Aquatic physical therapy as a treatment modality in healthcare for non-institutionalized elderly persons : a systematic review

Objective: To review scientific literature pertaining to aquatic physical therapy in the elderly and institutionalized population. Methods: A qualitative systematic review of electronic databases MEDLINE and LILACS, with the topic


INTRODUCTION
With the progressive demand on the part of a population in constant growth -the population of elderly peoplean increase is expected in the offer of beds in hospitals and long-stay institutions for the elderly (LSIEs) over the next few years (1) .These LSIEs may be governmental or nongovernmental, with a residential atmosphere, destined to be the collective residence for persons aged 60 years or more, with or without family support, under conditions of freedom, dignity, and citizenship (2) .
The elderly citizens who live in these institutions or at geriatric homes and clinics have unique characteristics, such as mean age of about 80 years, sedentarism, low autonomy, and absence of family members.These factors contribute towards the increase in prevalence of morbidities and comorbidities related to autonomy (1) .
One of the most important complications in this age group is the occurrence of falls, a public health problem due to its frequency, associated morbidities, and high social and economic costs, especially when it causes increased dependency and the beginning of life in an institution (3) .
Physical activity for the elderly person is able to provide beneficial organic effects, including general well-being, preservation of independence, prevention of diseases, control of special situations (stress and obesity, for example), and a decrease in chronic pain (4) .
Aquatic physical therapy programs have frequently been indicated for the elderly population since they are carried out in a safe environment, with less susceptibility to falls, and with good acceptance of and compliance with treatment (5) .This resource is applied in a thermalheated pool by means of techniques developed especially with objectives of preventing diseases, promoting and maintaining, treating, curing and rehabilitating health (6) .
The present study aimed to search scientific literature regarding effectiveness of aquatic physical therapy in the elderly and institutionalized population.

Type of study
Systematic narrative review was carried out.

Data collection procedures
Bibliographic search was carried out using LILACS and MEDLINE databases in reference to publications of clinical trials in the last 10 years.The following index terms were used: "hydrotherapy", "homes for the aged", "residential facilities", and "aged".
No studies were found on hydrotherapy in this specific population.In light of this fact, we decided to review the literature on effectiveness of this modality of physical therapy treatment in the non-institutionalized aged population in order to produce knowledge that may be critically analyzed concerning its potential applicability in the institutionalized population.
The intersection of sets was used (index terms, type of publication, and 10-year period).The terms used for this new search were "hydrotherapy" and "aged.
Twenty-seven articles resulted from the search with the mentioned criteria.All of them underwent analysis of the abstract by a single evaluator, and only those with the following inclusion criteria were selected: -clinical controlled/randomized trials; -treatment with any type of intervention protocol, as long as with complete immersion in a therapeutic pool.
The articles meeting these criteria had their entire content reviewed and underwent critical analysis, being confronted with other publications on the topic.
For evaluation of the methodological quality, Delphi's Listing, comprising eight items, was used.The answers are presented in the form of "yes/no/I don't know", in which one of the alternatives must be chosen for each item; the greater the quantity of affirmative answers, the better the quality of the study (7) (Figures 1 and 2).

RESULTS AND DISCUSSION
Ten of the 27 studies analyzed by their abstracts were excluded since they did not present the desired association between aquatic physical therapy and the elderly.These studies addressed local application techniques (without immersion in the pool) and they were not experimental, besides using a population under 60 years of age.LSIEs = long stay instituitions for the elderlies out that the study conducted by Silva et al. (23) was the only one that had sample with a mean age of 59 years.
Regarding exclusion criteria, 41% of the articles excluded those individuals who had pathologies that limited exercise (4,10,11,13,17,23,25) , those dependent on help for daily activities, and those who engaged in other exercises besides what was proposed in the given study.
Applegate and Curb (8) stated that many studies do not allow a true double-blind characteristic, but even so, it is possible to carry out successful randomized trials without complete blinding if the outcome evaluators are blind to the proposed treatment.

Result measurements
As to measurements of results, 35% of the articles (13)(14)(15)(16)20,23) applied the Western Ontario McMaster Universities (WOMAC) quality of life questionnaire specific for osteoarthritis, which is capable of assessing intensity of pain, joint stiffness, and functional difficulties resulting from hip or knee osteoarthritis (9) .
In 23% of the studies (11,12,14,25) , the questionnaire used to evaluate quality of life was the Short Form Health Survey (SF-36).
Another prevalent fact was pain assessment, also performed in 23% of the studies by means of the Visual Analog Scale (VAS) (16,17,(23)(24) .
Blood pressure (BP) was mentioned as an outcome measurement by Candeloro and Caromano et al. (10) along with heart rate.On the other hand, for Gimenes et al. (4) , only BP was used as a result.
In order to avoid biases, it is important to identify all resulting variables and to report hypotheses before beginning the study.Nevertheless, investigators conduct trials with aged individuals, many times confronted with the problem of various results.For example, quality of life or physical function may have more important  The remaining 17 articles were comprehensively analyzed.The classifications and characteristics of these articles are included in this review and presented in chart 1.
All studies presented specified eligibility criteria, intention to treat, and most reported primary outcome measurements, thus providing better quality studies.
With this discussion, we intended to describe the findings of the articles searched and to associate them to the dynamics of institutionalized aged persons.

Subject characteristics
As to subject characteristics of the articles analyzed, 29% of the articles had as inclusion criterion patients diagnosed with osteoarthritis of the hip and/or knee (13,14,17,(23)(24) .As to gender, 23% of the studies involved aged women (10,12,18,21) , and the mean age of all study subjects was 68 years.However, it is important to point results than mortality, despite the latter being easier to measure (8) .Since intervention in these studies had a curative character, large groups of diagnoses related to specific functional losses were selected.In institutionalized elderly persons, studies such as these, with intention to treat, could use more generic outcome measurements such as functional capacity and quality of life, since this population has a higher degree of functional fragility.

Intervention strategies
In general, the protocol of exercises performed in the therapeutic pool obeyed the following sequence: warmup, strengthening of lower limbs, flexibility, resistance, and stretching, all with increasing degrees of difficulty and in groups.
In addition to these, Devereux et al. (12) also proposed water exercises based on Tai Chi and demonstrated that exercises in the water produced significant changes in balance and quality of life, but not in the fear of falling.
Fransen et al. (13) compared groups in hydrotherapy, Tai Chi exercises, and a control group and verified clinical benefits in both intervention groups.
In 23% of the articles, exactly the same intervention group was used (14,17,22,25) , which consisted of hydrotherapy, floor exercises, and a control group.
Stener-Victorin et al. (24) compared hydrotherapy, electroacupuncture, combined with educational talks and a group that received only the educational talk.The authors were able to affirm that the two intervention groups produced lasting effects, and demonstrated reduced movement pain and quality of life.Only this latter study used combined therapy.In cases in which the objective was the recovery of functionality, elderly patients were benefited by combined therapy, e.g., by hydrotherapy and floor exercises.
The duration of intervention varied from only 10 sessions, in Medeiros et al. (19) , to a 6-month follow-up, in Rahmann et al. (20) .Almost all studies applied their protocols with a frequency of 2 to 3 times a week, with 30 minutes to 1 hour duration of each session.

Intervention sites and professionals involved in application of the method
Of all articles reviewed, none of them had an LSIE as the site of the intervention.Of these, 52% were conducted in teaching clinics of universities (4,10,15,16,19,21- 24) , while 23% were held in therapeutic pools within hospitals (13,14,20,25) .Only 11% made no mention as to where they were carried out (11,17) .There was also a study conducted in a community aquatic center and gym (12,18) .

CONCLUSION
Even though a large part of the studies demonstrated results with the practice of aquatic physical therapy, none of them was applied in an LSIE environment.Based on these studies in community elderly persons, a model of aquatic physical therapy assistance can be proposed, with well-defined inclusion and exclusion criteria.Thus, further studies are needed in this area to propose a model of assistance in LSIEs.

Figure 1 .
Figure 1.Flowchart of the first review.

Figure 2 .
Figure 2. Flowchart of the second review.

Chart 1 .
List of articles resulting from bibliographic search on effectiveness of aquatic physical therapy in the elderly.