Effects of aquatic exercise on muscle strength and functional performance of individuals with osteoarthritis: a systematic review

Mattos, Fernanda de; Leite, Neiva; Pitta, Arthur; Bento, Paulo Cesar Barauce

doi:10.1016/j.rbre.2016.09.003

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Review articles • Rev. Bras. Reumatol. 56 (6) • Nov-Dec 2016 • https://doi.org/10.1016/j.rbre.2016.09.003 copy

Effects of aquatic exercise on muscle strength and functional performance of individuals with osteoarthritis: a systematic review

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Water-based exercises are recommended for people with osteoarthritis (OA), due to the beneficial effects on physical function, quality of life and symptom reduction. However, the effects on muscle strength are still controversial. The aim of this review was to assess and compare the effects of aquatic exercise programs on muscle strength and physical function in people with OA. A systematic search was performed at Pubmed, Scopus and Web of Science databases. Clinical trials with interventions involving aquatic exercises for individuals with OA were included. The methodological quality of the studies was evaluated using the PEDro scale. 296 studies were found and twelve were selected: six studies comparing water-based exercises with land-based exercise, and six comparing water-based exercise groups with the control group. Exercise programs included muscle strengthening, aerobic, balance, flexibility and stretching exercises. Duration of the program, weekly frequency, intensity and progression varied between studies. Beneficial effects of aquatic exercise were found on physical function. However, only two of five studies that assessed muscle strength observed positive effect of aquatic exercise. Although it is difficult to compare studies and establish guidelines for the standardized protocol formulation, it was observed that water-based exercises can be effective on improving physical function and increasing muscle strength, since they are well-structured, with exercise intensity and overload controlled.

Keywords:
Osteoarthritis; Water-based exercise; Physical function; Muscle strength

Reference	1	2	3	4	7	8	9	10	11	Total
Wyatt et al. (2001)	1	1	0	0	1	1	1	1	1	7
Wang et al. (2007)	1	1	0	1	0	1	1	1	1	7
Hinman et al. (2007)	1	1	1	1	1	1	1	1	1	9
Silva et al. (2008)	1	1	1	1	1	1	1	1	1	9
Lund et al. (2008)	1	1	1	1	1	1	1	1	1	9
Lim et al. (2010)	1	1	1	1	1	1	1	1	1	9
Arnold and Faulkner (2010)	1	1	1	1	1	1	1	1	1	9
Wang et al. (2011)	1	1	0	1	1	1	1	1	1	8
Hale et al. (2012)	1	1	1	1	1	1	1	1	1	9
Wallis et al. (2014)	1	0	0	1	1	1	1	1	1	7
Bressel et al. (2014)	1	0	0	1	0	1	1	1	1	6
Fisken et al. (2015)	1	1	1	1	0	0	1	1	1	7

Authors, year/country, type of study	Sample (N), mean age (years), number of women, site of OA	Groups	Assessments outcomes	Intervention	Results
Wyatt et al., 2001/USA Experimental study	N = 42	AG = ^* * Not informed.	Initial (s0) and final (s6) assessment	AG: 3× wk/6 wk	Increase in ROM and thigh thickness, and reduction of pain and in 1-mile travel time in both groups
	45–70 years OA knee	GG = ^* * Not informed.	ROM (goniometer), thigh thickness, pain (VAS) and speed (1-mile walk time)	Manual resistance + strengthening exercises	A difference between groups only in pain; AG with greater reduction in pain
				LLMs + 244-meter walk
				GG: 3x wk/6 wk
				Manual resistance exercises + LLMs + + 244-meter walk
Wang et al. 2007/USA	N = 42	AG = 20	Initial (s0), medium (s6), and final (s12) assessment	AG: 3× wk/50 min/12 wk	Increased hip and knee flexibility, muscle strength and distance covered in 6 min walk

Randomized clinical trial	66 years	CG = 18	ROM flexibility of knee and hip (goniometer), maximal isometric strength of hip and knee extension and flexion, and hip abduction and adduction (hand dynamometer), gait (6-min walk test), functionality and ADLs (MDHAQ) and pain (VAS)	Flexibility + aerobic + strengthening exercises for LLMs, ULMs and trunk (AFAP Protocol)	No difference in self-reported function and in pain between groups
	32 women			Progressive intensity (scale 0–10): s0-s4 (2–3), s5-s8 (3–4), and s9–s12 (4)
	OA knee and hip			CG: activities of daily living

Hinman et al. 2007/Australia Randomized clinical trial	N = 71	AG = 36	Initial (s0), final (s6), and follow-up (s12) assessment	AG: 2×/45–60 min/6 wk	Hip muscle strength and QOL improved in AG after 6 weeks. AG had a 33% reduction in pain and 72% of the group reported improvement throughout the intervention
	62 years	CG = 35	Pain (VAS), change in pain and functionality (5-point scale), osteoarthritis (WOMAC), QOL (15-item scale), physical activity level (PASE), isometric strength of hip abduction and knee extension (hand dynamometer), the Step test, TUG and 6-min walk test	Strengthening exercises for LLMs: 2 × 10 reps + 6–10 min walk on water	At follow-up (s12) the benefits were maintained
	48 women			Water depth decreased throughout the intervention
	OA knee and hip			CG: activities of daily living

Silva et al., 2008/Brazil Randomized clinical trial	N = 64	AG = 31	Initial (s0), medium (s9), and final (s18) assessment	AG: 3× wk/50 min/18 wk	The 15-m test in a comfortable speed ↓ in both groups, but at high-speed GG improved between s1 and s9, and AG between s9 and s18A
	59 years	GG = 26	Pain (VAS), osteoarthritis (Lequesne and WOMAC), speed (two-speed 15-meter walk test) and pain during the walk test (VAS) and NSAIDs	Stretching: 2 × 20 s + Strengthening exercise for LLMs: 7–10 reps of 6 s (isometric contractions) and 20–40 reps	Pain ↓ in both groups. LEQUESNE and WOMAC ↓ in both groups until S9; from S9 to S18 a decrease occurred only in AG.
	59 women OA knee			Increased resistance to the use of elastic or of a 1-kg weight
				GG: 3× wk/50 min/18 wk
				Stretching 2 × 20 s + strengthening exercise for lower limbs: 7–10 6-s reps (isometric contractions) and 20–40 reps
				Floater to ↑ speed (isotonic exercises)

Lund et al., 2008/Denmark Randomized clinical trial	N = 79	AG = 27	Initial (s0), final (s8), and follow-up (s20) assessment	AG and GG: 2× wk/50 min/8 wk	Muscle strength ↑ in GG and ↓ in AG versus CG both at the end of the intervention and at follow-up. The aquatic exercise showed a better effect on balance versus ground exercise. Pain ↓ in GG versus CG in follow-up
	68 years	GG = 25	Pain (VAS), osteoarthritis (KOOS), body sway (static equilibrium – Balance Master Pro) and isokinetic strength at 30, 60 and 90°/s (isokinetic dynamometer – Biodex)	Resisted exercises + balance and stability + stretching of LLMs
	62 women OA knee	CG = 27		Intensity control: music
	62 women OA knee	CG = 27		CG: activities of daily living

Lim et al., 2010/Korea Randomized clinical trial	N = 75	AG = 26	Initial (s0) and final (s8) assessment	AG: 3× wk/40 min/8 wk	AG showed improved functionality, pain and quality of life. Both groups improved the functionality of lower limbs. There was no change in knee flexor and extensor strength in both groups. The physical component scale improved slightly in both groups
	65 years	GG = 25	Pain (BPI), osteoarthritis (WOMAC), QOL (SF-36 version 2.0), isokinetic strength of knee extensors and flexors at 60°/s (isokinetic dynamometer – Biodex)	Heating + Walk + strength + resistance + force − aerobic exercises
	65 women OA knee	CG = 24		Intensity >65% of CF
				GG: 3× wk/40 min/8 wk
				Joint mobilization + strengthening
				Intensity of 40–60% of 1RM
				CG: home exercises: isometrics (quadriceps) and partial squats

Arnold and Faulkner, 2010/Canada Randomized clinical trial	N = 83	AG = 28	Initial (s0) and final (s11) assessment	AG: 2× wk/45 min/11 wk	In physical performance, AEG has improved versus CG and AG. Similar trends were found for TUG and for the 6-min walk test. An improvement was found in efficacy of falls in AEG versus CG
	75 years	AEG = 26	Balance (Berg Balance Scale), gait (6-min walk test), falls (ABC), functionality (STS and TUG), osteoarthritis (AIMS-2), and physical activity level (PASE)	Heating + strengthening exercises of LLMs and ULMs + trunk control + balance and practical posture
	56 women OA hip	CG = 27
				AEG: 2× wk/45 min/11 wk
				Same program of AG + 30-min educational session before water training (functional tasks)
				CG: activities of daily living

Wang et al., 2011/Taiwan Randomized clinical trial	N = 78	AG = 26	Initial (s0), medium (s6), and final (s12) assessment	AG: 3× wk/60 min/12 wk	Significant improvement in KOOS, ROM, 6-min walk test and pain in AG and GG versus control group; no significant change was found between AG and GG
	67 years	GG = 26	Osteoarthritis (KOOS), ROM (goniometer) and gait (6-min walk test)	Flexibility + aerobic exercises (AFAP protocol)
	67 women OA knee	CG = 26		Intensity 3–4 (Borg CR10 Scale)
				GG: 3× wk/60 min/12 wk
				Flexibility + aerobic exercises (PACE Protocol)
				Intensity 3–4 (Borg CR10 Scale)
				CG: activities of daily living

Hale et al., 2012/New Zealand Randomized clinical trial	N = 39	AG = 23	Initial (s0) and final (s12) assessment	AG: 2× wk/20–60 min/12 wk	In both groups there was a significant improvement in Step test and also improvement in two items of PPA (reaction time and contrast sensitivity) in CG. There was no significant improvement in TUG
	74 years	CG = 16	Falls (PPA and ABC), dynamic balance (Step Test), functionality (TUG), and osteoarthritis (WOMAC andAIMS-2)	Heating + balance exercises ↑ difficulty
	29 women OA knee and hip			Water depth ↓ throughout the intervention
				CG: 2× wk/60 min/12 wk
				SeniorNet (computer skills’ training offered by the elderly for the elderly)

Wallis et al., 2014/Australia Experimental study	N = 20	AG = 20	Pre (s-0), initial (s0), and final (s6) assessment	AG: 2× wk/105 min/6 wk	An increase of 12% was found for the fast walk test. There was no significant improvement in STS
	71 years		Self-efficacy (Arthritis Self-efficacy Scale), osteoarthritis (WOMAC), gait (10-min walk test), functionality (STS), and QOL (EQ-5D and EQ-VAS)	Educational sessions (60 min) + water exercises (45 min): Functional, aerobic, ROM, strengthening exercises of LLMs and exercises at home (counseling)
	9 women OA knee and hip			Moderate intensity and individual progression

Bressel et al., 2014/USA Single group posttest, double pretest design	N = 18	AG = 18	Pre- (s4), initial (s0), and final (s6) assessment	SG: 2-3x wk/18–30 min/6 wk	There was significant improvement in functionality, mobility and balance, and reduction in knee pain
	64 years		Osteoarthritis (KOSS), pain (VAS), balance and motor function (SMART EquiTest system), and functionality (STS, FLT and 10-min walk test)	Balance exercises + HIT components (aquatic mat)/water jets to balance disorder
	16 women			Intensity of 14–19 over RPE
	OA knee and hip			Intensity of 14–19 over RPE

Fisken et al., 2015/New Zealand Experimental study	N = 35	AG = 19	Initial (s0) and final (s12) assessment	AG: 2× wk/45–60 min/12 wk	In both groups, ↓ in time in the 400-m walk test. AG improved on Step test and AIMS-2. AG improved in FES-I versus CG. There was no significant change in TUG, STS and grip strength in both groups
	70 years	CG = 16	Functionality (TUG and STS), dynamic balance (15-sec Step Test), muscle strength (hand dynamometer), grip strength (Jamar dynamometer), gait (400-m walk test), osteoarthritis (AIMS2-SF), falls (FES-I), physical activity level (RAPA)	Strength + aerobic exercise
	23 women OA knee, hip, spine and hands			Intensity control: music
				CG: 1× wk/35–40 min/12 wk
				HT-type exercise + hydrotherapy exercises (AFAP) wk progression

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[1] *Corresponding author. E-mail: ferdymattos@hotmail.com (F. Mattos).