Aquatic exercise for the treatment of knee and hip osteoarthritis

Else Marie Bartels; Hans Lund; Kåre Birger Hagen; Hanne Dagfinrud; Robin Christensen; Bente Danneskiold‐Samsøe

doi:10.1002/14651858.CD005523.pub2

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Analysis 1.1

Comparison 1 Aquatic exercise versus control after treatment ‐ knee&hip mixed, Outcome 1 Pain.

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Analysis 1.2

Comparison 1 Aquatic exercise versus control after treatment ‐ knee&hip mixed, Outcome 2 Function.

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Analysis 1.3

Comparison 1 Aquatic exercise versus control after treatment ‐ knee&hip mixed, Outcome 3 Walking ability.

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Analysis 1.4

Comparison 1 Aquatic exercise versus control after treatment ‐ knee&hip mixed, Outcome 4 Stiffness.

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Analysis 1.5

Comparison 1 Aquatic exercise versus control after treatment ‐ knee&hip mixed, Outcome 5 Quality of life.

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Analysis 1.6

Comparison 1 Aquatic exercise versus control after treatment ‐ knee&hip mixed, Outcome 6 Mental health.

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Analysis 2.1

Comparison 2 Aquatic exercise versus control after treatment ‐hip, Outcome 1 Function.

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Analysis 2.2

Comparison 2 Aquatic exercise versus control after treatment ‐hip, Outcome 2 Quality of life.

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Analysis 3.1

Comparison 3 Aquatic exercise versus land after treatment ‐ knee, Outcome 1 Pain.

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Analysis 3.2

Comparison 3 Aquatic exercise versus land after treatment ‐ knee, Outcome 2 Walking ability.

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Analysis 3.3

Comparison 3 Aquatic exercise versus land after treatment ‐ knee, Outcome 3 Stiffness.

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Analysis 4.1

Comparison 4 Aquatic exercise versus control at follow up ‐ knee&hip mixed, Outcome 1 Pain.

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Analysis 4.2

Comparison 4 Aquatic exercise versus control at follow up ‐ knee&hip mixed, Outcome 2 Function.

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Analysis 4.3

Comparison 4 Aquatic exercise versus control at follow up ‐ knee&hip mixed, Outcome 3 Stiffness.

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Analysis 4.4

Comparison 4 Aquatic exercise versus control at follow up ‐ knee&hip mixed, Outcome 4 Mental health.

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Analysis 5.1

Comparison 5 Aquatic exercise versus control at follow up ‐ hip, Outcome 1 Pain.

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Analysis 5.2

Comparison 5 Aquatic exercise versus control at follow up ‐ hip, Outcome 2 Function.

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Analysis 5.3

Comparison 5 Aquatic exercise versus control at follow up ‐ hip, Outcome 3 Quality of life.

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Table 1. Clinical relevance table ‐ Knee and hip mixed OA

Study	Outcome (scale)	# patients (# trials	Ctl baseline mean,SD	Wt absolute change	Relative % change	Statistical Sig.	Quality of evidence
Cochrane (2005) ; Foley (2003)	WOMAC (Western Ontario McMaster Osteoarthritis Index) (pain) (0‐20)	380 (2)	9.10 (3.14)	3.0% (0.6 fewer points on a scale 0 to 20 scale)	6.6% (I)	statistically significant but not clinically significant	GOLD
Wang (2004)	VAS (Visual Analogue Scale) pain (0‐100)	43 (1)	55.3 (24.6)	12% (12.3 fewer points on a 0‐100 scale)	0.2% (I)	not significant	GOLD
Patrick (2001)	HAQ (Health Assessment Questionnaire) pain (0‐3)	249 (1)	1.05 (0.61)	2% (0.07 fewer points on a 0‐3 scale)	7% (I)	not significant	GOLD
Cochrane (2005); Foley (2003)	WOMAC function (0‐68)	380 (2)	31.05 (11.24)	4.3% (2.9 points on scale of 0 to 68)	9.4% (1)	statistically significant but not clinically significant	GOLD
Patrick (2001); Wang (2004)	HAQ function (0‐3)	292 (2)	0.95 (0.5)	5.2% (0.16 fewer points on a 0‐3 scale)	16.3% (I)	statistically significant	GOLD
Cochrane (2005)	WOMAC pain (0‐20)	310 (1)	9.10 (3.14)	0.3% (0.35 points fewer on a 0‐20 scale)	4% (I)	not significant	GOLD
Cochrane (2005)	WOMAC function (0‐68)	310 (1)	31.05 (11.24)	0.1% (0.11 fewer points on a 0‐68 scale)	0.4% (I)	not significant	GOLD
Legend: ctl=control group; SD=standard deviation; wt=weighted; I=improvement; sig=significance;

Table 1. Clinical relevance table ‐ Knee and hip mixed OA

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Table 2. Clinical relevance table ‐ Hip OA

Study	Outcome (scale)	#patients #(trials)	Ctl baseline mean,SD	Absolute change	Relative % change	Statistical sig.	Quality of evidence
Stener‐Victorin (2004)	VAS (Visual Analog Scale) pain (0‐100)	28 (1)	56.0 (21.89)	22% (21.9 fewer points on a 0‐100 scale)	40% (I)	not statistically significant	SILVER
Legend: ctl=control group, SD=standard deviation, sig=significance, I=improvement

Table 2. Clinical relevance table ‐ Hip OA

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Table 3. Clinical relevance table ‐ Knee OA

Study	Outcome (scale)	#patients (# trials)	Ctl baseline mean,SD	Absolute change	Relative % change	Statisitical sig.	Quality of evidence
Wyatt (2001)	VAS (Visual Analog Scale) pain (0‐10)	46 (1)	5.6 (1.4)	12% (1.2 fewer points on a 0‐10 scale)	22% (I)	statistically significant	SILVER
Legend: ctl=control group; sig=significance; I=improvement

Table 3. Clinical relevance table ‐ Knee OA

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Comparison 1. Aquatic exercise versus control after treatment ‐ knee&hip mixed

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain Show forest plot	4	638	Std. Mean Difference (IV, Random, 95% CI)	0.19 [0.04, 0.35]

1.1 WOMAC pain	2	380	Std. Mean Difference (IV, Random, 95% CI)	0.20 [‐0.00, 0.40]
1.2 Visual Analogue Pain	1	43	Std. Mean Difference (IV, Random, 95% CI)	0.50 [‐0.10, 1.11]
1.3 HAQ pain	1	215	Std. Mean Difference (IV, Random, 95% CI)	0.12 [‐0.15, 0.39]
2 Function Show forest plot	4	648	Std. Mean Difference (IV, Random, 95% CI)	0.26 [0.11, 0.42]

2.1 WOMAC function	2	375	Std. Mean Difference (IV, Random, 95% CI)	0.23 [0.03, 0.44]
2.2 HAQ function	2	273	Std. Mean Difference (IV, Random, 95% CI)	0.31 [0.07, 0.55]
3 Walking ability Show forest plot	2	355	Std. Mean Difference (IV, Random, 95% CI)	0.18 [‐0.03, 0.39]

3.1 Six‐minute walk	1	43	Std. Mean Difference (IV, Random, 95% CI)	‐0.03 [‐0.63, 0.57]
3.2 8‐foot walk time	1	312	Std. Mean Difference (IV, Random, 95% CI)	0.21 [‐0.01, 0.43]
4 Stiffness Show forest plot	2	380	Std. Mean Difference (IV, Random, 95% CI)	0.14 [‐0.06, 0.34]

4.1 WOMAC stiffness	2	380	Std. Mean Difference (IV, Random, 95% CI)	0.14 [‐0.06, 0.34]
5 Quality of life Show forest plot	3	599	Std. Mean Difference (IV, Random, 95% CI)	0.32 [0.03, 0.61]

5.1 SF‐12 physical	1	70	Std. Mean Difference (IV, Random, 95% CI)	0.69 [0.21, 1.17]
5.2 PQOL ‐ perceived quality of life	1	222	Std. Mean Difference (IV, Random, 95% CI)	0.35 [0.09, 0.62]
5.3 EURO‐QOL	1	307	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.12, 0.33]
6 Mental health Show forest plot	4	642	Std. Mean Difference (IV, Random, 95% CI)	0.16 [0.01, 0.32]

6.1 SF‐36 mental	1	307	Std. Mean Difference (IV, Random, 95% CI)	0.15 [‐0.08, 0.37]
6.2 SF‐12 mental	1	70	Std. Mean Difference (IV, Random, 95% CI)	0.19 [‐0.28, 0.66]
6.3 Psychological Distress	1	43	Std. Mean Difference (IV, Random, 95% CI)	0.37 [‐0.24, 0.97]
6.4 QWB ‐ quality of well being	1	222	Std. Mean Difference (IV, Random, 95% CI)	0.13 [‐0.13, 0.40]

Comparison 1. Aquatic exercise versus control after treatment ‐ knee&hip mixed

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Comparison 2. Aquatic exercise versus control after treatment ‐hip

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Function Show forest plot	1	28	Std. Mean Difference (IV, Random, 95% CI)	0.76 [‐0.02, 1.53]

1.1 DRI‐disability rating index	1	28	Std. Mean Difference (IV, Random, 95% CI)	0.76 [‐0.02, 1.53]
2 Quality of life Show forest plot	1	28	Std. Mean Difference (IV, Random, 95% CI)	0.76 [‐0.02, 1.53]

2.1 GSI ‐ global self rating index	1	28	Std. Mean Difference (IV, Random, 95% CI)	0.76 [‐0.02, 1.53]

Comparison 2. Aquatic exercise versus control after treatment ‐hip

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Comparison 3. Aquatic exercise versus land after treatment ‐ knee

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain Show forest plot	1	46	Std. Mean Difference (IV, Random, 95% CI)	0.86 [0.25, 1.47]

1.1 VAS pain	1	46	Std. Mean Difference (IV, Random, 95% CI)	0.86 [0.25, 1.47]
2 Walking ability Show forest plot	1	46	Std. Mean Difference (IV, Random, 95% CI)	0.43 [‐0.16, 1.01]

2.1 1 MILE walk time	1	46	Std. Mean Difference (IV, Random, 95% CI)	0.43 [‐0.16, 1.01]
3 Stiffness Show forest plot	1	46	Std. Mean Difference (IV, Random, 95% CI)	‐0.26 [‐0.84, 0.32]

Comparison 3. Aquatic exercise versus land after treatment ‐ knee

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Comparison 4. Aquatic exercise versus control at follow up ‐ knee&hip mixed

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain Show forest plot	1	310	Std. Mean Difference (IV, Random, 95% CI)	0.11 [‐0.12, 0.33]

1.1 WOMAC pain	1	310	Std. Mean Difference (IV, Random, 95% CI)	0.11 [‐0.12, 0.33]
2 Function Show forest plot	1	306	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.12, 0.33]

2.1 WOMAC function	1	306	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.12, 0.33]
3 Stiffness Show forest plot	1	310	Std. Mean Difference (IV, Random, 95% CI)	0.13 [‐0.09, 0.36]

3.1 WOMAC stiffness	1	310	Std. Mean Difference (IV, Random, 95% CI)	0.13 [‐0.09, 0.36]
4 Mental health Show forest plot	1	309	Std. Mean Difference (IV, Random, 95% CI)	0.05 [‐0.17, 0.27]

4.1 SF‐36 mental	1	309	Std. Mean Difference (IV, Random, 95% CI)	0.05 [‐0.17, 0.27]

Comparison 4. Aquatic exercise versus control at follow up ‐ knee&hip mixed

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Comparison 5. Aquatic exercise versus control at follow up ‐ hip

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain Show forest plot	1	17	Std. Mean Difference (IV, Random, 95% CI)	1.00 [‐0.04, 2.04]

1.1 VAS pain	1	17	Std. Mean Difference (IV, Random, 95% CI)	1.00 [‐0.04, 2.04]
2 Function Show forest plot	1	17	Std. Mean Difference (IV, Random, 95% CI)	1.00 [‐0.04, 2.04]

2.1 DRI‐disability rating index	1	17	Std. Mean Difference (IV, Random, 95% CI)	1.00 [‐0.04, 2.04]
3 Quality of life Show forest plot	1	17	Std. Mean Difference (IV, Random, 95% CI)	1.00 [‐0.04, 2.04]

3.1 GSI ‐ global self rating index	1	17	Std. Mean Difference (IV, Random, 95% CI)	1.00 [‐0.04, 2.04]

Comparison 5. Aquatic exercise versus control at follow up ‐ hip

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