RESEACH PAPER

The Efficacy of Land versus Water Exercise Program on Body Composition in Obese
Patients with Knee Osteoarthritis
Tirza Z. Tamin, Natalia Loekito
Physical Medicine and Rehabilitation, Medical Faculty of University Indonesia/Dr. Cipto
Mangunkusumo National General Hospital Jakarta, Indonesia

ABSTRACT
Objective : Obesity and Osteoarthritis (OA) can affect each other and make a reciprocal
causal chain with negative feedback that caused by physical inactivity. Water-based (WB) and
land-based (LB) exercises are effective to improve body composition and physical activities.
The aim of this study was to compare the effects of both exercise programs on body
composition in obese patients with knee OA.
Materials and Methods: A single-blind randomized controlled trial was done involving 33
men and women aged 40-80 years old with BMI ≥ 25 kg/m2 and knee OA grade 2 and 3
based on Kellgren-Lawrence grading scale. Subjects were randomly divided into LB (n = 18)
and WB group (n = 15) with aerobic and knee-strengthening exercises for 8 weeks. Body
weight (BW), body mass index (BMI), and waist circumference (WC) were measured before
and after the program. Data will be analyzed using SPSS 20.0 with independet t test,
Wilcoxon and Mann Whitney test if necessary.
Results: Participants who performed the LB exercise program showed significant
improvement in BW (mean, 0.22 ± 0.92 ; p = 0.025), BMI (median, 0.36 (0.68 – 2.88) ; p =
0.040), and WC (mean, 2.13 ± 3.66 ; p = 0.024). While there was no significant improvement
of body composition in WB group. However, when both groups were compared, BMI was
the only variable that was significantly different (p = 0.048), with subjects of LB group
showing better result than the WB group.
Conclusion: Land-based exercise program was more effective to improve body composition
in obese patients with knee OA due to the effect of gravity that improved muscle
strengthening without buoyancy such as in the water. Warm water temperature gives
relaxation effect that increases appetite. We suggest longer period of research and greater
number of participants to better show a significant improvement for WC and BW variables.

Keywords: obesity, knee osteoarthritis, aquatic exercise, land-based exercise, body

composition, body weight, body mass index, waist circumference.
INTRODUCTION
World Health Organization (WHO, 2011) defines obesity as excessive build up of fat tissue
that can interfere individual health. Based on Riskesdas 2013, there is an increase in the
prevalence of obesity in Indonesia compared to year 2007 for both men (from 13.9% to
19.7%) and women (from 13.9% to 32.9%)1. Osteoarthritis (OA) is a cartilage and
periarticular degenerative disease, most often in knee joints, that causes pain and disability
later in life2. Obesity increases stress in all weight-bearing joints, that is the main factor
causing joint degeneration, also alter joint posture, gait, and decrease level of physical
activity. Therefore obesity and osteoarthritis (OA) can affect each other and make a
reciprocal causal chain with negative feedback due to physical inactivity. Supported by
Vincent et al (2012) study which showed there will be an escalation of risk of OA as much as
36% in every 5 kilograms increase in body weight. Increased of BMI values then worsen the
joint pain then higher the risk of sedentary lifestyle because patients usually avoid doing any
kind of activities that potentially produce pain.
Losing weight will prevent the onset of osteoarthritis also decrease symptoms and disability.
Study showed that reduction of body weight through physical exercise improve pain, physical
function, and walking distance by average 26%, 31%, and 15% respectively3,4.
Some practitioners claim that certain types of aerobic activities are more effective than others
and that some activities will not promote weight loss at all, but weight-bearing exercises
suspected will overuse the knee joint, exacerbate the existing joints condition, frequently lead
to discontinuation of the program. Therefore non-weight-bearing exercises are more
recommended for obese individuals also for patients with orthopaedic conditions, one of
which is aquatic/water exercise that known decreased the joint load by buoyancy5.
The aim of this study was to compare the effects of water-based (WB) and land-based (LB)
exercise programs on body composition in obese patients with knee OA.

MATERIALS AND METHODS

A single-blind randomized controlled trial was done involving 33 men and women aged 40-

80 years old with BMI ≥ 25 kg/m2 and knee OA grade 2 and 3 based on Kellgren-Lawrence
grading scale. Subjects were randomly divided into LB (n = 18) and WB group (n = 15) with
aerobic and knee-strengthening exercises for 8 weeks. Body weight (BW), body mass index
(BMI), and waist circumference (WC) were measured before and after the program. Data will
be analyzed using SPSS 20.0 with independet t test, Wilcoxon and Mann Whitney test if
necessary.

RESULTS
Participants who performed the LB exercise program showed significant improvement in BW
(mean, 0.22 ± 0.92 ; p = 0.025), BMI (median, 0.36 (0.68 – 2.88) ; p = 0.040), and WC
(mean, 2.13 ± 3.66 ; p = 0.024). While there was no significant improvement of body
composition in WB group. However, when both groups were compared, BMI was the only
variable that was significantly different (p = 0.048), with subjects of LB group showing better
result than the WB group.

Parameter Pre Post P-value

BW (Median(max-min)) 69.50 (109-55) 68.50 (110 – 54.50) 0.025

BMI (Mean ± SD)) 30.59 ± 4.35 30.18 ± 4.25 0.040

WC (Mean ± SD)) 95.58 ± 7.85 93.44 ± 8.45 0.024

Table 1. A Comparison of Body Composition in LB Exercise Pre & Post Intervention

Parameter Pre Post P-value

BW (Median(max-min)) 69.13 (86-57) 68.00 (85.00 – 0.336

0.001)

BMI (Mean ± SD)) 29.6 ± 3.54 29.68 ± 3.66 0.548

WC (Mean ± SD)) 93.26 ± 8.83 93.30 ± 8.20 0.968

Table 2. A Comparison of Body Composition in WB Exercise Pre & Post Intervention

 Parameter Water (Mean ± SD) Land (Mean ± SD) P-value

BW 0.001 ± 0.94 -0.22 ± 0.92 0.502

BMI 0.086 ± 0.54 -.4089 ± 0.78 0.047

WC 0.033 ± 3.20 -2.13 ± 3.66 0.083

Table 3. A Comparison of Body Composition in LB & WB Exercise Post Intervention

DISCUSSION
Based on the results, LB exercise program showed significant improvement in body weight
(BW), Body mass index (BMI), and waist circumference (WC) while there was no significant
improvement of body composition in WB group even though both groups were given the
same type of exercise, aerobic and knee-strengthening. It shows similar results with study by
Gwinup (1987) which compared the effect of aerobic exercises (swimming, stationary
cycling, and walking on land) to weight reduction. At the end of the study, patients who walk
lost 10% of the initial weight, cyclist lost 12%, while swimmers’ weight not differ
significantly and even slightly increased even though it is found that the decreased of basal
pulse rate by swimmers are similar to walker and cyclist, this means it produced a
comparable degree of fitness. Caloric intake was not measured in this study as well as in
Gwinup’s study6.
The heat produced during exercise is not enough to cool down the body, especially for
swimmers who need a return to their initial core body temperature after leaving the water.
According to White et al, this might be the reason why after exercising in cold water (20oC)
individuals will need greater energy intake compared to in thermoneutral water (33oC). So if
the study finds that water exercise emit energy similar to land but there is no visible weight
reduction, one can think of that WB group probably compensates their expenditure of energy
with more calorie intake, or another possibility that there is formation of new muscle instead
of losing fat, hence the absence of weight loss in WB group6.
CONCLUSION
Land-based exercise program was more effective to improve body composition in obese
patients with knee OA due to the effect of gravity that improved muscle strengthening
without buoyancy such as in the water. Warm water temperature gives relaxation effect that
increases appetite. We suggest longer period of research and greater number of participants to
better show a significant improvement for WC and BW variables.

Acknowledgment
We would like to thank to the Department of Physical Medicine and Rehabilitation in Cipto
Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia and all that has
contributed to this study.

Conflict of interest
The authors affirm no conflict of interest in this study.
REFERENCES

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and Prevention of Osteoarthritis. PMRJ Vol. 4, S59-S67, May 2012
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for persons with chronic diseases and disabilities. Champaign, IL: Human Kinetics:
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