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r e v b r a s r e u m a t o l .

2 0 1 6;5 6(6):530542


Review article

Effects of aquatic exercise on muscle strength

and functional performance of individuals
with osteoarthritis: a systematic review

Fernanda de Mattos a, , Neiva Leite a , Arthur Pitta b , Paulo Cesar Barauce Bento a
aUniversidade Federal do Paran (UFPR), Curitiba, PR, Brazil
bUniversidade Federal do Paran (UFPR), Departamento de Educaco Fsica, Programa de Ps-graduaco em Educaco Fsica, Curitiba,
PR, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Water-based exercises are recommended for people with osteoarthritis (OA), due to the
Received 27 October 2015 benecial effects on physical function, quality of life and symptom reduction. However, the
Accepted 15 June 2016 effects on muscle strength are still controversial. The aim of this review was to assess and
Available online 4 October 2016 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 Sci-
Keywords: ence databases. Clinical trials with interventions involving aquatic exercises for individuals
Osteoarthritis with OA were included. The methodological quality of the studies was evaluated using the
Water-based exercise PEDro scale. 296 studies were found and twelve were selected: six studies comparing water-
Physical function based exercises with land-based exercise, and six comparing water-based exercise groups
Muscle strength with the control group. Exercise programs included muscle strengthening, aerobic, balance,
exibility and stretching exercises. Duration of the program, weekly frequency, intensity
and progression varied between studies. Benecial effects of aquatic exercise were found on
physical function. However, only two of ve studies that assessed muscle strength observed
positive effect of aquatic exercise. Although it is difcult to compare studies and establish
guidelines for the standardized protocol formulation, it was observed that water-based exer-
cises can be effective on improving physical function and increasing muscle strength, since
they are well-structured, with exercise intensity and overload controlled.
2016 Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Corresponding author.
E-mail: ferdymattos@hotmail.com (F. Mattos).
2255-5021/ 2016 Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
r e v b r a s r e u m a t o l . 2 0 1 6;5 6(6):530542 531

Efeitos do exerccio aqutico na forca muscular e no desempenho

funcional de indivduos com osteoartrite: uma reviso sistemtica

r e s u m o

Palavras-chave: Exerccios aquticos so recomendados para pessoas com osteoartrite (OA), pois melho-
Osteoartrite ram a funcionalidade, a qualidade de vida e reduzem os sintomas da doenca. Entretanto,
Exerccio aqutico os efeitos na forca muscular ainda so controversos. O objetivo desta reviso foi avaliar e
Funcionalidade comparar o efeito de programas de exerccios aquticos na forca muscular e na funcionali-
Forca muscular dade de pessoas com OA. Foi realizada uma busca bibliogrca nas bases de dados Pubmed,
Scopus e Web of Science. Foram includos ensaios clnicos realizados com intervences
envolvendo exerccios aquticos para indivduos com OA. A qualidade metodolgica dos
estudos foi avaliada por meio da escala PEDro. Foram encontrados 296 estudos no total.
Destes, doze foram selecionados, sendo seis estudos que compararam exerccios aquticos
com exerccios realizados em solo, e seis que compararam um grupo de exerccios aquticos
com grupo controle. Os programas contemplaram exerccios de fortalecimento muscular,
aerbios, de equilbrio, de exibilidade e alongamento. A duraco do programa, a frequncia
semanal, a intensidade e a progresso variaram entre os estudos. Foram encontrados efeitos
bencos do exerccio aqutico na funcionalidade, porm, dos cinco estudos que avaliaram
a forca muscular, apenas dois vericaram efeito positivo dos exerccios aquticos. Emb-
ora haja diculdades para comparar os estudos e estabelecer diretrizes para a formulaco
de protocolos padronizados, observou-se que exerccios aquticos podem ser ecientes na
melhora da funcionalidade e no aumento da forca muscular, desde que os programas sejam
bem estruturados com intensidade e sobrecarga controlada e progressiva.
2016 Elsevier Editora Ltda. Este e um artigo Open Access sob uma licenca CC
BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

pressure promote muscle relaxation and stress relief, and

Introduction also decrease muscle spasms,1316 which facilitate the execu-
tion of movements. In addition, studies in healthy adults and
Osteoarthritis (OA) is a chronic degenerative disease of mul- older subjects have shown that water exercises are effective
tifactorial origin, beginning usually between 50 and 60 years to increase muscle strength.13,17
of age,1 primarily affecting knee and hip joints.2,3 Pain is the Previously conducted systematic reviews on the effects of
main symptom of the disease and, when associated with joint aquatic exercise in people with osteoarthritis found benets
stiffness, instability and weakness, can cause functional limi- for pain, function and quality of life.12,13,15,18 However, there
tations and difculties in performing activities of daily living.4 are no reviews to identify the effect of these interventions on
The treatment of OA includes drug therapy, manual the performance of function and muscle strength tests. Thus,
therapy, and exercise.5,6 Exercise is a highly recommended the aim of this review was to evaluate and compare the effect
conservative treatment, with easy application and low cost, of aquatic exercise programs on muscle strength and on the
and with little chance of adverse reactions.4 The types of exer- functionality of people with OA.
cises most recommended for people with OA are those causing
a low-impact on the joints, for muscle strengthening, aerobics,
or some combination thereof, carried out in water or on the Methods
The strengthening of the muscles around the affected joint To develop this study, a literature search was performed in
is a key part in the treatment of OA, because this contributes the following electronic databases: Pubmed, Scopus, and Web
to the quality of cartilage, increases the neural activation of Science. The selection of descriptors was based on terms
and improves intra- and intermuscular coordination.8 In addi- indexed in Descriptors in Health Sciences (DeCS) and included
tion, muscles act as a load-absorbing mechanism during the the following keywords in English: osteoarthritis, aquatic,
gait. Therefore, stronger muscles can better absorb and dis- aqua, deep-water, water-based, exercise, motor activity, phys-
tribute the impact on the hip and knee, which increases the ical activity, and training. The keywords were combined using
stability810 and contributes to the improvement of the func- the Boolean operators AND and OR, and were adapted for
tionality and mobility.11 each database, as required.
When compared to land-based exercises, water exercises There was no restriction on the publication year, consid-
can offer some advantages to overweight patients, with mobil- ering the low number of studies found in this area. Two
ity difculties, since the body weight relief provided by the researchers surveyed all databases and, at the end of the
uctuation reduces the impact on joints and the perception application of inclusion and exclusion criteria, confronted the
of pain intensity.12,13 The heated water and the hydrostatic articles found. In the case of disagreement with the selected
532 r e v b r a s r e u m a t o l . 2 0 1 6;5 6(6):530542

Table 1 Methodological quality of the studies analyzed.

Reference 1 2 3 4 5 6 7 8 9 10 11 Total

Wyatt et al. (2001) 1 1 0 0 0 0 1 1 1 1 1 7

Wang et al. (2007) 1 1 0 1 0 0 0 1 1 1 1 7
Hinman et al. (2007) 1 1 1 1 0 0 1 1 1 1 1 9
Silva et al. (2008) 1 1 1 1 0 0 1 1 1 1 1 9
Lund et al. (2008) 1 1 1 1 0 0 1 1 1 1 1 9
Lim et al. (2010) 1 1 1 1 0 0 1 1 1 1 1 9
Arnold and Faulkner (2010) 1 1 1 1 0 0 1 1 1 1 1 9
Wang et al. (2011) 1 1 0 1 0 0 1 1 1 1 1 8
Hale et al. (2012) 1 1 1 1 0 0 1 1 1 1 1 9
Wallis et al. (2014) 1 0 0 1 0 0 1 1 1 1 1 7
Bressel et al. (2014) 1 0 0 1 0 0 0 1 1 1 1 6
Fisken et al. (2015) 1 1 1 1 0 0 0 0 1 1 1 7

1, Eligibility criteria specied; 2, randomization or random assignment; 3, secret allocation; 4, similar groups at the beginning; 5, subjects blinded
to participation; 6, treatment carried out by blinded researchers; 7, blinded evaluators; 8, evaluations carried out in at least 85% of the sample;
9, all evaluated subjects were submitted to the intervention; 10, results of the comparisons between groups were described; 11 the study shows
precision and variability measurements for the results.

studies, the researchers conducted a pooled analysis of studies

with the aim of reaching consensus.
The following inclusion criteria were adopted: articles
In the electronic search conducted, 296 studies in all three
published in English, Portuguese or Spanish; only original arti-
databases were found. After the exclusion of repeated titles,
cles; controlled clinical trials or experimental studies with
170 articles remained for analysis. After the application of
an experimental group versus control group or period; pre-
inclusion and exclusion criteria, 83 titles were excluded. In the
senting an intervention with supervised aquatic exercises
abstract analysis stage, 48 articles and 8 systematic reviews
for people with osteoarthritis; describing intervention details,
were excluded, since these studies did not meet the objectives
such as duration, frequency, type and intensity of exercise;
of this review. Of the 31 remaining articles for a full reading,
with an evaluation and presentation, as primary or secondary
12 were included in this review: eight randomized controlled
outcomes, of muscle strength and/or functionality through
trials and four experimental studies (Fig. 1).
physical performance tests.
Conference abstracts, monographs, dissertations and the-
ses, case studies, non-controlled trials, systematic reviews, Methodological quality
animal studies and also studies with mixed groups of sub-
jects (osteoarthritis and other conditions inuencing strength The scoring of the selected studies in the evaluation of their
and/or functionality); interventional studies lasting less than methodological quality is described in Table 1. The mean score
six weeks, and those with a weekly frequency of the exercise of the studies was 8 (69) points. The maximum score (9 points)
program under two sessions/week, based on reviews of rec- was ascribed to six of the 12 studies assessed.14,2125 Four crite-
ommendations for the treatment of OA, were excluded from ria were covered by all studies selected: eligibility criteria;
this review.4,19 all evaluated subjects received intervention; results of the
The selected studies were also analyzed for methodo- comparisons between groups; and precision and variability
logical quality, according to the evaluation protocol adapted measurements. In nine of the 12 studies, the evaluators were
for this study, based on the PEDro scale.20 This evaluation unaware of the group in which participants were allocated
included eleven criteria which, together, generated a score of (single-blinded).14,2128 Only those studies which used a single
11 (Table 1). Criteria 5 and 6, which deal with the blinding of group with a double pre-test (with a four-week control period)
participants and therapists regarding the treatment applied, had not a random allocation of participants.28,29
were not scored, due to the characteristics of the selected
studies. In experimental studies including interventions with Characteristics of studies
programs of physical activity, one cannot omit from partici-
pants and therapists the treatment carried out. Therefore, the The characteristics of the studies (participants, measuring
maximum score achieved is 9 points. The higher the score on instruments, interventions, and main results) are summa-
the scale, the better the quality of the study. rized in Table 2. However, these features are presented and
The analysis of the quality of the studies was performed grouped in the following text.
independently by two researchers, and disagreements were
discussed in consensus meetings. Methodological quality was Location and characteristics of the participants
assessed with the aim of identifying the internal validity The selected studies were performed in the United
(criteria 29) and the quality of statistical information for the States,26,29,30 Australia,14,28 Brazil,25 Denmark,24 Korea,23
interpretation of results (criteria 1011).20 After this step, the Canada,21 Taiwan,27 and New Zealand.22,31 The study par-
outcomes assessed and the results of the studies were ana- ticipants were recruited from Orthopedic Clinics in local
lyzed and grouped into topics, for comparison and discussion. hospitals,14,23,25,28,31 medical ofces and physiotherapy
r e v b r a s r e u m a t o l . 2 0 1 6;5 6(6):530542 533

PubMed=71 Scopus=109 Web of science=116


Evaluation by title

Excluded (n=126)
126 repeated
Evaluation by summary
Excluded (n=143)
43 revisions
100 did not meet the objectives of this study
Full-text reading
(n=27) Excluded (n=15)
9 Korean language
2 mixed group with osteoarthritis and
rheumatoid arthritis
1 less than 6 weeks of intervention
Studies included in the
1 summary of a monograph
systematic review
(n=12) 1 intervention less than 2 times per week
1 Insufficient data intervention

Fig. 1 Schematic representation of the selection of the studies included in this review.

clinics,14,21,22,24,27,29 through dissemination in the local at home,23 hydrotherapy exercises were performed in immer-
community and in community centers.14,21,22,24,27,2931 All sion in a sitting position in the water,31 and computer-assisted
participants had a diagnosis of knee and/or hip OA,14,22,2831 activities.22
only hip OA,21 and only knee OA,2327 were aged between 60 The applied intensity also varied among protocols. Only
and 75 years, and most were female (72% of total participants). one study used heart rate as a reference, from a basal value
of 65% HR for aquatic exercise and 4060% of one-repetition
maximum (1RM) for land-based exercise.23 In other studies,
Characteristics of interventions
the intensity was controlled on the basis of perceived exertion
The protocols of exercise programs differ among studies, but
scales (010, Borg CR10 or 620),27,29,30 cadence of music,24,31
one can identify the main components of each program. Six
and the number of sets and repetitions.14,25 Only two studies
studies conducted interventions with a group that partici-
did not control or describe the intensity,21,26 and some stud-
pated in aquatic exercise and another group that performed
ies did not offer in-depth information on the progression of
land-based exercise,21,2327 and six other studies only con-
ducted interventions with aquatic exercise.14,22,2831
The programs duration ranged from six14,26,28,29 to 18
weeks.25 Two studies conducted 8-week interventions,23,24 Outcomes
Arnold and Faulkner21 did 11 weeks of exercise, and other 4
studies used 12 weeks in their protocol.22,27,30,31 The weekly To be included in this review, the studies should indi-
frequency of exercise programs varied from two14,21,22,24,28,31 cate the functionality and/or muscle strength as a primary
to three23,2527,29,30 weekly sessions. or secondary outcome, assessed by physical performance
Aquatic exercise protocols were composed primarily of tests. Only two studies pointed out functionality as a
muscle strengthening exercises for upper and lower limbs primary endpoint.21,31 Of the ve studies that evaluated mus-
and trunk,14,21,28,30,31 aerobic walking exercises and shifts in cle strength, three presented this variable as the primary
water,14,22,2830 and High-Intensity Training (HIT) in an aquatic outcome,23,24,30 and two as a secondary outcome.14,31 Pain was
treadmill,29 balance disturbance exercises,29 one-foot shifts assessed in all studies; however, it was considered as the pri-
and movements,21,22 exibility,27,30 and stretching.24,25 mary outcome in three of them.4,24,25
Studies comparing programs of water versus land-based Of the 12 studies included, only the work by Lim et al.
exercises sought to follow similar protocols in both media, (2010) evaluated the functionality without performing phys-
with strengthening exercises of upper and lower limb mus- ical performance tests. In this study, the authors used only
cles, stretching,2327 aerobic walking exercises2427 and water questionnaires. The physical tests most used in other stud-
bike and on the oor,23 as detailed in Table 2. ies to evaluate the functionality were walking tests that
Five of the 12 studies used a control group without inter- measure the distance covered in a given time in a usual
vention for comparison with the groups that performed speed,14,21,27,28,30 tests that measure the time to cover a certain
the exercise.14,21,24,27,30 In studies where the control group distance at different speeds,25,26,29,31 and the Timed Up and Go
received some kind of intervention, exercises were performed Test (TUG), which was used in 4 of the 12 studies.14,21,22,31
Table 2 Summary of the characteristics of the articles included in the review.
Authors, Sample (N), mean Groups Assessments outcomes Intervention Results
year/country, type age (years),
of study number of
women, site of OA

Wyatt et al., N = 42 AG = * Initial (s0) and nal AG: 3 wk/6 wk Increase in ROM and
2001/USA (s6) assessment thigh thickness, and
Experimental study reduction of pain
and in 1-mile travel
time in both groups
4570 years OA knee GG = * ROM (goniometer), Manual resis- A difference
thigh thickness, pain tance + strengthening between groups only
(VAS) and speed exercises in pain; AG with
(1-mile walk time) LLMs + 244-meter greater reduction in
walk pain

r e v b r a s r e u m a t o l . 2 0 1 6;5 6(6):530542
GG: 3x wk/6 wk
Manual resistance
exercises + LLMs + +
244-meter walk
Wang et al. 2007/USA N = 42 AG = 20 Initial (s0), medium AG: 3 wk/50 min/ Increased hip and
(s6), and nal (s12) 12 wk knee exibility,
assessment muscle strength and
distance covered in
6 min walk

Randomized clinical 66 years CG = 18 ROM exibility of knee Flexibility + aerobic + No difference in

trial and hip (goniometer), strengthening self-reported
maximal isometric exercises for LLMs, function and in pain
strength of hip and knee ULMs and trunk between groups
extension and exion, (AFAP Protocol)
32 women and hip abduction and Progressive intensity
adduction (hand (scale 010): s0-s4
dynamometer), gait (23), s5-s8 (34), and
(6-min walk test), s9s12 (4)
OA knee and hip functionality and ADLs CG: activities of daily
(MDHAQ) and pain (VAS) living

Hinman et al. N = 71 AG = 36 Initial (s0), nal (s6), AG: 2/4560 min/ Hip muscle strength
2007/Australia and follow-up (s12) 6 wk and QOL improved
Randomized clinical assessment in AG after 6 weeks.
trial AG had a 33%
reduction in pain
and 72% of the group
throughout the
Table 2 (Continued)
Authors, Sample (N), mean Groups Assessments outcomes Intervention Results
year/country, type age (years),
of study number of
women, site of OA

62 years CG = 35 Pain (VAS), change in pain Strengthening At follow-up (s12)

and functionality (5-point exercises for LLMs: the benets were
scale), osteoarthritis 2 10 maintained
(WOMAC), QOL (15-item reps + 610 min walk
scale), physical activity on water
48 women level (PASE), isometric Water depth
strength of hip abduction decreased
and knee extension (hand throughout the
dynamometer), the Step intervention

r e v b r a s r e u m a t o l . 2 0 1 6;5 6(6):530542
OA knee and hip test, TUG and 6-min walk CG: activities of daily
test living

Silva et al., N = 64 AG = 31 Initial (s0), medium AG: 3 wk/50 min/ The 15-m test in a
2008/Brazil (s9), and nal (s18) 18 wk comfortable speed
Randomized clinical assessment in both groups, but
trial at high-speed GG
improved between
s1 and s9, and AG
between s9 and s18A
59 years GG = 26 Pain (VAS), Stretching: Pain in both
osteoarthritis 2 20 s + Strengthening groups. LEQUESNE
(Lequesne and exercise for LLMs: and WOMAC in
WOMAC), speed 710 reps of 6 s both groups until S9;
(two-speed 15-meter (isometric from S9 to S18 a
walk test) and pain contractions) and decrease occurred
during the walk test 2040 reps only in AG
59 women OA knee (VAS) and NSAIDs Increased resistance
to the use of elastic
or of a 1-kg weight
GG: 3 wk/50 min/
18 wk
2 20 s + strengthening
exercise for lower
limbs: 710 6-s reps
contractions) and
2040 reps
Floater to speed
(isotonic exercises)

Table 2 (Continued)
Authors, Sample (N), mean Groups Assessments outcomes Intervention Results
year/country, type age (years),
of study number of
women, site of OA

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

r e v b r a s r e u m a t o l . 2 0 1 6;5 6(6):530542
(isokinetic CG: activities of daily
dynamometer Biodex) living

Lim et al., N = 75 AG = 26 Initial (s0) and nal AG: 3 wk/40 min/ AG showed improved
2010/Korea (s8) assessment 8 wk functionality, pain and
Randomized clinical 65 years GG = 25 Pain (BPI), osteoarthritis Heating + Walk + strength + quality of life. Both
trial (WOMAC), QOL (SF-36 resistance + groups improved the
version 2.0), isokinetic force aerobic functionality of lower
strength of knee exercises limbs. There was no
65 women OA knee CG = 24 extensors and exors at Intensity >65% of CF change in knee exor
60 /s (isokinetic GG: 3 wk/40 min/ and extensor strength
dynamometer Biodex) 8 wk in both groups. The
Joint mobiliza- physical component
tion + strengthening scale improved slightly
Intensity of 4060% in both groups
of 1RM
CG: home exercises:
(quadriceps) and
partial squats

Arnold and Faulkner, N = 83 AG = 28 Initial (s0) and nal AG: 2 wk/45 min/ In physical
2010/Canada (s11) assessment 11 wk performance, AEG has
Randomized clinical 75 years AEG = 26 Balance (Berg Balance Heating + strengthening improved versus CG and
trial Scale), gait (6-min exercises of LLMs and AG. Similar trends were
walk test), falls (ABC), ULMs + trunk found for TUG and for
functionality (STS and control + balance and the 6-min walk test. An
TUG), osteoarthritis practical posture improvement was
(AIMS-2), and physical found in efcacy of falls
activity level (PASE) in AEG versus CG
Table 2 (Continued)
Authors, Sample (N), mean Groups Assessments outcomes Intervention Results
year/country, type age (years),
of study number of
women, site of OA

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

r e v b r a s r e u m a t o l . 2 0 1 6;5 6(6):530542
Wang et al., N = 78 AG = 26 Initial (s0), medium AG: 3 wk/60 min/ Signicant
2011/Taiwan (s6), and nal (s12) 12 wk improvement in KOOS,
Randomized clinical assessment ROM, 6-min walk test
trial 67 years GG = 26 Osteoarthritis Flexibility + aerobic and pain in AG and GG
(KOOS), ROM exercises (AFAP versus control group; no
(goniometer) and protocol) signicant change was
67 women OA knee CG = 26 gait (6-min walk Intensity 34 (Borg found between AG and
test) CR10 Scale) GG
GG: 3 wk/60 min/
12 wk
Flexibility + aerobic
exercises (PACE
Intensity 34 (Borg
CR10 Scale)
CG: activities of daily

Hale et al., 2012/New N = 39 AG = 23 Initial (s0) and nal AG: 2 In both groups there
Zealand (s12) assessment wk/2060 min/12 wk was a signicant
Randomized clinical 74 years CG = 16 Falls (PPA and ABC), Heating + balance improvement in Step
trial dynamic balance (Step exercises difculty test and also
29 women OA knee Test), functionality Water depth improvement in two
and hip (TUG), and throughout the items of PPA (reaction
osteoarthritis (WOMAC intervention time and contrast
andAIMS-2) CG: 2 wk/60 min/ sensitivity) in CG. There
12 wk was no signicant
SeniorNet (computer improvement in TUG
skills training
offered by the
elderly for the

Table 2 (Continued)
Authors, Sample (N), mean Groups Assessments outcomes Intervention Results
year/country, type age (years),
of study number of
women, site of OA

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

r e v b r a s r e u m a t o l . 2 0 1 6;5 6(6):530542
and hip and individual

Bressel et al., N = 18 AG = 18 Pre- (s4), initial (s0), and SG: 2-3x There was
2014/USA Single nal (s6) assessment wk/1830 min/6 wk signicant
group posttest, 64 years Osteoarthritis (KOSS), Balance improvement in
double pretest pain (VAS), balance and exercises + HIT functionality,
design motor function (SMART components (aquatic mobility and
EquiTest system), and mat)/water jets to balance, and
functionality (STS, FLT balance disorder reduction in knee
16 women and 10-min walk test) Intensity of 1419 pain
OA knee and hip over RPE

Fisken et al., N = 35 AG = 19 Initial (s0) and nal (s12) AG: 2 In both groups, in
2015/New Zealand assessment wk/4560 min/12 wk time in the 400-m
Experimental study 70 years CG = 16 Functionality (TUG and STS), Strength + aerobic walk test. AG
dynamic balance (15-sec Step exercise improved on Step
23 women OA knee, Test), muscle strength (hand Intensity control: test and AIMS-2. AG
hip, spine and hands dynamometer), grip strength music improved in FES-I
(Jamar dynamometer), gait CG: 1 versus CG. There was
(400-m walk test), wk/3540 min/12 wk no signicant
osteoarthritis (AIMS2-SF), falls HT-type exer- change in TUG, STS
(FES-I), physical activity level cise + hydrotherapy and grip strength in
(RAPA) exercises (AFAP) wk both groups

OA, osteoarthritis; CG, control group; AG, Aquatic Exercise Group; AEG, Aquatic Exercise + Education Group; GG, Ground Exercise Group; SG, Single Group; ROM, range of motion; VAS, Visual Analogic
Scale; ADL, Activities of Daily Living; QOL, quality of life; MDHAQ, Multidimensional Health Assessment questionnaire; AFAP, Arthritis Foundation Aquatics Program; WOMAC, Western Ontario
and McMaster Universities Osteoarthritis Index; PASE, Physical Activity Scale for the Elderly; TUG, Timed Up & Go test; NSAIDs, Nonsteroidal Anti-inammatory Drugs; KOOS, Knee Injury and
Osteoarthritis Outcome Score; BPI, Brief Pain Inventory; SF-36, Short Form 36-item Health Survey; ABC, Activities and Balance Condence; STS, Sit-to-stand; AIMS-2, Arthritis Impact Scale measurement;
PPA, Physiological Prole Assessment; EQ-5D, EuroQo-5D; EQ-VAS, EuroQol-VAS; FLT, Forward Lunge Test; FES-I, Falls Efcacy Scale-International; RAPA, Rapid Assessment of Physical Activity; RPE,
Rating of Perceived Exertion; LLMs, Lower limb muscles; ULMs, Upper Limb Muscles; , increase; , reduction or decrease. * Not informed.
r e v b r a s r e u m a t o l . 2 0 1 6;5 6(6):530542 539

The evaluation of muscle strength of lower limbs was studies, which reported an increase of 510% of the isomet-
performed by indirect tests (Chair Stand Test) in four ric strength of the hip abductor muscles,14 45% in the knee
studies.21,28,29,31 Only two studies conducted muscle strength extensors, 11.5% in the hip extensors, and 14.3% in the hip
tests using an isokinetic dynamometer.23,24 Three other stud- abductors.30 On the other hand, Fisken et al. (2015) found no
ies assessed muscle strength through isometric testing of effect of aquatic exercise in the evaluation through manome-
lower limbs with a dynamometer14,30 and handgrip strength try. Pain levels also showed controversial results. Three studies
test.31 reported reduced pain after the intervention.14,29,31 However,
Pain is the only outcome present in all studies and in the study by Fisken et al. (2015) both groups had a reduc-
was assessed by a visual analog scale (VAS) of pain tion in pain, but with no difference between them. On the
perception,14,2426,29,30 or through questionnaires.2123,27,28,31 other hand, Wang et al. (2007) and Wallis et al. (2014) found
Although not an inclusion criterion in this study, the outcome no signicant effects of aquatic exercise in reducing pain.
pain was added to the results, considering that this factor
was present in all analyzed studies. Additionally, pain is one
of the most common symptoms of OA and is associated with Discussion
functional limitations caused by the disease32,33 and by the
impact of OA on the patients quality of life.34,35 The objective of this review was to evaluate and compare the
effect of aquatic exercise programs on muscle strength and
Effects of interventions function of people with hip or knee osteoarthritis. Interven-
tions with exercises that can slow or stop the progression of
Water land-based exercises the disease are important to the health system, considering
All studies comparing aquatic exercise programs and that they can reduce the cost of treatments, surgeries, and
land-based exercise found some benecial effect on the func- hospitalizations; moreover, these interventions can improve
tionality, for example, an increase in the distance covered27 the quality of life of participants.12
and a decrease in the time to perform walking tests.25 How- The aquatic exercise, a procedure highly recommended
ever, the aquatic exercise proved to be more efcient versus in the treatment of OA, may have advantages compared to
land-based exercise to improve balance in the study by Lund land-based exercise, because, due to the physical properties
et al. (2008). of water, the execution of the movements can become easier,
The results of muscle strength are controversial.14,30 Only decreasing also the sensation of pain.12,13 Strengthening the
two of the ve studies that evaluated muscle strength found muscles surrounding the affected joint is an important part
improvement after the practice of aquatic exercise. None of of the treatment of OA.810 Therefore, the resistance of the
the studies comparing muscle strength between the groups water is used as an overloading factor for muscle strength-
who underwent aquatic versus land-based exercise14,23,24,30,31 ening exercises. The use of resistive materials promotes an
found some effect of aquatic exercise in increasing strength. increased area of contact with water, and will also increase
Lim et al. (2010) could not observe changes in muscle strength the exercise overload.17,37 However, there is no consensus yet
in none of their groups. However, Lund et al. (2008) found on the effects of aquatic exercise on muscle strength.
improvement in muscle strength only in the group that In this review, only two of the ve studies that evalu-
performed oor exercise, while the group that underwent ated muscle strength showed signicant effects.14,30 Wang
aquatic exercise showed a decreased strength in the isokinetic et al. (2007) conducted a 12-week program with three weekly
test. sessions with a standardized protocol of muscle strengthen-
In all articles comparing the two interventions, signicant ing, aerobic and exibility exercises (AFAP protocol)38 with
reductions were observed in pain, regardless of the environ- controlled and progressive intensity, and achieved signicant
ment where the exercise was held,24,25 but only Wyatt et al. improvement in isometric muscle strength of knee exten-
(2001), Silva et al. (2008) and Lim et al. (2010) reported a greater sors and exors and hip abductors, adductors, extensors and
effect in the group that performed aquatic exercises. exors. Similar results were found by Hinman et al. (2007),
who prescribed two weekly sessions of aquatic exercise for
Water exercises control six weeks, with the progression of the volume and degree
The studies that compared a group of aquatic exercises and of difculty of the exercises; these authors reported signif-
a control group found benets of aquatic exercise, in terms icant improvement in isometric muscle strength of the hip,
of functionality, with physical performance tests. However, as assessed with hand dynamometry. The progression of
Hale et al. (2012) found no difference between the group the intensity and the specicity of exercise are crucial fac-
that received the intervention with aquatic exercise and tors. Both studies performed specic exercises of muscle
the control group, as both showed improved functionality. strengthening, whose strength and volume increased over the
Of the studies that performed the 30-Second Chair Stand program, which may have resulted in neuromuscular adapta-
Test,21,28,31,36 only Arnold and Faulkner (2010) found a sig- tions throughout the exercise program.
nicant improvement after the intervention. The group that On the other hand, studies by Lund et al. (2008), Lim et al.
performed aquatic exercises and participated in educational (2010) and Fisken et al. (2015) found no improvement in mus-
sessions for the prevention of falls increased by 12% the num- cle strength. While one study reported a signicant reduction
ber of repetitions versus the other two groups. in muscle strength of knee extensors and exors in an isoki-
Signicant effects of aquatic exercise were found in muscle netic evaluation at 60 /s in the group that underwent aquatic
strength compared to the group without intervention in two exercise,24 other studies found no differences among groups
540 r e v b r a s r e u m a t o l . 2 0 1 6;5 6(6):530542

(water exercise, land-based exercise, and control) in the isoki- interventions. In the study by Hinman et al. (2007), the sample
netic evaluation23 or in handgrip strength in the group that was more physically active and had a lower functional impair-
performed aquatic exercises.31 These results may be asso- ment, as the participants were aged under 65 and with only a
ciated with the choice of exercises, the progression of the slight degree of involvement of OA, which may have inuenced
program, exercise intensity, and tests used. Perhaps the hand- the results.14 Physical exercise promotes more signicant ben-
grip strength test does not properly identify strength gains in ets in older people with greater functional impairment.47,48
lower limbs.39,40 Even using balance-specic exercises, Hale et al. (2012) found
Interventions of these studies have examined aquatic exer- no difference between experimental and control groups in
cises without using resistive materials to increase overload; terms of balance, due to the intervention performed in the
this was done with the progression of the volume of exercise, control group. According to these authors, the increase in daily
increases in the number of repetitions,24 or in the degree of dif- physical activity and in social interaction resulting from the
culty of movements23 and also in the speed and magnitude intervention with computer games promoted benets similar
of implementation of exercises31 throughout the program. to those in the experimental group.
Lund et al. (2008) suggested that there was no improvement Some limitations of this review were observed. The specic
in muscle strength due to the small resistance imposed in the goal of this study restricted the number of articles that met
exercises. The use of materials that increase the contact area the inclusion and review quality criteria. However, the studies
with the water and the practice of high-speed movements pro- found represent the literature on the subject. It was not pos-
mote an increased exercise overload and consequent increase sible to pool the data to perform a meta-analysis, due to the
in force production.17,37,41 methodological diversity of the studies and the lack of detail
Additionally, Lund et al. (2008) and Fisken et al. (2015) in the description of interventions, which also made it difcult
used the rhythm of the music to determine exercise intensity. to identify a standardized protocol for exercise programs.
Perhaps this is not an effective strategy because it does not
respect the individuality of the participants. By using the same
rate for all participants, the absolute effort is the same, but the
relative effort may differ depending on the participants phys-
This review study suggests that well-designed and controlled
ical tness. In the study of Fisken et al. (2015), the increase in
interventions with aquatic exercise lasting at least six weeks,
the speed of execution of exercises, according to the rhythm of
contemplating muscle strengthening exercises and aerobic
the music, was not enough to promote improvement in mus-
exercises, can be effective in increasing muscle strength of
cle strength. The music cadence progressed every two weeks,
lower limbs and in improving the functionality of patients
ranging from 92 to 162 bpm in the rst four weeks, and from
with OA.
92 to 220 bpm for the remaining period.
Although there is difculty in comparing different exercise
Studies comparing aquatic exercise programs versus land-
programs due to methodological differences, it seems impor-
based exercises2327 found similar effects in both groups in
tant an individualized control of intensity and overload, as
terms of functionality and in reducing the pain; however, land-
well as of their progression. However, there is no way to estab-
based exercise programs were more effective in increasing
lish safe guidelines to formulate protocols. Therefore, it is
muscle strength.24 Similar results were observed in previous
suggested greater standardization/control and also a greater
experimental studies4,42 and in systematic reviews.43,44 The
level of detail of the programs in future experimental studies.
land-based exercise can be more effective versus water exer-
cise, as the control and increase in overload can be performed
more objectively. Conicts of interest
However, when properly known, the hydrodynamic prop-
erties of water can be used to increase efciently the exercise The authors declare no conicts of interest.
overload.45 Bento et al. (2014) reported an increase in muscle
strength in healthy older subjects when comparing a proto-
col of aquatic versus land-based exercises. The strategy used
was the gradual increase in the intensity of exercise at every
four weeks, increasing the projected area of the lower limbs
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