Exercise as it relates to Disease/Improving knee osteoarthritis in elderly women with the use of hydrotherapy

This Wikibooks page is a critical appraisal of the journal article " Hydrotherapy improves pain and function in older women with knee osteoarthritis: a randomized

controlled trial" (Dias et al, 2017)

What is the background to this research?

Only cardiovascular disorders cause more severe chronic disabilities than osteoarthritis, which is a consequence of aging and affects close to 10% of those over the age of 60. The rising interest in understanding the basic mechanisms by which this disease affects human joints can be attributed to both its prevalence and the associated expenditures, which in total,can cost billions of dollars in terms of medicines, surgeries, and lost workdays over the span of someones life. Axial, or spinal, as well as peripheral joints, including weight-bearing joints (such as the hips and knees), can be affected by osteoarthritis and are the most common areas that are effected in people. The impact of motion is minimised by the moveable joints' proper alignment and the resilience of the subchondral bone beneath the articular cartilage.

The practice of hydrotherapy in physiotherapy has grown out of the scientific theory of hydrodynamics. It has been easier for physiotherapists to use hydrotherapy as a method for promoting movement and regaining function because they have a better grasp of the physiology of human immersion, as well as the ability to analyze human movement within water . The aim of hydrotherapy is to help individuals rehabilitate injuries or soreness, exercise or simply relaxation. Because of buoyancy, it can be substantially more comfortable and easier for an individual who has trouble weight bearing due to osteoarthritis to complete functional movements and exercises in water because of the reduced amount of stress and friction on the joints.

Where is the research from?

This study that is getting critically appraised took the form of a randomised controlled trial designed to see whether it is beneficial for people to use hydrotherapy for people (in particular women) with knee osteoarthritis. The blueprints of the study were approved by the ethics committee of Universidade Federal de Minas Gerais, Brazil. Joao Marcos Dias who is the main author of this article as well as his fellow editors have written other articles and completed other studies on health and disease related issues. Despite this research being conducted in Brazil, it will still have some degree of relevance to the same specific population type in other countries.

What kind of research was this?

In this particular study the research undertaken was done in a randomised control trial (RCT) style. Participants in an RCT are randomly selected into either one of two groups. One group would be receiving a more conventional style of treatment in regards to osteoarthritis (phone calls, lectures, verbal advice) and the other group will be known as the ‘experimental group’ receiving the intervention treatment (hydrotherapy) the researchers want to test.

What did the research involve?

This study involved a total of 73 elderly community dwelling females with knee osteoarthritis in small city called Belo Horizante, Brazil. In this study, 36 participants were put into what was called the 'educational group' (controlled). This consisted of face to face lectures on the diagnosis, symptoms and how to take basic care of knee osteoarthritis. Telephone calls were also given to this group providing them with strategies and preventative measures of reducing pain associated with weight-bearing whilst performing basic daily activities. The remaining 37 participants were in the intervention group which consisted of progressive hydrotherapy exercises, twice a week for six weeks.

The layout of the hydrotherapy program contained warm-up exercises, strengthening exercises and a cool down, all together the session ran for approximately 40 minutes. The primary outcomes that were measured included function and pain of the patients knee, this was measured with the Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC), which is a very reliable and renowned knee osteoarthritis index test. A secondary measure was also assessed testing the muscular strength of the individual pre and post-intervention. The results for this were gathered through the use of an isokinetic device testing the individual's knee extension. Data from these measures were conducted pre and post-intervention for all participants.

What were the basic results?

The results indicated that there was a significant improvement in the experimental group over the control group. In both Primary and secondary measures, data shows that the hydrotherapy intervention group proved to make enough difference to improve significantly over the 6-week duration of the study in areas such as pain levels, functional ability, strength, power and resistance.

The tables below includes the data from " Hydrotherapy improves pain and function in older women with knee osteoarthritis: a randomised controlled trial" (Dias et al, 2017)

Table 1: Data showing primary measures

         Experimental                                     Control

	Initial	6 weeks	Initial	6 weeks
Pain (0-100)	51.1	37.7	50.9	48.6
Function (0-100)	52.7	36.3	55.3	50.2

Table 2. Data showing secondary measure outcomes

                  Experimental                           Control

	Initial	6 weeks	Initial	6 weeks
Strength (%)	mean (SD)
Extension	104.1	111.6 (23.1)	106.9 (29.1)	106.7 (34.3)
Flexion	51.3 (15.6)	57.8 (15.2)	54.2 (20.6)	52.8 (19.6)
Power (%)	mean (SD)
Extension	59.9 (14.6)	64.5 (14.4)	59.9 (15.9)	61.7 (15.4)
Flexion	25.6 (10.1)	25.9 (9.6)	30.3 (29.6)	26.1 (11.3)
Resistance (%)	mean (SD)
Extension	22.2 (16.2)	27.6 (9.1)	24.1 (15.6)	23.7 (13.4)
Flexion	21.5 (20.0)	27.8 (14.8)	24.4 (20.2)	26.0 (28.5)

What conclusions can we take from this research?

The data demonstrates that participating in an activity such as hydrotherapy can be well worth someone's time and effort if they have knee osteoarthritis. This study is  a promising indicator that demonstrates improvement with increased function, less pain and improved strength for anyone who has knee osteoarthritis.

Practical advice

Further research needs to be done on this topic as there is not much evidence to say this helps all the time. Additionally, more studies should take into account men and women with knee osteoarthritis and it would be beneficial to have all of the participants engage in the intervention as they could all potentially feel the benefits of hydrotherapy. The study design itself was good in the fact that it kept the programs the same for both groups throughout the duration of the study and did not change any of the variables.

Further reading/studies

Journal article: "Evidence for Effective Hydrotherapy"

Journal article: "Exercise therapy for older adults with lower-back pain"

Journal article: "An update on the pathophysiology of osteoarthritis"