Water‐based exercise training for chronic obstructive pulmonary disease

Renae J McNamara; Zoe J McKeough; David K McKenzie; Jennifer A Alison

doi:10.1002/14651858.CD008290.pub2

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 4

Forest plot of comparison: 1 Water‐based exercise versus no exercise, outcome: 1.1 Exercise capacity (mean change in metres).

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Figure 5

Forest plot of comparison: 2 Water‐based exercise versus land‐based exercise, outcome: 2.1 Exercise capacity (mean change in metres).

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Figure 6

Forest plot of comparison: 1 Water‐based exercise versus no exercise, outcome: 1.2 Quality of life (mean change in total scores).

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Analysis 1.1

Comparison 1 Water‐based exercise versus no exercise, Outcome 1 Exercise capacity (mean change in metres).

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Analysis 1.2

Comparison 1 Water‐based exercise versus no exercise, Outcome 2 Quality of life (mean change in total scores).

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Analysis 1.3

Comparison 1 Water‐based exercise versus no exercise, Outcome 3 Quality of life (mean change in individual domain scores).

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Analysis 1.4

Comparison 1 Water‐based exercise versus no exercise, Outcome 4 Pulmonary function (mean change).

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Analysis 1.5

Comparison 1 Water‐based exercise versus no exercise, Outcome 5 Respiratory muscle strength (mean change).

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Analysis 2.1

Comparison 2 Water‐based exercise versus land‐based exercise, Outcome 1 Exercise capacity (mean change in metres).

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Analysis 2.2

Comparison 2 Water‐based exercise versus land‐based exercise, Outcome 2 Quality of life (mean change in total scores).

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Analysis 2.3

Comparison 2 Water‐based exercise versus land‐based exercise, Outcome 3 Quality of life (mean change in individual domain scores).

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Analysis 2.4

Comparison 2 Water‐based exercise versus land‐based exercise, Outcome 4 Pulmonary function (mean change).

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Analysis 2.5

Comparison 2 Water‐based exercise versus land‐based exercise, Outcome 5 Respiratory muscle strength (mean change).

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Analysis 2.6

Comparison 2 Water‐based exercise versus land‐based exercise, Outcome 6 Body composition (mean change in kilograms).

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Analysis 2.7

Comparison 2 Water‐based exercise versus land‐based exercise, Outcome 7 Attendance (mean number).

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Summary of findings for the main comparison. Summary of findings (water exercise vs no exercise)

Water‐based exercise training compared with no exercise training for people with chronic obstructive pulmonary disease (COPD)
Patient or population: people with COPD Settings: pulmonary rehabilitation centres Intervention: water‐based exercise training Comparison: no exercise training
Outcomes	*Illustrative comparative risks (95% CI)**		No. of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	No exercise training	Water‐based exercise training
Exercise capacity ‐ functional Six‐minute walk test (mean distance change in metres)	Mean change in six‐minute walk distance ranged across control groups from ‐39 metres to ‐16 metres	Mean change in six‐minute walk distance in the intervention groups was 62 metres higher (44 metres to 80 metres higher)	99 (three)	⊕⊕⊕⊝ moderate¹
Exercise capacity ‐ peak Incremental shuttle walk test (mean distance change in metres)	Mean change in incremental shuttle walk distance in the control group was ‐1 metre	Mean change in incremental shuttle walk distance in the intervention group was 50 metres higher (20 metres to 80 metres higher)	30 (one)	⊕⊕⊕⊕ high
Exercise capacity ‐ endurance Endurance shuttle walk test (mean distance change in metres)	Mean change in endurance shuttle walk distance in the control group was ‐50 metres	Mean change in endurance shuttle walk distance in the intervention group was 371 metres higher (121 metres to 621 metres higher)	30 (one)	⊕⊕⊕⊕ high
Quality of life St George's Respiratory Questionnaire (total score) Lower value post intervention is favourable, indicating improvement in QoL	Mean change in St George's Respiratory Questionnaire total score in the control group was +6 points	Mean change in St George's Respiratory Questionnaire total score in the intervention group was 10 points lower (1 point to 19 points lower)	19 (one)	⊕⊕⊝⊝ low²
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval.
GRADE Working Group grades of evidence. High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Two studies showed limitations in design; selection and performance bias unknown. ²Study showed limitations in design (selection and performance bias unknown).

Summary of findings for the main comparison. Summary of findings (water exercise vs no exercise)

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Summary of findings 2. Summary of findings (water exercise vs land exercise)

Water‐based exercise training compared with land‐based exercise training for people with chronic obstructive pulmonary disease (COPD)
Patient or population: people with COPD Settings: pulmonary rehabilitation centres Intervention: water‐based exercise training Comparison: land‐based exercise training
Outcomes	*Illustrative comparative risks (95% CI)**		No. of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Land‐based exercise training	Water‐based exercise training
Exercise capacity ‐ functional Six‐minute walk test (mean distance change in metres)	Mean change in six‐minute walk distance ranged across control groups from 14 metres to 43 metres	Mean change in six‐minute walk distance in the intervention groups was 11 metres higher (11 metres lower to 33 metres higher)	62 (three)	⊕⊕⊕⊝ moderate¹
Exercise capacity ‐ peak Incremental shuttle walk test (mean distance change in metres)	Mean change in incremental shuttle walk distance ranged across control groups from 13 metres to 37 metres	Mean change in incremental shuttle walk distance in the intervention groups was nine metres higher (15 metres lower to 34 metres higher)	59 (two)	⊕⊕⊝⊝ low²
Exercise capacity ‐ endurance Endurance shuttle walk test (mean distance change in metres)	Mean change in endurance shuttle walk distance ranged across control groups from 33 metres to 117 metres	Mean change in endurance shuttle walk distance in the intervention groups was 313 metres higher (232 metres to 394 metres higher)	59 (two)	⊕⊕⊕⊝ moderate²
Quality of life St George's Respiratory Questionnaire (SGRQ; total score) Lower value post intervention is favourable, indicating improvement in QoL	Mean change in SGRQ total score ranged across control groups from ‐1 points to ‐16 points	Mean change in SGRQ total score in the intervention groups was 0.3 points higher (4 points lower to 5 points higher)	60 (three)	⊕⊕⊝⊝ low³
Body composition Weight (mean change in kilograms)	Mean change in body weight ranged across control groups from ‐0.2 kilograms to +1.3 kilograms	The mean change in body weight in the intervention groups was 1.3 kilograms lower (2.7 kilograms lower to 0.1 kilograms higher)	59 (two)	⊕⊕⊕⊝ moderate²
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval.
GRADE Working Group grades of evidence. High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹Two studies showed limitations in design; selection and performance bias unknown in two studies and one study, respectively. ²One study had selection bias. ³All studies showed limitations in design; selection bias present in one study and unknown in two remaining studies; performance and detection bias unknown in all three studies.

Summary of findings 2. Summary of findings (water exercise vs land exercise)

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Table 1. Intervention characteristics

Study	Water‐based exercise		Land‐based exercise		Other comparison group
Study	Description / Intensity	Frequency	Description / Intensity	Frequency
de Souto Araujo 2012	Continuous warm‐up exercises for upper and lower limbs (callisthenic activities with the respiratory cycle) for 15 minutes without weights; unsupported upper limb exercises using two diagonal movements and weights for two minutes with an equal rest period (initial weight 50% of maximum load and increased weekly); lower limb training using floats positioned between the legs and performing bicycling movements for 30 minutes (intensity determined by Borg dyspnoea and perceived effort score of 5); 15 minutes of cool‐down exercise for muscle groups used during the session	Eight weeks, three times a week, 90 minutes	Continuous exercise for upper and lower limbs (callisthenic activities with the respiratory cycle) for 15 minutes without weights; unsupported upper limb exercises using weights (initial weight 50% of maximum load and increased weekly) and diagonal movements for two minutes with equal rest periods; lower limb cycling for 30 minutes (intensity determined by Borg dyspnoea and perceived effort score of five); 15 minutes of cool‐down exercise for muscle groups used during the session	Same as water‐based exercise	No exercise training
McNamara 2013	Supervised sessions consisting of exercises in hydrotherapy pool matched as closely as possible for intensity, duration and muscle groups trained to the land‐based training exercises, and progressed by increasing water turbulence, speed and range of motion (specific exercise programme detailed in main publication)	Eight weeks, three times a week, 60 minutes	Supervised sessions consisting of upper limb endurance exercise and lower limb endurance exercise (walking and cycling) in a gym with initial intensity at 80% of walking speed on initial six‐minute walk test either over‐ground or on a treadmill, and progressed to maintain an intensity rating of three to five on the modified category ratio 0 to 10 dyspnoea and rating of perceived exertion scales	Same as water‐based exercise	Usual medical care, no exercise training, requested not to alter exercise level over study period
O'Brien 2004	Supervised in hydrotherapy pool using similar muscle groups to ensure standardisation to land‐based exercise programme and using properties of water to provide resistance, at an intensity of three to four on the modified Borg rating of perceived exertion scale	Six weeks, two times a week, 45 minutes	Supervised warm‐up of walking and stretches, aerobic training and strength and resistance training using free weights, at an intensity of three to four on the modified Borg rating of perceived exertion scale	Same as water‐based exercise	‐
Ozdemir 2010	Supervised in an aquatic centre with a warm‐up, stretches and strengthening exercises for shoulder girdle and upper extremity muscles utilising floatation devices for resistance	Four weeks, three times a week, 35 minutes	‐	‐	Medical therapy only
Wadell 2004	As per land‐based exercise training but in water	12 weeks, three times a week, 45 minutes	Supervised, intensity guided by music to achieve a mean heart rate of 80% to 100% of peak heart rate according to maximal cycle ergometer test and a Borg dyspnoea score of 5 and rating of perceived exertion score of 15, including warm‐up and flexibility exercises, followed by four minutes of endurance exercises and three minutes of strength exercises (repeated three times while focusing on the legs, arms and torso each time) and finally flexibility, stretching and cool‐down exercises	Same as water‐based exercise	No intervention

Table 1. Intervention characteristics

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Comparison 1. Water‐based exercise versus no exercise

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Exercise capacity (mean change in metres) Show forest plot	3		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

1.1 Functional ‐ six‐minute walk test	3	99	Mean Difference (IV, Fixed, 95% CI)	62.09 [44.34, 79.85]
1.2 Peak ‐ incremental shuttle walk test	1	30	Mean Difference (IV, Fixed, 95% CI)	50.0 [19.93, 80.07]
1.3 Endurance ‐ endurance shuttle walk test	1	30	Mean Difference (IV, Fixed, 95% CI)	371.0 [120.83, 621.17]
2 Quality of life (mean change in total scores) Show forest plot	2	49	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.97 [‐1.57, ‐0.37]

3 Quality of life (mean change in individual domain scores) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

3.1 Chronic Respiratory Disease Questionnaire ‐ total score	1	30	Mean Difference (IV, Fixed, 95% CI)	‐10.00 [‐20.60, ‐3.40]
3.2 Chronic Respiratory Disease Questionnaire ‐ dyspnoea score	1	30	Mean Difference (IV, Fixed, 95% CI)	‐3.0 [‐5.73, ‐0.27]
3.3 Chronic Respiratory Disease Questionnaire ‐ emotional function score	1	30	Mean Difference (IV, Fixed, 95% CI)	‐2.0 [‐5.24, 1.24]
3.4 Chronic Respiratory Disease Questionnaire ‐ fatigue score	1	30	Mean Difference (IV, Fixed, 95% CI)	‐5.0 [‐7.53, ‐2.47]
3.5 Chronic Respiratory Disease Questionnaire ‐ mastery score	1	30	Mean Difference (IV, Fixed, 95% CI)	‐2.0 [‐4.26, 0.26]
3.6 St George's Respiratory Questionnaire ‐ total score	1	19	Mean Difference (IV, Fixed, 95% CI)	‐10.0 [‐19.29, ‐0.71]
3.7 St George's Respiratory Questionnaire ‐ symptom score	1	19	Mean Difference (IV, Fixed, 95% CI)	2.0 [‐13.49, 17.49]
3.8 St George's Respiratory Questionnaire ‐ activity score	1	19	Mean Difference (IV, Fixed, 95% CI)	‐13.00 [‐26.18, 0.18]
3.9 St George's Respiratory Questionnaire ‐ impact score	1	19	Mean Difference (IV, Fixed, 95% CI)	‐13.0 [‐21.59, ‐4.41]
4 Pulmonary function (mean change) Show forest plot	3		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

4.1 FEV1 (% predicted)	2	49	Mean Difference (IV, Fixed, 95% CI)	6.32 [3.43, 9.22]
4.2 FVC (% predicted)	3	99	Mean Difference (IV, Fixed, 95% CI)	3.82 [0.25, 7.39]
4.3 FEV1/FVC ratio (%)	3	99	Mean Difference (IV, Fixed, 95% CI)	2.79 [‐0.74, 6.33]
5 Respiratory muscle strength (mean change) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

5.1 MIP (cm H2O)	2	49	Mean Difference (IV, Fixed, 95% CI)	13.83 [5.30, 22.35]
5.2 MIP (% predicted)	2	49	Mean Difference (IV, Fixed, 95% CI)	19.80 [9.36, 30.24]
5.3 MEP (cm H2O)	2	49	Mean Difference (IV, Fixed, 95% CI)	14.25 [5.23, 23.27]
5.4 MEP (% predicted)	2	49	Mean Difference (IV, Fixed, 95% CI)	15.22 [4.85, 25.59]

Comparison 1. Water‐based exercise versus no exercise

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Comparison 2. Water‐based exercise versus land‐based exercise

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Exercise capacity (mean change in metres) Show forest plot	4		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

1.1 Functional ‐ six‐minute walk test	3	62	Mean Difference (IV, Fixed, 95% CI)	10.85 [‐10.82, 32.51]
1.2 Peak ‐ incremental shuttle walk test	2	59	Mean Difference (IV, Fixed, 95% CI)	9.36 [‐15.22, 33.95]
1.3 Endurance ‐ endurance shuttle walk test	2	59	Mean Difference (IV, Fixed, 95% CI)	313.17 [232.35, 393.99]
2 Quality of life (mean change in total scores) Show forest plot	4	89	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.15 [‐0.58, 0.28]

3 Quality of life (mean change in individual domain scores) Show forest plot	4		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

3.1 Chronic Respiratory Disease Questionnaire ‐ total score	1	30	Mean Difference (IV, Fixed, 95% CI)	‐8.0 [‐16.38, 0.38]
3.2 Chronic Respiratory Disease Questionnaire ‐ dyspnoea score	1	30	Mean Difference (IV, Fixed, 95% CI)	‐2.0 [‐4.73, 0.73]
3.3 Chronic Respiratory Disease Questionnaire ‐ emotional function score	1	30	Mean Difference (IV, Fixed, 95% CI)	‐2.0 [‐5.24, 1.24]
3.4 Chronic Respiratory Disease Questionnaire ‐ fatigue score	1	30	Mean Difference (IV, Fixed, 95% CI)	‐3.0 [‐5.26, ‐0.74]
3.5 Chronic Respiratory Disease Questionnaire ‐ mastery score	1	30	Mean Difference (IV, Fixed, 95% CI)	‐1.0 [‐3.26, 1.26]
3.6 St George's Respiratory Questionnaire ‐ total score	3	60	Mean Difference (IV, Fixed, 95% CI)	0.31 [‐4.14, 4.75]
3.7 St George's Respiratory Questionnaire ‐ symptom score	3	59	Mean Difference (IV, Fixed, 95% CI)	7.84 [‐3.06, 18.74]
3.8 St George's Respiratory Questionnaire ‐ activity score	3	59	Mean Difference (IV, Fixed, 95% CI)	‐2.82 [‐7.67, 2.04]
3.9 St George's Respiratory Questionnaire ‐ impact score	3	59	Mean Difference (IV, Fixed, 95% CI)	‐0.49 [‐4.44, 3.45]
4 Pulmonary function (mean change) Show forest plot	3		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

4.1 FEV1 (litres)	2	41	Mean Difference (IV, Fixed, 95% CI)	0.08 [‐0.04, 0.19]
4.2 FEV1 (% predicted)	3	62	Mean Difference (IV, Fixed, 95% CI)	0.21 [‐2.88, 3.31]
4.3 FVC (litres)	2	41	Mean Difference (IV, Fixed, 95% CI)	0.12 [‐0.04, 0.28]
4.4 FVC (% predicted)	2	51	Mean Difference (IV, Fixed, 95% CI)	2.89 [‐4.24, 10.02]
4.5 FEV1/FVC ratio (%)	3	62	Mean Difference (IV, Fixed, 95% CI)	2.22 [‐1.89, 6.34]
5 Respiratory muscle strength (mean change) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

5.1 MIP (cm H2O)	2	51	Mean Difference (IV, Fixed, 95% CI)	0.06 [‐7.21, 7.34]
5.2 MIP (% predicted)	2	51	Mean Difference (IV, Fixed, 95% CI)	3.40 [‐5.77, 12.58]
5.3 MEP (cm H2O)	2	51	Mean Difference (IV, Fixed, 95% CI)	‐6.80 [‐16.42, 2.83]
5.4 MEP (% predicted)	2	51	Mean Difference (IV, Fixed, 95% CI)	‐3.88 [‐13.88, 6.12]
6 Body composition (mean change in kilograms) Show forest plot	2	59	Mean Difference (IV, Fixed, 95% CI)	‐1.29 [‐2.65, 0.07]

7 Attendance (mean number) Show forest plot	2		Std. Mean Difference (IV, Fixed, 95% CI)	Subtotals only

7.1 Attendance at supervised exercise sessions	2	41	Std. Mean Difference (IV, Fixed, 95% CI)	0.44 [‐0.18, 1.07]

Comparison 2. Water‐based exercise versus land‐based exercise

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