclusion criteria for further analysis. The average
methodological quality for all studies was 6.8 using the PEDro scale. Most of the studies reported favourable
outcomes for a hydrotherapy intervention compared with no treatment or other interventions for patients with
RA. Improvement was particularly noted in reducing pain, joint tenderness, mood and tension symptoms, and
increasing grip strength and patient satisfaction with hydrotherapy treatment in the short term.
Conclusions. There is some evidence to suggest that hydrotherapy has a positive role in reducing pain and improving
the health status of patients with RA compared with no or other interventions in the short term. However, the
long-term benefit is unknown. Further studies are needed. Copyright © 2012 John Wiley & Sons, Ltd.
Keywords
Rheumatoid arthritis; hydrotherapy; aquatic physiotherapy; aqua therapy; water therapy; pain; quality of life; physical activity
*Correspondence
Abebaw Mengistu Yohannes, Reader in Physiotherapy, Department of Health Professions, Manchester Metropolitan University, Elizabeth
Gaskell Building, Hathersage Road, Manchester, M13 0JA, UK. Tel: 44 (0) 161 247 2943; Fax: 44 (0) 161 247 6571.
Email: A.Yohannes@mmu.ac.uk
Published online 16 July 2012 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/msc.1028
Introduction
Rheumatoid arthritis (RA) is a chronic, systemic, inflam-
matory, symmetrical polyarthritis disease that can be
both erosive and deforming (Arthritis Research UK,
2011; McMahone and Allard, 2002; Waldburger and
Firestein, 2008). It affects many organs and tissues in
the body, although the joints are usually the most
severely affected (Arthritis Research UK, 2011; National
Institute for Health and Clinical Excellence (NICE),
2009; Waldburger and Firestein, 2008). The disease is
characterized by joint pain, swelling, tenderness and the
3Musculoskelet. Care 11 (2013) 3–18 © 2012 John Wiley & Sons, Ltd.
destruction of the synovial joints, leading to severe
disability and premature mortality (NICE, 2009;
Tehlirian and Bathon, 2008; Waldburger and Firestein,
2008). It results from an immune system disturbance
caused by the interaction of immunological, genetic,
environmental and hormonal factors (Arthritis Research
UK, 2011; NICE, 2009; Waldburger and Firestein, 2008).
It typically affects the small joints of the hands, especially
the knuckles and second joints, such as metacarpopha-
langeal joint and proximal interphalangeal joint, as well
as the wrists, knees, ankles, elbows, shoulders and feet
(Tehlirian and Bathon, 2008). Usually, both sides of the
body are equally affected in a symmetrical fashion,
although any synovial joint can be affected. The lumbar
spine and hips are often spared (Tehlirian and Bathon,
2008). In the USA, the average annual incidence of RA
is 0.5 per 1,000 persons per year (Drosos, 2004; Tehlirian
and Bathon, 2008), and in the UK it affects approxi-
mately 0.5–1% of the population (McMahone and
Allard, 2002; Symmons et al., 1994, 2002). The overall
prevalence of RA worldwide in the general population
is 1–2%, and it affects more women than men; this prev-
alence is expected to rise to 5% of people by the age of
70 years in the next few decades (NICE, 2009; Symmons
et al., 1994; Tehlirian and Bathon, 2008). In the UK,
there are 100 new cases of inflammatory joint disease
per hundred thousand of the population per year, of
whom 24 will have RA (Söderlin et al., 2002). The direct
costs to the National HealthService are estimated at £560
million and to the wider economy (e.g. loss of earnings
due to ill health) are estimated at £1.8 billion per annum
(Comptroller and Auditor General, 2009), whereas the
total costs of RA in the UK, together with the indirect
costs and the effects of early mortalityand lost productiv-
ity, have been approximated at between £3.8 and £4.75
billion per year (NICE, 2009).
Exercise is the cornerstone of the treatment of RA
and it improves function, muscle strength and general
well-being (Hurkmans et al., 2009; van den Ende
et al., 2008; Vliet Vlieland and van den Ende, 2011).
The term ‘hydrotherapy’or ‘aquatic exercise’is defined
as exercise in warm water under supervision by
utilizing the buoyancy, assistance and resistance of
warm water to relieve pain, induce muscle relaxation
and promote more effective exercise (Campion, 1997;
Eversden et al., 2007; Hall et al., 2008; Schrepfer,
2002). Hydrotherapy is a safe and efficient medium
treatment modality for achieving exercise-related goals
and it is commonly used as part of a rehabilitation
intervention for patients with rheumatic disease
(Beardmore, 2008; Rintala et al., 1996).
Unblinded studies that examined the efficacy of
hydrotherapy in patients with RA demonstrated a reduc-
tion in pain and an increase in quality of life (QoL),
muscle strength, aerobic conditioning and physical func-
tioning (Danneskiold-Samsøe et al., 1987; Hart et al.,
1994; Minor et al., 1989). However, the generizability
of the findings were limited because of small sample sizes
and a lack of controlled intervention.
To our knowledge, there has been no recent exclusive
systematic review to examine the efficacy of hydrother-
apy for patients with RA. We hypothesized that
hydrotherapy therapy is far superior than other types of
therapy, including ‘usual care’, for improving QoL and
physical activity in patients with RA.
The aim of this review was to synthesize the available
literature on the efficacy of hydrotherapy in the
management of patients with RA.
Materials and methods
Identification and selection criteria
An electronic database search of AMED, CINAHL, the
Cochrane Library, EMBASE, MEDLINE, ProQuest,
Pub Med, Science Direct and the Web of Science was
conducted (1988 to May 2011). In order to standardize
the patient sample included, the search was conducted
from 1988 [which was the date of the publication of the
American College of Rheumatology (ACR) criteria for
RA] to May 2011(Arnett et al., 1988). The search was
limited to human adults (age >18 years) across all
articles published in English. The keywords used
were: ‘rheumatoid arthritis’,‘hydrotherapy’,‘aquatic
physiotherapy’,‘aqua therapy’and ‘water therapy’.
Keyword combinations were: ‘rheumatoid arthritis
and hydrotherapy’,‘rheumatoid arthritis and aquatic
physiotherapy’,‘rheumatoid arthritis and aqua therapy’
and ‘rheumatoid arthritis and water therapy’. Studies
that used the following keywords were excluded from
this literature search: ‘colonic irrigation’,‘water birth’,
‘Kneipp therapy’,‘spa therapy’,‘whirlpool therapy’,
‘contrast baths’and ‘balneotherapy’. There is a lack of
clarity in the usage of the terms ‘hydrotherapy’and
‘balneotherapy’(Bender et al., 2005). Hydrotherapy
uses water as a treatment, while balneotherapy uses
natural thermal mineral water (Bender et al., 2005).
Although these terms have often been used interchangeably,
The Effectiveness of Hydrotherapy in RA Al-Qubaeissy et al.
4Musculoskelet. Care 11 (2013) 3–18 © 2012 John Wiley & Sons, Ltd.
balneotherapy is not easily accessible to healthcare
professionals and so studies involving this treatment
were excluded.
Trials investigating solely the physiological responses
(such as heart rate, blood pressure and renal function)
of subjects immersed or exercising in water were
also excluded.
The database search was supplemented by a manual
search of: Clinical Journal of Rheumatology, Annals of
the Rheumatic Disease, British Medical Journal, Physio-
therapy, Arthritis and Rheumatism, Rheumatology and
Journal of Rheumatology and Physical Therapy. Journals
were searched from 1988 to May 2011. A further hand
search of the bibliographic references in the extracted
articles and existing reviews was also conducted
to identify potential studies that were not captured by
the electronic database searches. To ensure that all of
the relevant articles were obtained, an iterative process
was used.
Inclusion and exclusion criteria for
considering studies for this review
Studies were included if:
•they were randomized controlled trials (RCTs);
•they were published in the English language;
•they included participants aged 18 years or above who
had been diagnosed with RA according to the 1987
ACR criteria (Arnett et al., 1988) or they used the
criteria of Steinbrocker (Steinbrocker et al., 1949);
•a water-based intervention (hydrotherapy) had been
used in the study, and compared with the results
without intervention;
•patients had received a minimum of four weeks of
hydrotherapy intervention.
•they used one of the following outcome measures:
pain, patient global assessment, activity of daily living
(ADL), physical function, disease activity and QoL
(Boers et al., 1994; Haigh et al., 2001).
Articles were excluded if:
•they had insufficient information available (abstract only);
•they did not involve an RCT;
•they were not adult trials (juvenile trials);
•they did not involve human trials;
•they included participants without rheumatic diseases;
•the treatment modality included balneotherapy, Kneipp
therapy, mud therapy or sulphur therapy;
•they were not written in English (even if the abstract
was in English);
•participants were primarily and predominantly
diagnosed with osteoarthritis, fibromyalgia syndrome,
back pain, neurological disease or osteoporosis.
Assessment of the validity of the study
Two reviewers (A.M.Y. and F.A.F.) made the decisions
regarding the inclusion of the relevant articles in
the present review. They independently applied the
inclusion/exclusion criteria to papers identified by the
literature search and classified the identified studies
according to predetermined criteria. The abstracts were
reviewed first and, if deemed appropriate, the full papers
were then reviewed and scored. The methodological
quality of each study was reviewed by using the Physio-
therapy Evidence Database (PEDro) scale (Maher et al.,
2003). A consensus method was used to solve any dispute
regarding the inclusion or exclusion of a particular study.
When there was disagreement, consensus was sought,
but when disagreement persisted, a third independent
reviewer (P.G.) made the final decision.
The PEDro scale contains 11 items (Table 1). The
first item represents the external validity of the trial.
This item is not included in the calculation of the total
PEDro score (maximum 10); therefore, our score was
based on items 2 to 11 and the PEDro score was thus
a score out of 10. These items are scored either yes
(1 point) or no (0 points). The individual item scores
and the total PEDro scores have been shown to be
reliable (Maher et al., 2003). A study that scores 7
(i.e. scores positive in seven out of ten criteria) is
considered to have a high methodological quality, a
score of 5–6 a moderate methodological quality and a
score between 0 and 4 is regarded as poor quality
(Kollen et al., 2009; Maher et al., 2003; Moseley et al.,
2002). Although the PEDro scale is scored out of 10
(Maher et al., 2003; Sherrington et al., 2000), the
maximum achievable score for a high-quality study is
8 because it is difficult to blind the therapist delivering
the intervention or the participants in a trial of hydro-
therapy rehabilitation (Maher et al., 2003; Sherrington
et al., 2000). The PEDro scores for the present review
ranged from 4 to 8 out of the maximum possible score
of 10, without including the first item of the PEDro
scale (see above).
Al-Qubaeissy et al. The Effectiveness of Hydrotherapy in RA
5Musculoskelet. Care 11 (2013) 3–18 © 2012 John Wiley & Sons, Ltd.
Data collection and analysis
Articles fulfilling the inclusion criteria were subsequently
assessed for methodological quality using the criteria list
and operational instructions outlined and recommended
by the PEDro for the quality assessment of RCTs (Maher
et al., 2003; Sherrington et al., 2000), as shown in Table 1.
Data extraction
The two reviewers (A.M.Y. and F.A.F.) independently
extracted data using a standardized form regarding: the
author(s), place and date of publication, study design,
sample size and percentage of female sample, mean age,
the interventions, type of outcome measures, and
follow-up or failure to follow-up, to ensure that no
significant information was omitted from the review.
Meta-analysis or statistical pooling were not considered
because of the heterogeneity among the studies, including
the small sample size, variations in symptoms and dura-
tion, interventions and the reporting of the outcomes.
Results
A total of 197 studies were identified, based on the key
search terms and the hand search of bibliography refer-
ences (CINAHL 12; Medline 42; PubMed 122; AMED
13; manual search eight). After the initial screening of
the titles and abstracts, 32 studies were found to satisfy
the inclusion criteria and were further scrutinized for the
presentsystematicreview(seeFigure1).Fromthesix
studies that were of high enough quality to analyse are
presented in Table 2.
Methodological quality of the studies
The methodological quality of the studies ranged from
5 to 8 on the PEDro scale of internal validity (Table 3),
with a mean score of 6.8. Four studies were of high
quality, whereas two were of moderate quality. Two
studies (Sanford-Smith et al., 1998; Stenstrom et al.,
1991) failed to report or describe whether an intent-
to-treat analysis or concealment of the treatment
allocation was used. In three studies (Eversden et al.,
2007; Hall et al., 1996; Sanford-Smith et al., 1998),
the outcome assessor was blinded to the intervention.
All of the participants were randomized in the included
trials; however, only three studies (Bilberg et al., 2005;
Eversden et al., 2007; Hall et al., 1996) specified the
methods used. Two studies used optimal allocation
using a computer program (Bilberg et al., 2005; Eversden
et al., 2007) and one used block randomization
(Hall et al., 1996).
Participants
The six studies described above included both men and
women (total no = 419); 326 (78%) of the participants
were women. The participants’age across the studies
ranged from 18–80 years. The average number of
participants in the treatment group post-randomization
and before any withdrawals was 29 (range 12–57), with
only three studies having groups with more than 30 par-
ticipants (Eversden et al., 2007; Hall et al., 1996; Rintala
et al., 1996).
Table 1. Criteria list for methodological quality assessment [Physiotherapy Evidence Database (PEDro)]. Adapted from Maher et al. (2003).
Each PEDro scale item satisfied (except the first item) contributes 1 point to the total PEDro score (range 0–10 points)
Category number PEDro items Answer
1 Eligibility criteria were specified Y/N
2 Subjects were randomly allocated to groups (in a crossover study,
subjects were randomly allocated an order in which treatments were received)
Y/N
3 Allocation was concealed Y/N
4 The groups were similar at baseline regarding the most important prognostic indicators Y/N
5 There was blinding of all subjects Y/N
6 There was blinding of all therapists who administered the therapy Y/N
7 There was blinding of all assessors who measured at least one key outcome Y/N
8 Measurements of at least one key outcome were obtained from more than 85% of the
subjects initially allocated to groups
Y/N
9 All subjects for whom outcome measurements were available received the treatment or
control condition as allocated, or where this was not the case, data for at least one key outcome
were analysed by ‘intent to treat’
Y/N
10 The results of between-group statistical comparisons are reported for at least one key outcome Y/N
11 The study provides both point measurements of variability for at least one key outcome Y/N
The Effectiveness of Hydrotherapy in RA Al-Qubaeissy et al.
6Musculoskelet. Care 11 (2013) 3–18 © 2012 John Wiley & Sons, Ltd.
Outcome measures
RA affects physical, social and psychological aspects of
patients’health status or quality of life. The outcome
measures that were used in the present review reflected
one or more of the variables (Fitzpatrick et al., 1992;
Hakala, 1997).
Pain: A pain scale was used in all the reviewed
studies. Scores on these scales were measured before
and after the intervention. Various instruments were
used to measure sensory pain. The 10-cm visual analogue
scale (VAS) was the tool used most commonly (Langley
and Sheppeard, 1984). VAS was used in three studies
(Eversden et al., 2007; Rintala et al., 1996; Stenstrom
et al., 1991). Another instrument that was used, by Hall
et al. (1996), to assess pain was the McGill Pain Ques-
tionnaire (Melzack, 1975). Moreover, pain subscales
from a variety of self-reported questionnaires were used,
such as the Arthritis Impact Measurement Scale (AIMS)
(Meenan et al., 1980), Health Assessment Questionnaire
(HAQ) (Bruce and Fries, 2005; Felson et al., 1993; Fries
et al., 1980) and the Short Form-36 (SF-36) (Ware and
Sherbourne, 1992). Rintala et al. (1996) used pain as a
primary outcome measure and found that there was a
statistically significant reduction in the level of pain after
use of a water exercise programme in patients with RA.
None of the studies used pain as an outcome measure
for a power calculation to determine the sample size.
Figure 1. Flow chart of the literature search
Al-Qubaeissy et al. The Effectiveness of Hydrotherapy in RA
7Musculoskelet. Care 11 (2013) 3–18 © 2012 John Wiley & Sons, Ltd.
Table 2. Summary of studies meeting the selection criteria for inclusion in the systematic review for RA.
Authors,
country, origin
of study
Sample n
(female)%
Study
design
Drop
outs
Mean age (SD)
in years
Intervention
Outcome measures Patient assessment/follow-up Results/comments
•duration
•programme
•setting
Hall et al., 1996;
UK
139 (66%) RCT 1 58.2 (11.1) A: aquatic exercise
(n=35)30 minutes
twice weekly for 4 weeks,
Pain; using McGill
Questionnaire
Baseline No significant differences between interventions in terms
of pain (all patients demonstrated a significant pain
reduction (p≤0. 005)
B: land-based exercise
(n= 34)
Ritchie articular index
(RAI)
4 weeks Significant reduction in joint tenderness in a number of
tender joints in hydrotherapy group (p= 0.03)
C: immersion (n= 35)
D: land relaxation (n= 35) Morning stiffness duration 3 months
Post treatment
Grip strength, wrist ROM, duration of morning stiffness
andCRPlevelsdidnotchangesignificantly (p≥0.05)Grip strength (digital monitor
inflated to 20 mm Hg)
Wrist and knee ROM; using
astandardgoniometer
Significant increase in knee ROM, mainly in women in
hydrotherapy group (p≤0.02)
AIMS-2 for health status Significant improvement in mood and tension occurred for
all patients after treatment in both groups; the effect was
most marked in women, with a greater effect in the
hydrotherapy group (p= 0.003)
Patient perception All groups reported similar perceptions of the effectiveness
of the interventions at pre-test and post-test (p≤0.0001)
Sanford-Smith
et al., 1998;
Canada
24 (75%) RCT 4 58.4 (11.6) A: aquaerobics group 3
times/week for 10 weeks
AJC Baseline (one
week prior)
There were no between-group differences; however, both
groups showed a similar decrease in AJC and ESR (p ≥0.05)
B: ROM group ESR Post treatment assessment
occurred within one week
after the completion of the
10 weeks exercise programme
Both groups demonstrated an improvement in grip
strength (p≤0.05), but there was no significant
difference between the groups
Grip strength measured using
Martin Vigorimeter (Hillside
Medical Supplies Limited,
Nottingham, UK)
Both group showed an increase in exercise tolerance (p≤0.05)
(Continues)
The Effectiveness of Hydrotherapy in RA Al-Qubaeissy et al.
8Musculoskelet. Care 11 (2013) 3–18 © 2012 John Wiley & Sons, Ltd.
HAQ for function HAQ result showed a statistically significant
improvement in two components of HAQ in the control
group (p≤0.05) and no significant improvement in the
aqua-aerobics group (p≥0.05)
Treadmill stress test No significant between-group effects for duration and
peak workload on treadmill (p≥0.05)
Bilberg et al.,
2005; Sweden
47 (89%) RCT 4 49 A: treatment group, twice
weekly for 12 weeks in
group of 8 or 9 in a
temperate pool, each
session for 45 minutes,
moderate aerobic intensity
Sub-maximum ergometer
cycle (Astrand, Varberg,
Sweden) for aerobic capacity
as primary outcome measure
Baseline No significant changes were found for the primary
outcome measure between baseline and post-treatment
(p≥0.05)
B: control group, home
exercise programme and
continuation of their daily
activity
SF-36 for health status as
primary outcome measure
post treatment (3 months) At follow up, SF-36 showed significant improvement
within training group (p<0.05); no significant changes
were found in between-group differences (p≥0.05)
6 months for training group
Chair test as secondary
outcome measure
Performance on the chair test increased significantly in the
training group compared with the control group (p = 0.005)
Shoulder endurance test as
secondary outcome measure
Performance on the shoulder endurance test increased
significantly in the training group compared with the
control group(p≤0.001)
Grip strength (electronic
instrument (Grippit)
Grip strength of the left hand increased significantly in the
training group compared with the control group (p≤0.001)
HAQ for functional disability
and AIMS-2 for quality of life
AIMS-2 and HAQ displayed a significant within-group
improvement (p= 0.007) and 0.04, respectively), but there
was no significant differences between the groups (p≥0.05)
Eversden et al.,
2007; UK
115 (69%) RCT 30 55.2 (13.3) A: intervention group,
one session/week for 6
weeks in hydrotherapy
pool at 35C
Primary outcome measure was
self-rated overall effects on a
Likert 7-point scale
Baseline Patients in the hydrotherapy group felt very much
better in their overall health status compared with
patients treated in the land exercise group (p<0.001)
Post-treatment (6 weeks)
Post-treatment (3 months)
B: control group, land
exercise for 6 weeks
Secondary outcome measure
include: VAS pain, ten-meter
walkspeed,HAQ,EQ-5Dutility,
EQ-VAS
There were no significant differences between groups in
terms of changes to HAQ (p= 0.09), EQ-5D utility score
(p=0.61),EQ-VAS(p= 0.57) and pain VAS (p= 0.40)
(Continues)
Al-Qubaeissy et al. The Effectiveness of Hydrotherapy in RA
9Musculoskelet. Care 11 (2013) 3–18 © 2012 John Wiley & Sons, Ltd.
Table 2. (Continued)
Authors,
country, origin
of study
Sample n
(female)%
Study
design
Drop
outs
Mean age (SD)
in years
Intervention
Outcome measures Patient assessment/follow-up Results/comments
•duration
•programme
•setting
Rintala et al.,
1996; Finland
34 (85%) RCT 0 48 (10) A: aquatic exercise (n=18)
45-60 minutes twice a week
for 12 weeks, setting and
pool temperature 30C
VAS pain Baseline Pain more diminished in experimental group than in
control group (p≤0.05)
B: no-treatment control
(n=16)
Joint mobility by using signals
of functional impairment
Post-treatment (12 weeks) Joint mobility improved in experimental group
(p≤0.05)
Muscle strength and
endurance by using digital
dynamometer
Muscle strength and endurance improved in experimental
group compared with control group (p≤0.001)
Stenstrom
et al., 1991;
Sweden
60 (86%) RCT 5 52 (11.2) A: training group (n=30),
once weekly in group of 5,
for40minutes,for4years
in temperature of 34C
in hospital pool
(each year there is a
vacation for 2.5 months)
Ritchie’sarticularindexfor
disease activity
Post training (4years) No significant difference between the groups in Ritchie’s
articular index, Larsen’s radiological index, soft tissue
swelling or laboratory markers (p>0.05)
Larsen radiological index
Laboratory inflammatory
markers
B: comparison group
(n=30)
Sphygmomanometer cuff for
grip strength
Improvedrighthandgripstrengthintraininggroup(p≤0.01);
decreased grip strength in left hand of comparison group (p>0.05)
VAS for pain and functional
testssuchasoutdoorwalking,
indoor walking, lifting, learning
forward and rising
No significant difference between the groups in VAS or
functional tests (p>0.05)
Activity level such as exercise
habits two open-ended questions
Significant difference in activity levels between the groups in
training group compared with comparison group (p≤0.01)
Two-year follow-up at the end of the training period; the
difference between the training and comparison groups was
significant (p≤0.001)
AIMS-2, Arthritis Impact Measurement Scale version 2; CRP, C-reactive protein; EQ-5D, EuroQoL; EQ-VAS, health-related QoL; HAQ, Health Assessment Questionnaire, AJC, active joint count; ESR, erythrocyte
sedimentation rate; QoL, quality of life; RCT, randomized controlled trial; ROM, range of motion; SD, standard deviation; SF-36, Short Form-36; VAS, visual analogue scale.
•duration
•programme
•setting
The Effectiveness of Hydrotherapy in RA Al-Qubaeissy et al.
10 Musculoskelet. Care 11 (2013) 3–18 © 2012 John Wiley & Sons, Ltd.
Physical function: HAQ was the most commonly
used instrument in the reviewed studies (Bruce and
Fries, 2005; Felson et al., 1993; Fries et al., 1980). It
was used in three studies (Bilberg et al., 2005; Eversden
et al., 2007; Sanford-Smith et al., 1998). However, only
one of these (Bilberg et al., 2005) found a significant
improvement in physical function compared with the
control group. HAQ was used as a primary outcome
measure in one study (Sanford-Smith et al., 1998).
Sanford-Smith et al. (1998) showed a trend for an
improvement in physical function using the total HAQ
score in the aqua-aerobics group compared with the con-
trol group; however, this was not statistically significant.
Health status: The category of health status was
investigated in the three studies using the EuroQoL
(EQ-5D) (Bilberg et al., 2005; Eversden et al., 2007;
Hall et al., 1996). Hurst et al. (1997) and Eversden
et al. (2007) used the EQ-5D to examine the efficacy
of hydrotherapy for improving health status. The
findings from both studies showed that there was no
statistically significant difference in health status be-
tween the hydrotherapy and control groups. Similarly,
Bilberg et al. (2005) administered the SF-36 (Ware and
Sherbourne, 1992) and showed that, while there was a
significant within-group improvement from baseline
to post-treatment in the hydrotherapy group, these
differences were not statistically significant between the
two groups. Hall et al. (1996) used AIMS-2 (Meenan
et al., 1992) and demonstrated a statically significant
improvement for all of the participants in both groups
in the category of mood and tension. Women in the
hydrotherapy group showed a statistically significant
reduction in the level of tension and mood compared
with those in the control group.
Disease activity: In terms of disease activity, a variety
of categories were measured separately in four studies
(Bilberg et al., 2005; Hall et al., 1996; Sanford-Smith
et al., 1998; Stenstrom et al., 1991), such as morning
stiffness, joint tenderness, joint swelling, grip strength
and laboratory markers [acute-phase reactants such as
C- reactive protein (CRP)]. The results of Bilberg et al.
(2005) indicated that grip strength of the left hand
increased significantly in the training group compared
with the control group between 0–3months(p<0.001).
This contrasted with the findings of Hall et al. (1996)
and Sanford-Smith et al. (1998), who did not find any
significant difference between the groups in terms of
grip strength, duration of morning stiffness and CRP
Table 3. Methodological quality using the Physiotherapy Evidence Database (PEDro) scale scoring the items out of 10
Study Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Item 7 Item 8 Item 9 Item 10 Item 11 Total score (/10)
Stenstrom et al., 1991; Sweden YYNYNNNYN Y Y5/10 moderate quality
Hall et al., 1996; UK YYYYNNYYY Y Y8/10 high quality
Sanford-Smith et al., 1998; Canada YYNYNNNYN Y Y5/10 moderate quality
Bilberg et al., 2005; Sweden YYYYNNYYY Y Y8/10 high quality
Eversden et al., 2007; UK YYYYNNYYY Y Y8/10 high quality
Rintala et al., 1996; Finland YYYYNNNYY Y Y7/10 high quality
Y, yes (= 1); N, no (= 0)
Al-Qubaeissy et al. The Effectiveness of Hydrotherapy in RA
11Musculoskelet. Care 11 (2013) 3–18 © 2012 John Wiley & Sons, Ltd.
level or erythrocyte sedimentation rate (p>0.05). In
Stenstrom et al. (1991), grip strength improved signifi-
cantly in the right hand of training group participants
(p<0.01) while it deteriorated in the left hand of the
control group (p>0.05). Hall et al. (1996) also showed
that there was a significant reduction in joint tenderness
in the hydrotherapy group.
Patient perception:Patients’perception of hydrotherapy
treatment was investigated in two studies (Eversden et al.,
2007; Hall et al., 1996). Hall et al. (1996) used a five-point
Likert-type perception scale, which was designed by Langley
and Sheppeard (1984); their findings were unexpected and
showed that both groups reported similar perceptions of
the effectiveness of the intervention. Eversden et al.
(2007) used a seven-point scale and their findings
showed that the largest set of significant clusters of feel-
ing ‘very much better’was in the hydrotherapy group
compared with the land exercise group.
A Scandinavian study undertaken by Stenstrom et al.
(1991) failed to show any statistically significant
differences in pain rating, functional outcomes tests
(Stenstrom et al., 1990), Ritchie’s articular index (Ritchie
et al., 1968), Larsen’s radiological index (Larsen et al.,
1977), soft tissue swelling or laboratory parameters
between the training group and the control group.
Perceptions of activity levels were measured in this study
using self-reported questions (e.g. ‘what do you think is
positive regarding the training?’and ‘what do you think is
negative regarding the training?’) recommended for use
in patients with chronic pain (Dolce et al., 1986; Doleys
et al., 1982). There was a significant difference in the per-
ceptions of activity levels between the treatment group
compared with the control group (p<0.01). The two-
year follow-up data showed that there was a statistically
significant difference in the perception of activity levels
between the treatment and control groups (p<0.001).
Hall et al. (1996) showed that hydrotherapy was
effective in improving physical and emotional aspects
in patients with RA. This finding indicates that
hydrotherapy provided greater benefits in terms of
physical and psychological functioning in comparison
with the control group. AIMS-2 measured mood and
tension, and a significant improvement in psychologi-
cal well-being was found during the follow-up period.
However, the hydrotherapy group derived a significant
improvement in joint tenderness and knee range of
movement in women only.
Rintala et al. (1996) assessed the efficacy of a water
based-exercise programme on chronic pain in patients
with RA. Pain was assessed using VAS (Ekdahl et al.,
1989; Fries, 1983). These authors also assessed ranges
of movement by measuring joint mobility (Eberhardt
et al., 1988), muscle strength and endurance (Talvitie,
1991). The researchers (Rintala and co-workers)
randomly allocated 34 patients with RA to aquatic ex-
ercise (n= 18) or the control group (n= 16). The
aquatic exercise group undertook muscle strength, en-
durance and joint mobility exercises in sessions lasting
45–60 minutes, twice a week for 12weeks. The control
groupparticipatedintheirdailyactivitywithnoaddi-
tional exercise during the study period. The major find-
ings of this study were decreased pain, and increased
muscle strength and endurance in the hydrotherapy
group compared with the control group during the 12-
week training period.
Sanford-Smith et al. (1998) recruited 24 participants
(19 females and five males), with a mean age of
58.4 years, to participate in their study. Subjects were
randomly allocated to the aqua-aerobic exercise group
or the range of motion (ROM) exercise group. The
aqua-aerobics sessions were held three times per week
for ten weeks. Each session consisted of an hour of
exercises performed in a hydrotherapy pool heated to
36 C. Fifteen minutes of warm-up aerobic stretches
for the spine, chest and extremities was followed by
20–25 minutes of aerobics exercise. Subjects exercised
to a maximum target heart rate of 70% exercise tolerance
(Beals et al., 1985; Ekblom etal., 1974; Minor et al., 1988;
Nordemar et al., 1981). The control group participants
received a ROM exercise and isometric strength exercises
programme for ten weeks. Nonetheless, the results failed
to reveal a differential effect between the intervention
and control groups.
Bilberg et al. (2005) undertook a study in which they
hypothesized that pool exercise for three months would
improve patients’aerobic capacity, functional ability and
perception of physical health. Forty-seven participants
(42 women and five men) were divided into two groups
(the treatment group and the control group). The
treatment group exercised twice a week for 12 weeks in
groups of eight or nine patients in a temperate pool.
The duration of each session was 45 minutes and the
exercise was of moderate aerobic intensity. The patients
in the control group continued with their usual daily
activities, and provided a home exercise programme.
The outcome measurements were carried out at baseline
and at three months post-intervention for both groups.
The patients in the training group were followed up to
The Effectiveness of Hydrotherapy in RA Al-Qubaeissy et al.
12 Musculoskelet. Care 11 (2013) 3–18 © 2012 John Wiley & Sons, Ltd.
six months after completion of the study. Aerobic
capacity, estimated using a sub-maximum ergometer
cycle (Åstrand, 2003), and the physical component of
the SF-36 were chosen as the primary outcome measures.
The study was unable to confirm whether the interven-
tion was effective in improving aerobic capacity and
quality of life. However, a significant improvement was
found in the hydrotherapy group for the secondary
outcome measures, isometric shoulder endurance, grip
force, dynamic endurance of the lower extremities (chair
test) and muscle function of the lower extremities,
compared with the control group. The chair test was
assessed by counting the maximum number of times that
the patient was able to get up from a chair during one
minute (Mannerkorpi and Ekdahl, 1997) and the
isometric shoulder endurance test, which is used to
measure the isometric endurance of the shoulder abduc-
tor muscles. This was measured as the maximum length
of time that a person was able to hold his/her arm at
90-degree abduction with a 1-kg cuff attached proximally
to the wrist joint (Mannerkorpi et al., 1999) at baseline
and three months post-treatment. The difference in all
of the primary and secondary outcome measures
between baseline assessment and follow-up for the train-
ing group were statistically significant, with the exception
of aerobic capacity.
Eversden et al. (2007) evaluated the effects of hydro-
therapy withexercises versus land exercises on the overall
response to treatment, physical function and QoL of
patients with RA. These authors designed a programme
of 30-minute hydrotherapy sessions once a week for six
weeks (at 35 C), with a control group on a land-based
programme for six weeks. Patients were randomly
allocated to hydrotherapy or land-based exercises using
sealed opaque envelopes indicating their treatment
allocation. The participants performed warm-up
exercises for ten minutes using mobilizing and stretching
exercises. The core exercises, repeated ten times a
week, focused on joint mobility, muscle strength and
functional activities.
The primary outcome measure applied in this study
was self-rated QoL, in which the effect of treatment was
measured as the change on a seven-point scale ranging
from 1 (very much worse) to 7 (very much better)
(Richards and Scott, 2002). Secondary outcomes were
collected at baseline, on the day of the last treatment
session and three months post-treatment. Pain was
assessed using a 10-cm VAS, where 0 cm represented
no pain and 10 cm represented severe pain (Langley
and Sheppeard, 1984). Physical function was assessed
using the HAQ (Bruce and Fries, 2005; Felson et al.,
1993; Fries et al., 1980). The ten-metre walk speed
was used to assess lower limb function; this primarily
indicated in patients with neurological problems and
had also been used by the authors who carried out
the previous pilot study (Eversden et al., 2001; Wade
et al., 1987). The EQ-5D valuation questionnaire
comprised a self-report of health-related QoL (EQ-VAS)
and a health status valuation (EQ-5D index or utility
score) (Hurst et al., 1997). Eversden et al. (2007) showed
that RA patients who attended outpatient clinics were
more likely to report feeling much better or very much
better if they were treated with hydrotherapy than if they
were treated with exercises on land. This benefitwas
reported immediately after completion of the treatment;
there was no difference between treatment groups in the
secondary outcome measures.
Discussion
The objective(s) of the present systematic review was to
evaluate the available evidence for the effectiveness of
hydrotherapy in the treatment of RA patients. Our find-
ings suggest that patients who received hydrotherapy
treatment for RA gained some beneficial effects in im-
proving their health status (e.g. reduced pain scores)
compared with the control groups. Further additional
benefits included a substantial increase in physical
activity and emotional well-being in patients in
the aquatic programmes compared with control groups
in the short term. However, the long-term benefits were
found to be inconclusive. There is no cure for RA, and it
is therefore important to look into both disease preven-
tion and non-pharmacological treatment that reduces
the burden to patients and carers. A treatment for RA
which reduces or slows down the inflammatory process
would therefore be of great benefit, both from the
health service perspective and also in terms of the
perceived benefit to RA patients in improving their
QoL.
The PEDro scores for all of the papers reviewed
ranged from 5–8, and were regarded as being of
moderate to high quality. The average methodological
quality of all the studies was 6.8 and was regarded as
moderate. However, all of the studies reviewed suffered
from methodological flaws that limited their generaliz-
ability to the wider population of RA patients.
Al-Qubaeissy et al. The Effectiveness of Hydrotherapy in RA
13Musculoskelet. Care 11 (2013) 3–18 © 2012 John Wiley & Sons, Ltd.
The six studies appraised differed in the frequency
and duration of the hydrotherapy sessions given to
participants: twice weekly over four weeks, once weekly
over six weeks, three times weekly over ten weeks, twice
weekly for 12 weeks and once weekly for four years
(long term study); they also differed in the duration
of hydrotherapy. Therefore, we were unable to
determine from the present review the ideal number
of hydrotherapy sessions that are needed for RA
patients to derive clinically significant benefit from this
intervention. A possible explanation for this might be
that each study was designed with specific targets and
goals, and different primary outcome measures. A
recent national survey in the UK by Bryant et al. (2009)
reported that the median optimal number sessions for
the treatment of RA patients was six weeks.
Methodological critique of the reviewed
articles
The choice of outcome measures used in the reviewed
studies should be examined with caution. The HAQ
was the most common instrument used to measure
physical function. In terms of the efficacy of hydrother-
apy, it was used as a primary outcome measure in one
study only (Sanford-Smith et al., 1998). Significant
improvements in health status (health-related QoL)
were found in two studies (Bilberg et al., 2005; Hall
et al., 1996) by using two different health-related QoL
scales of measurement. This means that no standard-
ized, specific scale, which was superior to another,
was used when measuring health status or QoL in RA
patients. Grip strength and joint tenderness were the
most common disease activity indices, which were
found to be statistically significant in hydrotherapy
trials in comparison with other disease activity indices
in patients with RA (Bilberg et al., 2005; Hall et al.,
1996; Stenstrom et al., 1991). These findings should
be interpreted with caution because few studies have
investigated the disease activity domains in RA patients.
The contradictory results of grip strength measures can
be explained by the different types of assessment tools
employed in the various studies. Hall et al. (1996)
measured the grip strength of the dominant hand by
using a digital grip strength monitor inflated to
20 mmHg (Lee et al., 1974; Rhind et al., 1980). The
mean of three readings was recorded, whereas Bilberg
et al. (2005) measured grip strength by using an
electronic instrument (Grippit, AB Detektor, Göteborg,
Sweden), recording the maximum and mean strength
and the best performance of three (Nordenskiöld, 1990;
Nordenskiöld and Grimby, 1993, 1997). Conversely,
Stenstrom et al. (1991) measured grip strength manually
by using a Sphygmomanometer cuff rolled up two turns
and inflated to 20 mmHg (Lansbury, 1958). Sanford-
Smith and colleagues (Sanford-Smith et al., 1998) did
not report the method of assessment used to measure
the grip strength. Therefore, future studies should
consider using appropriate standardized procedures in
measuring grip strength in patients with RA with
malfunction of dexterity and pain.
The reduced joint tenderness observed in the hydro-
therapy group of Hall et al. (1996) might be attributed
to the reduction in joint loading supported by buoyancy.
Furthermore, the hydrostatic pressure of water immer-
sion is considered to be effective in reducing oedema
(Poyhonen et al., 2000).
However, we noted many substantial methodological
shortcomings in the research we reviewed, mainly in
the inadequate reporting of interventions in terms of
their setting, water temperature, depth of pool, and the
type and intensity of the exercise programme. In
addition, there were other methodological flaws relating
to RCT design, such as inappropriate randomization,
concealment of allocation to groups and the blinding
procedure to the outcome measurements.
Overall, many of the studies involved in the present
review had a relatively small sample size and lacked
adequate statistical power to examine the effectiveness
of hydrotherapy in the treatment of patients with RA.
In addition, the studies reviewed used different primary
outcome measures and a few studies had inadequate
and variable follow-up periods.
The present review had several limitations. First, the
review focused only on studies published in English; it
is possible that potentially relevant articles published in
other languages may have been missed. Such studies
were excluded because of the limited resources avail-
able for the present review. Second, the searches were
limited to published articles. Third, some of the studies
did not give detailed information about their data
analysis. This will have affected the conclusions drawn
from these studies, so caution is required in the
interpretation of their findings. Fourth, the variation
in the dosages of the intervention in the six studies
analysed makes it difficult to provide clear guidance in this
area. Fifth, we did not investigate the cost-effectiveness
of hydrotherapy. Unfortunately, none of the studies
The Effectiveness of Hydrotherapy in RA Al-Qubaeissy et al.
14 Musculoskelet. Care 11 (2013) 3–18 © 2012 John Wiley & Sons, Ltd.
reviewed reported the cost-effectiveness of their
intervention. Costs versus benefits assessments will
become increasingly important in medical rehabilitation
and physiotherapy research, as RA patients are more
likely to continue to use healthcare services for a long
period because of the chronic nature of the condition.
Therefore, future studies should consider the cost-effec-
tiveness of a hydrotherapy intervention. Finally, the pres-
ent review focused on RCTs. It is therefore imperative
that future studies assess the value of grey literature and
case-controlled studies to evaluate the benefitofhydro-
therapy for this patient group.
Implications for practice
The results of the present review indicate the beneficial
effects of hydrotherapy compared with no intervention,
or with other interventions. An important practical
implication is that the outcome measures used to assess
pain, physical function, disease activity and QoL scales
are appropriate for the assessment of patients with RA.
In addition, some of the studies reviewed showed
hydrotherapy to be associated with improvements,
particularly in regard to pain, disease activity (grip
strength, joint tenderness) and health status (mood and
tension). The evidence from this review might give
further option for rheumatologists to refer appropriate
RA patients for hydrotherapy treatment as part of their
medical rehabilitation.
Implications for research
Few RCTs have examined the effects of a hydrotherapy
intervention on RA. The present review indicates that
there is no consistency in the literature in terms of the
type of exercise and the dose (intensity, frequency and
duration) used in hydrotherapy treatment for patients
with RA. In addition, future studies should consider
examining the cost-effectiveness of hydrotherapy and
the optimal use of aquatic exercise for patients with
RA. Considerably more work is needed to determine
the effectiveness of hydrotherapy on disease activity,
psychological aspects of RA (anxiety and depression)
and physical function using appropriate outcome
measures. Large, high-quality RCTs are needed which
could provide more definitive evidence for the efficacy
of hydrotherapy using rigorous methodology (e.g. an
adequate sample size). In addition, case-controlled
studies should be considered.
Conclusions
There is some evidence to suggest that hydrotherapy
has a positive role in reducing pain and improving
the health status of patients with RA in the short term.
However, the long-term benefitisunknown.Itisdifficult
to make specific recommendations at this stage because
of lack of evidence (e.g. optimal duration and frequency)
for clinical practice. Therefore, further studies are
needed, using robust RCTs.
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