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The Effectiveness of Hydrotherapy in the Management of Rheumatoid Arthritis: A Systematic Review

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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', 5-6 as '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.
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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 benets 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,56asmoderate
qualityand less than 4 as poor quality.
Results. Initially, 197 studies were identied. 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 benet 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, inam-
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) 318 © 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 0.51% of the population (McMahone and
Allard, 2002; Symmons et al., 1994, 2002). The overall
prevalence of RA worldwide in the general population
is 12%, 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 inammatory 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 hydrotherapyor aquatic exerciseis dened
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 efcient 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 efcacy 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 ndings 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 efcacy 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 efcacy of hydrotherapy in the
management of patients with RA.
Materials and methods
Identication 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 therapyand 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 bathsand balneotherapy. There is a lack of
clarity in the usage of the terms hydrotherapyand
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) 318 © 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 insufcient 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, bromyalgia 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 identied by the
literature search and classied the identied studies
according to predetermined criteria. The abstracts were
reviewed rst 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 nal decision.
The PEDro scale contains 11 items (Table 1). The
rst 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 56 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 difcult 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 rst item of the PEDro
scale (see above).
Al-Qubaeissy et al. The Effectiveness of Hydrotherapy in RA
5Musculoskelet. Care 11 (2013) 318 © 2012 John Wiley & Sons, Ltd.
Data collection and analysis
Articles fullling 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
signicant 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 identied, 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) specied 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 participantsage across the studies
ranged from 1880 years. The average number of
participants in the treatment group post-randomization
and before any withdrawals was 29 (range 1257), 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 satised (except the rst item) contributes 1 point to the total PEDro score (range 010 points)
Category number PEDro items Answer
1 Eligibility criteria were specied 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) 318 © 2012 John Wiley & Sons, Ltd.
Outcome measures
RA affects physical, social and psychological aspects of
patientshealth status or quality of life. The outcome
measures that were used in the present review reected
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 signicant 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) 318 © 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 signicant differences between interventions in terms
of pain (all patients demonstrated a signicant pain
reduction (p0. 005)
B: land-based exercise
(n= 34)
Ritchie articular index
(RAI)
4 weeks Signicant 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
andCRPlevelsdidnotchangesignicantly (p0.05)Grip strength (digital monitor
inated to 20 mm Hg)
Wrist and knee ROM; using
astandardgoniometer
Signicant increase in knee ROM, mainly in women in
hydrotherapy group (p0.02)
AIMS-2 for health status Signicant 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 (p0.0001)
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 (p0.05), but there was no signicant
difference between the groups
Grip strength measured using
Martin Vigorimeter (Hillside
Medical Supplies Limited,
Nottingham, UK)
Both group showed an increase in exercise tolerance (p0.05)
(Continues)
The Effectiveness of Hydrotherapy in RA Al-Qubaeissy et al.
8Musculoskelet. Care 11 (2013) 318 © 2012 John Wiley & Sons, Ltd.
HAQ for function HAQ result showed a statistically signicant
improvement in two components of HAQ in the control
group (p0.05) and no signicant improvement in the
aqua-aerobics group (p0.05)
Treadmill stress test No signicant between-group effects for duration and
peak workload on treadmill (p0.05)
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 signicant changes were found for the primary
outcome measure between baseline and post-treatment
(p0.05)
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 signicant improvement
within training group (p<0.05); no signicant changes
were found in between-group differences (p0.05)
6 months for training group
Chair test as secondary
outcome measure
Performance on the chair test increased signicantly 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
signicantly in the training group compared with the
control group(p0.001)
Grip strength (electronic
instrument (Grippit)
Grip strength of the left hand increased signicantly in the
training group compared with the control group (p0.001)
HAQ for functional disability
and AIMS-2 for quality of life
AIMS-2 and HAQ displayed a signicant within-group
improvement (p= 0.007) and 0.04, respectively), but there
was no signicant differences between the groups (p0.05)
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 signicant 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) 318 © 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 (p0.05)
B: no-treatment control
(n=16)
Joint mobility by using signals
of functional impairment
Post-treatment (12 weeks) Joint mobility improved in experimental group
(p0.05)
Muscle strength and
endurance by using digital
dynamometer
Muscle strength and endurance improved in experimental
group compared with control group (p0.001)
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)
Ritchiesarticularindexfor
disease activity
Post training (4years) No signicant difference between the groups in Ritchies
articular index, Larsens radiological index, soft tissue
swelling or laboratory markers (p>0.05)
Larsen radiological index
Laboratory inammatory
markers
B: comparison group
(n=30)
Sphygmomanometer cuff for
grip strength
Improvedrighthandgripstrengthintraininggroup(p0.01);
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 signicant difference between the groups in VAS or
functional tests (p>0.05)
Activity level such as exercise
habits two open-ended questions
Signicant difference in activity levels between the groups in
training group compared with comparison group (p0.01)
Two-year follow-up at the end of the training period; the
difference between the training and comparison groups was
signicant (p0.001)
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) 318 © 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 signicant
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 signicant.
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 efcacy
of hydrotherapy for improving health status. The
ndings from both studies showed that there was no
statistically signicant 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
signicant within-group improvement from baseline
to post-treatment in the hydrotherapy group, these
differences were not statistically signicant between the
two groups. Hall et al. (1996) used AIMS-2 (Meenan
et al., 1992) and demonstrated a statically signicant
improvement for all of the participants in both groups
in the category of mood and tension. Women in the
hydrotherapy group showed a statistically signicant
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 signicantly in the training group compared
with the control group between 03months(p<0.001).
This contrasted with the ndings of Hall et al. (1996)
and Sanford-Smith et al. (1998), who did not nd any
signicant 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) 318 © 2012 John Wiley & Sons, Ltd.
level or erythrocyte sedimentation rate (p>0.05). In
Stenstrom et al. (1991), grip strength improved signi-
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 signicant reduction in joint tenderness
in the hydrotherapy group.
Patient perception:Patientsperception of hydrotherapy
treatment was investigated in two studies (Eversden et al.,
2007; Hall et al., 1996). Hall et al. (1996) used a ve-point
Likert-type perception scale, which was designed by Langley
and Sheppeard (1984); their ndings 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 ndings
showed that the largest set of signicant clusters of feel-
ing very much betterwas in the hydrotherapy group
compared with the land exercise group.
A Scandinavian study undertaken by Stenstrom et al.
(1991) failed to show any statistically signicant
differences in pain rating, functional outcomes tests
(Stenstrom et al., 1990), Ritchies articular index (Ritchie
et al., 1968), Larsens 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 signicant 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
signicant 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 nding indicates that
hydrotherapy provided greater benets in terms of
physical and psychological functioning in comparison
with the control group. AIMS-2 measured mood and
tension, and a signicant improvement in psychologi-
cal well-being was found during the follow-up period.
However, the hydrotherapy group derived a signicant
improvement in joint tenderness and knee range of
movement in women only.
Rintala et al. (1996) assessed the efcacy 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
4560 minutes, twice a week for 12weeks. The control
groupparticipatedintheirdailyactivitywithnoaddi-
tional exercise during the study period. The major nd-
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 ve 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
2025 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 patientsaerobic capacity, functional ability and
perception of physical health. Forty-seven participants
(42 women and ve 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) 318 © 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 conrm whether the interven-
tion was effective in improving aerobic capacity and
quality of life. However, a signicant 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 signicant, 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 benetwas
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 nd-
ings suggest that patients who received hydrotherapy
treatment for RA gained some benecial effects in im-
proving their health status (e.g. reduced pain scores)
compared with the control groups. Further additional
benets 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 benets 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 inammatory process
would therefore be of great benet, both from the
health service perspective and also in terms of the
perceived benet to RA patients in improving their
QoL.
The PEDro scores for all of the papers reviewed
ranged from 58, 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 aws 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) 318 © 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 signicant benet from this
intervention. A possible explanation for this might be
that each study was designed with specic 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 efcacy of hydrother-
apy, it was used as a primary outcome measure in one
study only (Sanford-Smith et al., 1998). Signicant
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, specic 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 signicant 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 ndings 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 inated 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 inated 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 aws 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 ndings. Fourth, the variation
in the dosages of the intervention in the six studies
analysed makes it difcult 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) 318 © 2012 John Wiley & Sons, Ltd.
reviewed reported the cost-effectiveness of their
intervention. Costs versus benets 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 benetofhydro-
therapy for this patient group.
Implications for practice
The results of the present review indicate the benecial
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 denitive evidence for the efcacy
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 benetisunknown.Itisdifcult
to make specic 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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The Effectiveness of Hydrotherapy in RA Al-Qubaeissy et al.
18 Musculoskelet. Care 11 (2013) 318 © 2012 John Wiley & Sons, Ltd.
... 1 According to the World Health Organization, its prevalence is between 0.3 to 1%. 2 The onset of RA is most common in the fourth and fifth decades of life. 3 This condition is mainly genetic in development; the majority of people carry the HLA-DRB1 04 cluster epitope. 4,5 Environment factors such as smoking and infection increase the rate of progress and severity of the disease. ...
... 9 The clinical features of RA are pain, swelling, tenderness and morning stiffness that are symmetrical in nature and involve small joints of the hands and feet, Other large peripheral joints, such as knee joints and elbow joints, may also be affected as the disease progresses. 3 There are extra-articular manifestations in the form of nodules, vasculitis, pericarditis, rheumatoid lung, uveitis and keratoconjunctivitissicca. Other common features of RA are fever, fatigue, weight loss, limited functional ability, depression and poor self-esteem. 4 This leads to decrease in the range of movement, functional limitation, loss of independence, reduction of quality of life (QoL). ...
... Extensive and qualitative randomized controlled trials with the large population; inclusion of sexes, different age group and severity of the disease is needed. 3 To measure the severity of the RA, there is no established "gold standard" outcome measure. Here, the reliability and validity of DAS were evaluated. ...
Article
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Background-Rheumatoid arthritis is a long standing illness for which a less invasive and easy therapy is not explored across the globe. Drugs have short term benefits and prevention of deterioration is essential in this case. Hence hydrotherapy and its effect on RA with DAS scale as a tool for measuring outcome needs to be considered for better assessment of the patient's condition. Material and Methods-A systematic search of past 10 year literature was carried out across PubMed, Scopus and Google Scholar search engines. The key search was related to RA, Hydrotherapy and DAS scale. A total of 21 papers under each section was selected after initial search. Only original work related to the therapy were selected. No risk of bias assessment was done. Results: No correlation with pathological changes were observed across any of the studies. No extrapolation is possible through the results obtained from these studies, due to small sample size and no long term follow ups. Conclusion: Though the studies report of a positive outcome; more robust data is required to apply hydrotherapy as a mechanism of regimen in RA cases. The DAS scale is a valid tool to assess the outcome post intervention.
... However, there is insufficient literature evidence to support a strong recommendation of aquatic exercises for early arthritis [7]. Most of the available reviews (published or in progress) focused on the treatment of a sole rheumatic disease [15][16][17][18][19] or the target condition was not a rheumatic disease. Thus, studies that included individuals with rheumatoid arthritis and/or spondyloarthritis probably could not be included in these mentioned reviews. ...
... In summary, therapy containing aquatic exercises proved effective in improving pain over time, even more than home exercise (land-based). Other systematic reviews also showed that aquatic exercise softens pain intensity in individuals diagnosed with rheumatoid arthritis [16] or other locomotor diseases [38]. However, additional scientific evidence is required to determine whether aquatic exercise is superior to other therapies and the long-term effectiveness of these treatments. ...
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Spondyloarthritis and rheumatoid arthritis are classified as inflammatory arthritis and represent a significant source of pain and disability. Non-pharmacological intervention with physical exercise is among the therapeutic approaches most used by health professionals. This study aimed to investigate the effectiveness of aquatic exercise in the treatment of inflammatory arthritis. The review was registered on the PROSPERO (CRD42020189602). The databases (PubMed, PEDro, Web of Science, and SciELO) were searched for studies involving adults with inflammatory arthritis and subjected to rehabilitation with aquatic exercise compared to any other control group, from the year 2010 to March 2022. Pain, disease activity, and physical function were regarded as primary outcomes. Two reviewers completed the eligibility screening and data extraction, and disagreements were resolved by a third reviewer. The methodological quality was assessed using the PEDro scale. A total of 5254 studies were identified, and nine articles were included, totalling 604 participants. Regarding pain, two studies showed that aquatic exercise was superior to home exercise. One study showed that disease activity was significantly improved in the aquatic group compared to the land-based exercise and the control groups (no exercise). Two studies reported that therapy containing aquatic exercise was able to improve physical function. Overall, the studies included in this review indicate that aquatic exercise is effective in treating pain, disease activity, and physical function in individuals with inflammatory arthritis. However, further studies carrying stronger evidence should be conducted to determine whether the treatment with aquatic exercise is superior to other types of therapies.
... 335 367 378 379 However, high rates of weight loss were associated with increased mortality risk. 335 340 356 381 Higher weight was associated with lower radiographic progression 337 [116][117][118][119][120][121][122][123][124][125][126][127][128][129][130][131][132]. ...
Article
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Background A European League Against Rheumatism (EULAR) taskforce was convened to develop recommendations for lifestyle behaviours in rheumatic and musculoskeletal diseases (RMDs). This paper reviews the literature on the effects of physical exercise and body weight on disease-specific outcomes of people with RMDs. Methods Three systematic reviews were conducted to summarise evidence related to exercise and weight in seven RMDs: osteoarthritis, rheumatoid arthritis, systemic lupus erythematosus, axial spondyloarthritis (axSpA), psoriatic arthritis, systemic sclerosis and gout. Systematic reviews and original studies were included if they assessed exercise or weight in one of the above RMDs, and reported results regarding disease-specific outcomes (eg, pain, function, joint damage). Systematic reviews were only included if published between 2013–2018. Search strategies were implemented in the Medline, Embase, Cochrane Library of systematic reviews and CENTRAL databases. Results 236 articles on exercise and 181 articles on weight were included. Exercise interventions resulted in improvements in outcomes such as pain and function across all the RMDs, although the size of the effect varied by RMD and intervention. Disease activity was not influenced by exercise, other than in axSpA. Increased body weight was associated with worse outcomes for the majority of RMDs and outcomes assessed. In general, study quality was moderate for the literature on exercise and body weight in RMDs, although there was large heterogeneity between studies. Conclusion The current literature supports recommending exercise and the maintenance of a healthy body weight for people with RMDs.
... A large proportion of oncological patients suffer from symptoms which in patients with other diseases as for example rheumatoid arthritis are traditionally treated with therapeutic concepts including water therapy (Al-Qubaeissy et al. 2013). So far, only few data are known on these treatments in cancer patients and there is some discussion on whether water therapies are beneficial for cancer patients or may even put them at risks (for example infections, deterioration of lymphedema). ...
Article
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Background Water therapies as hydrotherapy, balneotherapy or aqua therapy are often used in the relief of disease- and treatment-associated symptoms of cancer patients. Yet, a systematic review for the evidence of water therapy including all cancer entities has not been conducted to date. Purpose Oncological patients often suffer from symptoms which in patients with other diseases are successfully treated with water therapy. We want to gather more information about the benefits and risks of water therapy for cancer patients. Method In May 2020, a systematic search was conducted searching five electronic databases (Embase, Cochrane, PsychInfo, CINAHL and PubMed) to find studies concerning the use, effectiveness and potential harm of water therapy on cancer patients. Results Of 3165 search results, 10 publications concerning 12 studies with 430 patients were included in this systematic review. The patients treated with water therapy were mainly diagnosed with breast cancer. The therapy concepts included aqua lymphatic therapy, aquatic exercises, foot bathes and whole-body bathes. Outcomes were state of lymphedema, quality of life, fatigue, BMI, vital parameters, anxiety and pain. The quality of the studies was assessed with the AMSTAR2-instrument, the SIGN-checklist and the IHE-Instruments. The studies had moderate quality and reported heterogeneous results. Some studies reported significantly improved quality of life, extent of lymphedema, neck and shoulder pain, fatigue and BMI while other studies did not find any changes concerning these endpoints. Conclusion Due to the very heterogeneous results and methodical limitations of the included studies, a clear statement regarding the effectiveness of water therapy on cancer patients is not possible.
... Not only does water make up 60-80% of the human body weight, it is also used to sustain, maintain and hydrate the body (Balaskas & Gordon 1992;Marieb 2012). Further to this, water has well established therapeutic and rehabilitative benefits providing buoyancy, resistance and warmth which have in recent years been shown to decrease pain, improve function and relax muscles for the treatment of rheumatic diseases, osteoarthritis and burns (Al-Qubaeissy et al. 2013;Bender et al. 2005;Benfield et al. 2010;Foley et al. 2003;Han et al. 2014;Silva et al. 2008). Similarly, WI is believed to have positive effects on labour and birth. ...
Thesis
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Background The accessibility of water immersion (WI) for labour and/or birth is dependent on the views of the care provider/institution and the policies/clinical practice guidelines (CPGs) that underpin practice. With little quality research on the safety and efficacy of WI the policies and CPGs informing current practice lack the sound evidence base necessary to ensure they are well informed. Aims The aims of the study were to determine how WI policies and/or CPGs are informed, who interprets the evidence to inform policy/guideline development and to what extent the policy/guideline facilitate the option of WI for labour and birth. Method This study used a mixed-methods approach that included a critical analysis of Australian policies/CPGs, semi-structured interviews with policy/guideline informants and a survey of views of Australian midwives. Results Results reveal a limited evidence-base for use of water during labour and birth and that subjective opinion and views inform policy/CPGs and practice. Policies and CPGs pertaining to the use of water for labour and/birth are written from a risk perspective rather than providing the best available evidence to facilitate decision making for women considering this option. Implications for research and practice In order to overcome the current paucity of quality research available to determine the extent to which WI is used during labour and birth and more, to address concerns surrounding safety and risks surrounding the practice, there is a need for population level data to be collected. Furthermore, the need for both qualitative and quantitative research is pressing not only to determine outcomes of WI but also to determine experience, perceptions and views of both health practitioners and women within their care. The recommendations from this research can assist in the development of local, national and international policies/CPGs that are reflective of the current evidence-base and may lead to further review and critical analysis of policies and CPGs for WI. Conclusion A comprehensive evidenced-based approach to policy and guideline development for WI, including the best available evidence with incorporation of qualitative data examining views and experiences, is needed to better inform policy/CPGs. Such an approach would assist birthing women and their care providers to make an informed choice about the option of WI for labour and birth. Ethical Considerations The research was approved by the Human Research Ethics Committee of the University of South Australia. Conflict of Interest The Author declares no conflict of interest
Article
Rheumatoid arthritis is a chronic debilitating disease most commonly seen in middle-aged women and that has unique challenge in its management. A 30 year old woman diagnosed with rheumatoid arthritis (RA) for 4 years presented with severe morning stiffness, pain, occasional numbness and tingling in her hands, wrists, as well as elbows with gait aberration. Further, she presented with ulnar deviation and swan neck deformity and reported an inability to perform her daily chores. She was not on any medication when she was admitted in an alternative health care setting where she was intervened with a specified protocol of yoga & naturopathy based lifestyle intervention (YNBL) which included yoga therapy, hydrotherapy, manipulative therapies, physiotherapy, western acupuncture, therapeutic fasting and dietary modifications for 3 months. The patient was followed-up for a period of 3 months from discharge. The data reveals significant improvement in the RA related Quality of Life scores (28 to 4), Visual analog score for pain (8 to 2), weight (30 to 35 kg), hemoglobin (9 to 9.8 gm/dl), erythrocyte sedimentation rate (80 to 28 mm/hr), RA factor (81.5 to 65 IU/ml), Anti- Citrullinated Protein Antibody (410 to 198 EU/mL). YNBL protocol was well tolerated by the patient and has shown significant reduction in inflammation, improvement in quality of life as well reversal of structural deformity. The results are encouraging to conduct large scale randomized control trials to explore the possibility of utilizing YNBL in the management of RA.
Article
Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by inflammation and involvement of the synovial membrane, causing joint damage and deformities. No effective drug treatment is available, and physical exercise has been utilized to alleviate the inflammatory processes. This study aimed to investigate the effects of different exercise training protocols on Zymosan-induced RA inflammatory markers in the right knee of Wistar rats. The rodents were subjected to aerobic, resisted, and combined physical training protocols with variations in the total training volume (50% or 100% of resistance and aerobic training volume) for 8 weeks. All physical training protocols reduced cachexia and systemic inflammatory processes. The histological results showed an increase in the inflammatory influx to the synovial tissue of the right knee in all physical training protocols. The rats that underwent combined physical training with reduced volume had a lower inflammatory influx compared to the other experimental groups. A reduction in the mRNA expression of inflammatory genes and an increase in anti-inflammatory gene expression were also observed. The physical training protocol associated with volume reduction attenuated systemic and synovial inflammation of the right knee, reducing the impact of Zymosan-induced RA in rats.
Thesis
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The natural surrounds and resources wrapping hot or mineral springs belong to sustainable matter involving governance and strategic planning of public health, environment, welfare, tourism and mining sectors. Noted it, through the current Brazilian policy demand: social thermalism/hydrotherapy/crenotherapy selected like complementary alternative medicine (CAM) by health ministry law MS 971/2006 (PNPIC), hydro-thermal therapy qualifying DNPM (MME Ordinance 127/2011 and MME 337/2002), health and wellness tourism formally oriented by tourism ministry and environmental management groundwater resources (Resolution MME / CONAMA 396/2008 and MME / CNRH 107/2010). Whereas as fresh potable reserves or potential mineral aquatic strategic deposits, the main biologically active components (BAC) were identified, with their minimum levels needed to related health benefits. Similar to conventional mining prospection, these “cut off grade” detection, at natural occurrences from Brazil, was the major goal in this work. The bibliographic systematic review allowed identify the main bioactive substances (BAC) related to springs sources of elements enougth or proven as health beneficial and at which indications. Wards after, it was performed a georeferenced database with these same variables (BAC) from Brazilian springs. Overlays all through thematic maps assisted in geographical and geological evaluations, whereas, at the end, statistical comparisons filtered target selection at all. The total 60 possible natural BAC and its minimum values for efficacy globally reviewed and established were detected at least one BAC occurrence from 703 mineral springs at 525 Brazilian cities. The arguments utilized were important in demonstrating the abundant and diverse existence of this endowment, where its potential health applications are virtually unknown today.
Article
Objectives To explore two linked strategies to highlight the best current available evidence for hydrotherapy and to explore the barriers and enablers to mobilizing this evidence into practice. Method Phase 1: The best published evidence for hydrotherapy was collated using a Critically Appraised Topic (CAT) methodology. The focus was the best available research evidence for hydrotherapy in musculoskeletal conditions (i.e. osteoarthritis (OA), juvenile idiopathic arthritis (JIA), rheumatoid arthritis (RA), ankylosing spondylitis (AS), and low back pain (LBP)). Once evaluated for quality, a summary of the evidence was produced in a Clinical Bottom Line (CBL). Phase 2: A Focus Group explored the: CBL, the barriers and facilitators of embedding the best evidence for hydrotherapy into practice. Results Phase 1: The CAT identified seven studies that indicated hydrotherapy had beneficial, although short term, effects for common musculoskeletal conditions. Phase 2: Six participants from primary, secondary care, private practice, and education discussed the evidence identified. They highlighted issues such as: understanding the value of hydrotherapy, an overuse of quantitative methodologies and the quality of existing research as being barriers to this knowledge being actively mobilized into clinical care. Conclusions These two linked enquiries (CAT and Focus Group) identified the best evidence and the basis for discussion to explore barriers and facilitators of evidence use in practice. This gave an understanding of the reasons for the research to practice gap and thereby allows planning of knowledge mobilization strategies to reduce this.
Thesis
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Rheumatoid arthritis (RA) is a systemic inflammatory disease that affects approximately 0.5 to 1.0% of the adult population. It is mainly characterized by joint inflammation, which causes pain, swelling and stiffness and leads, in the long-term, to joint destruction, disability and increased mortality. The current treatment paradigm of RA, epitomized by the treat-to-target strategy (T2T), is guided by quantified clinical assessment of disease activity and frequent adjustments of therapy aiming to achieve a state of remission as soon and consistently as possible. The current definitions of remission are based on the number of tender and swollen joints counts, levels of acute phase reactants (such as C-reactive protein or erythrocyte sedimentation rate) and global assessments of disease activity by patient (such as patient global assessment – PGA) and/or physician, integrated into composite indices of disease activity. As a result of novel drugs (such as biologics) and T2T implementation, a marked improvement in the outcomes of RA management has been observed regarding both the inflammatory process and impact of disease. However, a considerable proportion (14 to 38%) of patients with RA do not achieve remission solely due to a high PGA, and report significant levels of disease impact, similar to those described by patients with active disease. Our research group hypothesized that the impact of RA on people’s lives could and should be improved through the introduction of adjunctive interventions targeting the uncontrolled domains of disease impact, especially after remission is achieved. To frame this approach, we had previously proposed a dual-target strategy, separating the control of the disease process (biological remission) and abrogation of the disease impact upon patient’s lives. The work described in this thesis was built on these foundations and designed to take these concepts further, by tackling recognised technical and knowledge gaps. Our initial work aimed at a deeper understanding the impact of RA on people's lives: we examined the determinants of happiness and quality of life and concluded that their optimisation requires considerably more than effective control of the disease process. In fact, psychological dimensions emerged as crucial factors in determining the perceived impact of the disease and overall levels of happiness. Opportunities to modify disease impact, besides immunosuppression, were highlighted. We developed a multifactorial explanatory model that evaluated the influence of personality traits, disease activity, perceived disease impact, and comorbidities upon depression, a decisive aspect of the burden of disease in individual patients. Again, personality was shown to play a pivotal mediating role. We discussed the importance of fatigue in the global impact of RA and proposed a meaningful, valid, and feasible process to measure it in clinical practice. Overall, these studies underlined the need for a more holistic assessment and management of patients with RA, encompassing potentially decisive psychological domains such as personality and personal life history. This perspective highlighted the potentially decisive role of nursing in a multiprofessional model of care focused on the optimization of outcomes relevant to patients. Subsequently, we explored the full potential of adjunctive interventions targeting the uncontrolled domains of disease impact. Through a systematic review we were able to identify all available non-pharmacological interventions as well as all their characteristics by impact domain of RA. We report that several domains of impact of disease remain unexplored and that the overall quality of available evidence is quite poor, highlighting opportunities for evidence-based research. Finally, we supported the development of the “Portuguese multidisciplinary recommendations” on non-pharmacological and non-surgical interventions in the management of patients with RA. This work was based on the consensus judgment of clinical experts from a wide range of disciplines, scientific societies, and patients’ representatives from Portugal. In the last set of studies, we seek to clarify and integrate the role of nursing in the multiprofessional management of RA. Through a systematic review we have demonstrated that nursing consultations are effective in controlling disease activity, reducing disease impact, and improving satisfaction with care in people with RA. This ultimately led us to propose an articulated multi-disciplinary teamwork model, patient centered, that integrates the contributions of the different studies we have produced. This thesis directly integrates 8 articles published in peer-reviewed journals, with a total of 36.985 Impact Factors and 1 article prepared for publication. It also includes substantial references to subsidiary studies from our group, with relevant contributions from the author of the thesis.
Article
Background and Purpose. Assessment of the quality of randomized controlled trials (RCTs) is common practice in systematic reviews. However, the reliability of data obtained with most quality assessment scales has not been established. This report describes 2 studies designed to investigate the reliability of data obtained with the Physiotherapy Evidence Database (PEDro) scale developed to rate the quality of RCTs evaluating physical therapist interventions. Method. In the first study, 11 raters independently rated 25 RCTs randomly selected from the PEDro database. In the second study, 2 raters rated 120 RCTs randomly selected from the PEDro database, and disagreements were resolved by a third rater; this generated a set of individual rater and consensus ratings. The process was repeated by independent raters to create a second set of individual and consensus ratings. Reliability of ratings of PEDro scale items was calculated using multirater kappas, and reliability of the total (summed) score was calculated using intraclass correlation coefficients (ICC [1,1]). Results. The kappa value for each of the 11 items ranged from .36 to .80 for individual assessors and from .50 to .79 for consensus ratings generated by groups of 2 or 3 raters. The ICC for the total score was .56 (95% confidence interval=.47–.65) for ratings by individuals, and the ICC for consensus ratings was .68 (95% confidence interval=.57–.76). Discussion and Conclusion. The reliability of ratings of PEDro scale items varied from “fair” to “substantial,” and the reliability of the total PEDro score was “fair” to “good.”
Article
The aim of this study was to investigate effects of elastic wrist orthoses on pain, grip strength, and function. Twenty-two women with seropositive rheumatoid arthritis (mean age, 53 years) registered their pain on a visual analogue scale both with and without orthosis on the wrist of the dominant hand in three standardized activities of daily living (ADL) situations. Grip force at onset of pain was measured on an electronic instrument (Grippit) with three different grips. Pain was decreased by 39%, 42%, and 52% when using an orthosis in the three ADL situations. Anecdotally, the women noted that the splints provided support and decreased pain both in home, at work, and during leisure activities. Orthoses improved grip force at onset of pain by 26%, 22%, and 29%. All subjects showed reduced strength (20%-25%) when compared to grip strength in a group of women without rheumatoid arthritis.
Article
Objective: The aim of this study was to evaluate the therapeutic effects of hydrotherapy which combines elements of warm water immersion and exercise. It was predicted that hydrotherapy would result in a greater therapeutic benefit than either of these components separately. Methods: One hundred thirty-nine patients with chronic rheumatoid arthritis were randomly assigned to hydrotherapy, seated immersion, land exercise, or progressive relaxation. Patients attended 30-minute sessions twice weekly for 4 weeks. Physical and psychological measures were completed before and after intervention, and at a 3-month followup. Results: All patients improved physically and emotionally, as assessed by the Arthritis Impact Measurement Scales 2 questionnaire. Belief that pain was controlled by chance happenings decreased, signifying improvement. In addition, hydrotherapy patients showed significantly greater improvement in joint tenderness and in knee range of movement (women only). At followup, hydrotherapy patients maintained the improvement in emotional and psychological state. Conclusions: Although all patients experienced some benefit, hydrotherapy produced the greatest improvements. This study, therefore, provides some justification for the continued use of hydrotherapy.
Article
The aim of the study was to survey the use of outcome measures in rehabilitation within Europe. It was envisaged that this would provide the basis for further studies on the cross-cultural validity of outcome measures. A postal questionnaire was distributed in November 1998 to 866 units providing rehabilitation. In total, 418 questionnaires were returned, corresponding to a response rate of 48%. These 418 centres treated an estimated 113,000 patients annually, undertaking 360,000 assessments. The survey focused on nine diagnostic groups: hip and knee replacement, low back pain, lower limb amputees, multiple sclerosis, neuromuscular disorders, rheumatoid arthritis, spinal cord lesions, stroke and traumatic brain injury. It identified a relatively small number of dominant outcome assessments for each diagnostic group and some variation in the preference for measures across regions. A large number of measures, however, are being used in one or a small number of locations and with relatively few patients. For rehabilitation of orthopaedic patients the majority of assessments undertaken are at the impairment level. For patients with neurological disorders the emphasis is mostly upon measures of disability.
Chapter
Rheumatoid arthritis (RA) is a chronic systemic autoimmune inflammatory disease that affects all ethnic groups throughout the world. Females are 2.5 times more likely to be affected than males. The onset of disease can occur at any age but peak incidence occurs within the fourth and fifth decades of life. The average annual incidence of RA in the United States is 0.5 per 1000 persons per year (1). The overall prevalence of RA is 1% to 2%, and it steadily increases to 5% in women by the age of 70 (2). However, there are differences in prevalence rates of RA in various ethnic groups, ranging from 0.1% in rural Africans to 5% in Pima or Chippewa Indians (3). Many factors contribute to the risk of developing RA and are reviewed in the following chapter (see Chapter 6B).
Article
The revised criteria for the classification of rheumatoid arthritis (RA) were formulated from a computerized analysis of 262 contemporary, consecutively studied patients with RA and 262 control subjects with rheumatic diseases other than RA (non-RA). The new criteria are as follows: 1) morning stiffness in and around joints lasting at least 1 hour before maximal improvement; 2) soft tissue swelling (arthritis) of 3 or more joint areas observed by a physician; 3) swelling (arthritis) of the proximal interphalangeal, metacarpophalangeal, or wrist joints; 4) symmetric swelling (arthritis); 5) rheumatoid nodules; 6) the presence of rheumatoid factor; and 7) radiographic erosions and/or periarticular osteopenia in hand and/or wrist joints. Criteria 1 through 4 must have been present for at least 6 weeks. Rheumatoid arthritis is defined by the presence of 4 or more criteria, and no further qualifications (classic, definite, or probable) or list of exclusions are required. In addition, a “classification tree” schema is presented which performs equally as well as the traditional (4 of 7) format. The new criteria demonstrated 91–94% sensitivity and 89% specificity for RA when compared with non-RA rheumatic disease control subjects.