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Aquatic Exercise for Pain Management in Older Adults with Osteoarthritis


Abstract and Figures

This literature review focused on the effects of aquatic exercise programs in reducing pain in older adults with osteoarthritis (OA). Studies were included that involved adults 50 years of age and older with OA. Effects of aquatic exercise programs involving strength, endurance, balance, stretching and aqua jogging on pain in these individuals were examined. Significant outcomes included reduced pain as well as improved motor functioning, reduced body weight, improved self-efficacy and enhanced quality of life.  Based on results, programming recommendations are provided to assist therapists in recognizing how facilities, water temperature, session length, frequency of programs, accessory equipment, education and social support can all contribute to positive outcomes.
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Therapeutic Recreation Journal VOL. XLIX, NO. 4 pp. 326–330 2015
Student Research
Keywords: aquatics; exercise; older adults; osteoarthritis; pain
Search Terms: Aquatic exercise AND arthritis AND pain management AND old-
er adults; water aerobics AND pain AND osteoarthritis AND seniors; hydrotherapy
AND arthritis AND pain reduction AND geriatrics OR elderly
Years: 2010–2015
Databases: EBSCO, Google Scholar, and PubMed
Number of Articles Reviewed: 6
Jamie Davis is a recent graduate of the BS in therapeutic recreation program at Temple Univer-
sity. Rhonda Nelson is an associate professor in the Department of Rehabilitation Sciences at
Temple University, and Program Director for the erapeutic Recreation Program. Please send
correspondence to
Aquatic Exercise for Pain Management in
Older Adults with Osteoarthritis
Jamie Davis
Rhonda Nelson
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Davis and Nelson 327
It is estimated that 70% to 80% of
adults 55 years and older experience de-
generative joint changes (Lim, Tchai, &
Jang, 2010), of which osteoarthritis (OA)
has been identied as the most prevalent
rheumatic disease aecting this popu-
lation (Wang, Lee, Liang, Tung, Wu, &
Lin, 2011). Common symptoms of OA
are pain and dysfunction in the aected
joints (Ansari, Elmieh, & Hojjati, 2014).
Exercise is frequently recommended as
a non-pharmacological treatment for
symptoms of OA. However, many land-
based exercises place strain on joints,
which can exacerbate symptoms (Kim,
Chung, Park, & Kang, 2012). Aquatic
exercise has been identied as one treat-
ment modality that may be well suited for
older adults with OA since weight load-
ing is minimized by the water’s buoyancy,
which simultaneously reduces stress on
joints and relieves pain (Kim et al., 2012).
Aquatic exercises are generally easy to
learn (Lim et al., 2010), and do not typi-
cally require expensive resources. is
makes them clinically suitable for many
individuals (Wang et al., 2011).
is six-article literature review ex-
amined the eects of aquatic exercise
programming in reducing pain in older
adults with OA. Five intervention studies
(Ansari et al., 2014; Fisken, Waters, Hing,
Steele, & Keogh, 2014; Kim et al., 2012;
Lim et al., 2010; Wang et al., 2011) and
one literature review focused on provid-
ing evidence-based application guidelines
(Tilden, Reicherter, & Reicherter, 2010)
were included. e ve intervention stud-
ies all focused on individuals with OA
who were over the age of 50, with some
researchers setting the minimum age for
inclusion at 55 (Wang et al., 2011) or 60
years of age (Fisken et al., 2014; Kim et
al., 2012). Two studies included partici-
pants with OA regardless of the primary
joint impacted (Fisken et al., 2014; Kim
et al., 2012), while three studies focused
exclusively on individuals with OA of the
knee (Ansari et al., 2014; Lim et al., 2010;
Wang et al., 2011). Individuals in one of
these studies also had co-occurring obe-
sity (Lim et al., 2010).
Participants in all studies were com-
munity-dwelling older adults. Mixed gen-
der groups were generally used (Fisken
et al., 2014; Lim et al., 2010; Wang et al.,
2011), however one study focused exclu-
sively on male participants (Ansari et al.,
2014), and another only included females
(Kim et al., 2012). Sample sizes ranged
from 13 (Fisken et al., 2014) to 84 partici-
pants (Wang et al., 2011).
e aquatic exercise interven-
tions were all structured dierently, and
were described as exercises focused on
strength, endurance, balance, and stretch-
ing (Ansari et al., 2012); aqua aerobic ex-
ercises including bounces, jogging, kicks,
twists, jumping jacks and side steps (Kim
et al., 2012); walking and aqua jogging
with weights (Lim et al., 2010); exercises
focused on exibility, balance, coordina-
tion, aerobics and resistance (Wang et al.,
2010); and a combination of body-weight
aqua tness, body-weight aqua jog-
ging, hydrotherapy, resisted aqua-tness
and resisted aqua-jogging (Fisken et al.,
Pain was measured using the Brief
Pain Inventory (BPI) (Lim et al., 2010);
the Knee and Osteoarthritis Outcome
Scores (KOOS) (Ansari et al., 2014; Wang
et al., 2011), the Numerical Rating of Pain
Scale (NRS) (Fisken et al., 2014); and the
Visual Analog Scale (VAS) for Pain (Kim
et al., 2012).
Participants experienced a signi-
cant decrease in pain (Ansari et al., 2014;
Fisken et al., 2014; Kim et al., 2012; Lim
et al., 2010; Wang et al., 2011), as well
as several other signicant outcomes
328 Aquatic Exercise, Osteoarthritis, and Pain
including improved motor function-
ing (Ansari et al., 2014); enhanced self-
ecacy and reduced depression (Kim et
al., 2012); decreased body fat (Lim et al.,
2010); improved range of motion (Wang
et al., 2011); and, improved quality of life
(Ansari et al., 2014; Lim et al., 2010; Wang
et al., 2011). Despite these promising re-
sults, Tilden et al. (2010) emphasized
that while aquatic exercises oen provide
short-term relief, they do not always re-
sult in long-term pain reduction. ere-
fore, while aquatic exercise can serve as
a valuable component of an overall pain
management program for older adults
with OA, continuous engagement may be
necessary for ongoing benets.
Knowledge Translation Plan
Based on the above ndings, it is
recommended that recreational thera-
pists consider using aquatic exercise to
address pain management in older adults
with OA through the utilization of a vari-
ety of water-based exercises focusing on
strength, balance, endurance, stretching
and/or aqua jogging. e Arthritis Foun-
dation Aquatics Program (AFAP) is one
resource that can provide guidance when
designing interventions and selecting
specic exercises (Wang et al., 2011). As
depicted in Figure 1, the current litera-
ture suggests that interventions should be
scheduled three times per week (Ansari
et al., 2014; Kim et al., 2012; Lim et al.,
2010; Wang et al., 2011) for 40 to 60 min-
utes and should be part of an extended
program that is oered over six (Ansari
et al., 2014), eight (Lim et al., 2010) or
12 consecutive weeks (Kim et al., 2012;
Wang et al., 2011). Sessions are typically
structured so they include a 5 to 10 min-
ute warm-up period followed by 30-40
minutes of the designated exercises and
then a 5-10 minute cool-down period
(Ansari et al., 2014; Kim et al., 2012; Lim
et al., 2010; Wang et al., 2011).
As part of overall program planning,
therapists should also consider the fol-
lowing: facilities, water temperature and
depth, accessory equipment, education
and social support. For safety, it is recom-
mended that facilities are equipped with
nonslip surfaces (Tilden et al., 2010), and
that participants have access to handrails
and/or ramps when accessing the pool
(Fisken et al., 2014). Water temperature
should be between 24 degrees Celsius
(Kim et al., 2012) and 36 degrees Celsius
(Lim et al., 2010; Tilden et al., 2010). is
is the recommended water temperature
range for persons with OA and colder wa-
ter may be viewed as unpleasant by some
participants (Fisken et al., 2014). How-
ever, therapists should exercise caution
when working with individuals who have
co-occurring cardiopulmonary disorders
since performing high intensity aerobic
exercise in warm pools can be contrain-
dicated for that population (Tilden, et al.,
2010). Water depth of 115 cm (Lim et al.,
2010) to 120 cm (Kim et al., 2012) is also
recommended to facilitate movements
and maximize eects.
Accessory equipment will provide
variety to exercises, reduce monotony,
and minimize boredom (Kim et al.,
2012). erapists can consider balls (Kim
et al., 2012), otation noodles (Fisken et
al., 2014; Kim et al., 2012), foam barbells
(Fisken et al., 2014; Tilden et al., 2010),
weighted devices (Tilden et al., 2010), or
gloves/mitts (Tilden et al., 2010). Music
can also be used to supplement the exer-
cise (Kim et al., 2012), but should not be
so loud that it is distracting or disruptive
to participants (Fisken et al., 2014).
Education can be a critical compo-
nent of any aquatic based exercise pro-
gram, especially at the programs onset.
is will assist participants in under-
standing the value of exercise, the pur-
Davis and Nelson 329
pose of the program, and the program’s
intended eects (Kim et al., 2012). Also,
since the social aspect of aquatic exercise
programs has been identied by partici-
pants as an enjoyable feature (Fisken et
al., 2014), therapists should encourage
peer interactions during programming
and incorporate informal opportunities
for social interactions before and aer
sessions so participants become better
acquainted (Kim et al., 2012).
Figure 1. Recommendations for Developing Evidence-Based
Aquatic Exercise Programs to Decrease Pain in Older Adults with
Ansari, S., Elmieh, A., & Hojjati, Z. (2014). Eects of aquatic exercise training on pain, symp-
toms, motor performance, and quality of life of older males with knee osteoarthritis. An-
nals of Applied Sport Science, 2(2), 29–38.
Fisken, A., Waters, D., Hing, W., Steele, M., & Keogh, J. (2014). Perception and responses to dif-
ferent forms of aqua-based exercise among older adults with osteoarthritis. Internati onal
Journal of Aquatic Research and Education, 8, 32–52.
Kim, I. S., Chung, S. H., Park, Y. J., & Kang, H. Y. (2012). e eectiveness of an aquarobic ex-
ercise program for patients with osteoarthritis. Applied Nursing Research, 25(3), 181–189.
Lim, J. Y., Tchai, E., & Jang, S. N. (2010). Eectiveness of aquatic exercise for obese patients with
knee osteoarthritis: A randomized controlled trial. American Academy of Physical Medicine
and Rehabilitation, 2(8), 723–731.
330 Aquatic Exercise, Osteoarthritis, and Pain
Tilden, H., Reicherter, A., & Reicherter, F. (2010). Use of an aquatics program for older adults
with osteoarthritis from clinic to the community. Topics in Geriatric Rehabilitation, 26(2),
Wang, T. J., Lee, S. C., Liang, S. Y., Tung, H. H., Wu, S. F. V., & Lin, Y. P. (2011). Comparing the
ecacy of aquatic exercises and land-based exercises for patients with knee osteoarthritis.
Journal of Clinical Nursing, 20(17–18), 2609–2622.
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Osteoarthritis is a degenerative joint process prevalent in the older adult population. Aquatic therapy is an effective and efficient method with which to address the pain, decreased strength, range of motion, and neuromotor control that can accompany arthritis. This article presents the current evidence-based support for the use of aquatic therapy with persons with osteoarthritis and provides progression application from a clinic-based to community-based, recreational exercise program. Sample exercise programs for the upper and lower body are provided to address a variety of outcomes.
The study aims to compare changes over time among three study groups on the primary outcome, pain, as well as on the secondary outcomes, other symptoms, activities of daily living function, sport and recreation function, knee-related quality of life, knee range of motions and the six-minute walk test and to investigate whether aquatic exercises would be superior compared with land exercise on pain reduction. Osteoarthritis is a prevalent musculoskeletal disorder. Appropriate exercise may prevent osteoarthritis-associated disabilities and increase life quality. To date, research that compares the effects of different types of exercise for knee osteoarthritis has been limited. The study is a randomised trial. Eighty-four participants with knee osteoarthritis were recruited from local community centres. Participants were randomly assigned to the control, aquatic or land-based exercise group. Exercise in both groups ran for 60 minutes, three times a week for 12 weeks. Data were collected at baseline, week 6 and week 12 during 2006-2007. The instruments included the Knee Injury and Osteoarthritis Outcome Score, a standard plastic goniometer and the six-minute walk test. Generalised estimation equations were used to compare changes over time among groups for key outcomes. Results showed statistically significant group-by-time interactions in pain, symptoms, sport/recreation and knee-related quality of life dimensions of Knee Injury and Osteoarthritis Outcome Score, knee range of motions and the six-minute walk test. However, the aquatic group did not show any significant difference from the land group at both weeks 12 and 6. Both aquatic and land-based exercise programmes are effective in reducing pain, improving knee range of motions, six-minute walk test and knee-related quality of life in people with knee osteoarthritis. The aquatic exercise is not superior to land-based exercise in pain reduction. Similar outcomes could be possible with the two programmes. Health care professionals may consider suggesting well-designed aquatic or land-based exercise classes for patients with osteoarthritis, based on their preferences and convenience.
Aquarobics, a combination of the words aqua and aerobics, is based on the idea that much more energy is consumed during exercise when resisting water rather than air. The aquarobic exercise program is composed of patient education and aquarobic exercise. The program was effective in enhancing self-efficacy, decreasing pain, and improving depression levels, body weight, and blood lipid levels in patients with osteoarthritis. Therefore, this program can be widely used in a community setting for the management of osteoarthritis.
To design an aquatic exercise (AQE) and land-based exercise (LBE) program to enhance knee function and reduce body fat in patients with obesity and knee osteoarthritis and to investigate the effectiveness of AQE and LBE on body fat, functional fitness, and functional status. Outpatient clinic at a Seoul National University Bundang Hospital. Obese patients with knee osteoarthritis were recruited from patients who visited the rehabilitation, orthopedic surgery, and geriatric outpatient clinics at the hospital. Study participants were limited to those who met the following criteria: body mass index more than 25 kg/m(2), abdominal circumference more than 90 cm (men) or 85 cm (women), clinically diagnosed osteoarthritis with Kellgren-Lawrence scale 2 or higher on radiographic studies, and independent ambulation state. Participants were randomly allocated into 3 groups: AQE (n = 26), LBE (n = 25), and the control group (n = 24). Exercise interventions were conducted 3 times a week for 8 weeks. Body fat analysis, brief pain inventory, Western Ontario and McMaster Universities' osteoarthritis index, Short Form-36 questionnaire, and knee isokinetic tests were evaluated to assess changes in body fat composition, pain, physical function, and quality of life before and after the exercise program. Although no significant difference was found in general characteristics among the 3 groups before exercise, body fat proportion in the AQE group decreased significantly (mean +/- SD, from 34.4 +/- 4.7 to 33.3 +/- 4.7; P = .031) after intervention. The body mass index was slightly reduced after intervention, but it was not statistically significant. The AQE group showed significant improvements in pain, disability, and quality of life. Notably, the change in pain interference in the AQE group (mean +/- SD, from 25.8 +/- 15.1 to 18.8 +/- 13.1; P = .009) was greater than that of the LBE group. Both exercise groups showed significant improvements in Western Ontario and McMaster Universities' osteoarthritis index disability compared with the control group. AQE had an advantage in controlling the interference with activity because of pain. AQE may be an effective tool for patients with obesity who have difficulties with active exercise due to knee osteoarthritis.