AQUATIC PHYSIOTHERAPY IN THE INPATIENT SETTING · Aquatic Physiotherapy in the Inpatient Setting Sarah Guille 2002, Geytenbeek 2008, Bartels et al 2009). In osteoarthritis, gold level

Aquatic Literature Reviews Level 3 Course Participants 2010 Aquatic Physiotherapy in the Inpatient Setting Sarah Guille

AQUATIC PHYSIOTHERAPY IN THE INPATIENT SETTING

SARAH GUILLE

[sarah_guillehotmailcom]

RESEARCH QUESTION

What evidence is there to support the use of aquatic physiotherapy in the inpatient setting

ABSTRACT

Background The purpose of this literature review was to search for and appraise the quality

of all research evidence supporting the use of aquatic physiotherapy in the inpatient setting

There is growing evidence for the use of aquatic physiotherapy in outpatient populations By

contrast aquatic rehabilitation in the inpatient setting remains largely understudied Method

Ten medical and allied health databases were systematically searched and relevant trials were

critically appraised using recognised critical review protocols Results 7 trials were

appropriate for inclusion and their methodological quality was analysed Moderate to high

quality evidence exists to support the use of aquatic physiotherapy in early post-operative

lower limb joint arthroplasty for benefit in muscle strength and self-reported functional

measures There is low level evidence for the application of aquatic physiotherapy in

neurological populations to reduce spasticity and medication use While three case studies

involving patients with orthopaedic and neuromuscular debility offer poor research merit they

indicate positive outcome trends for the use of aquatic physiotherapy in complex conditions

Conclusion More evidence is required to investigate the specific benefits of aquatic

physiotherapy as compared to land based treatment or general water exercise in acute patient

populations

INTRODUCTION

Use of aquatic physiotherapy in the management of musculoskeletal and orthopaedic

conditions is widespread There is growing evidence to support the use of aquatic

physiotherapy in chronic conditions including rheumatoid arthritis hip and knee osteoarthritis

(OA) chronic low back pain fibromyalgia and chronic regional pain syndrome (Geytenbeek


2002 Geytenbeek 2008 Bartels et al 2009) In osteoarthritis gold level evidence supports

the use of aquatic therapy for short term slight improvement in pain and function (Bartels et al

2007) while benefits in disability strength range of motion pain flexibility balance well-

being cost-effectiveness heath status and quality of life are also demonstrated (Geytenbeek

2002 Geytenbeek 2008) Scientific grounds and evidence from outpatient studies support the

use of aquatic physiotherapy in post-surgical rehabilitation and orthopaedic injury (Ahlqvist

2002 Fappiano and Gangaway 2008 Watts and Gangaway 2007) It has been demonstrated

that aquatic intervention can facilitate early initiation of exercise improve self-reported pain

and function and contribute to greater range of motion strength proprioception and decreased

risk of further injury (Fappiano and Gangaway 2008 Watts and Gangaway 2007 McAvoy

2009) In anterior cruciate ligament (ACL) rehabilitation aquatic physiotherapy has been

attributed to reduced joint effusion and earlier gains in range of motion (McClintock and

Kirkley 1995 Tovin et al 1994) In a reduced weight bearing environment which minimises

joint stress it is likely that the physiological and thermal properties of water including

hydrostatic pressure and buoyancy effect enable early initiation of exercise and increased

activity tolerance

Limited evidence exists to support the use of aquatic physiotherapy in inpatient populations

including acute orthopaedic rehabilitation (Geytenbeek 2008) Land-based studies of

intensive rehabilitation programmes and additional physiotherapy in the hospital setting

clearly demonstrate a positive relationship between physiotherapy service and positive patient

outcomes Increased intensity and frequency of physiotherapy intervention has been shown to

benefit parameters of functional mobility and total hospital cost including discharge

destination and reduced length of stay (Boxall 2004 Freburger 2000 Kirk-Sanchez 2001

Lawson 2006 Moffet 2004 and Roach 1998 Weigl 2003) In the post-operative recovery of

high risk patients undergoing elective hip or knee arthroplasty early inpatient rehabilitation

(day 3 instead of 7) was well tolerated and contributed to earlier obtainment of functional

goals at less overall cost (Munin et al 1998) Considering that aquatic physiotherapy is

indicated where land based activity is contraindicated due to pain or acute injury (Babb and

Simelson-Warr 1994) it is possible that aquatic physiotherapy could be used as a substitute

for land-based rehabilitation The inpatient setting provides a unique opportunity to explore

the use of aquatic physiotherapy in hospital patients recovering from surgery injury illness or

disease This review of the literature aims to investigate what evidence exists to support the


use of aquatic physiotherapy in the inpatient setting across the orthopaedic neurological and

general medical disciplines

METHODSSELECTION OF ARTICLES

Inclusion criteria All studies describing aquatic physiotherapy as an inpatient intervention

were included There was no limitation on the type of studies participants nor outcomes

selected for inclusion

Search Strategy The following search terms were used with various truncations

ldquohydrotherapyldquo ldquoaquatic therapyldquo ldquoaquatic physiotherapyldquo ldquoaquatic physical therapyrdquo

ldquowater therapyrdquo and ldquowater exerciserdquo combined with ldquoinpatientldquo ldquoin-patientldquo ldquomedical

patientldquo ldquosurgical patientldquo ldquohospital patientldquo ldquorehabilitationldquo or ldquolength of stayldquo The

reference lists of all relevant articles were also searched

Database searched The following databases were searched for English language abstracts

from the year 2000-September 2010 CINAHL MEDLINE PUBMED PEDro Cochrane

Library TrIP Database Up to Date Scopus Best Practise MD Consult

Exclusion Criteria Articles were excluded that described aquatic-based rehabilitation in an

outpatient setting Inpatient physiotherapy not specific to aquatic physiotherapy nor able to be

differentiated from concurrent land based therapy or where the nature of water exercise was

not described (including Kneipp Hydrotherapy Spa therapy and Balneotherapy unrelated to

physiotherapy intervention) were excluded

Full-text articles for all relevant abstracts were sourced and selection criteria were applied

Methodological quality was assessed by one reviewer using three separate assessment tools to

reflect the breadth and variety of studies sourced The Oxford Centre for Evidence-based

Medicine Levels of Evidence (OCEBM 2009) where level 1a (systematic reviews of

randomized controlled trials) represents the highest level of evidence or that which is least

flawed and level 5 (expert opinion) represents the most flawed or lowest level of evidence

the PEDro Scale (CEBP 1999) for Randomized Controlled Trials (to help identify which of

the known or suspected randomised clinical trials are likely to be internally valid (criteria 2-


9) and could have sufficient statistical information to make their results interpretable (criteria

10-11) and Law et al‟s (1998) Critical Review Form- Quantitative Studies

RESULTS

The search strategy yielded over 100 papers Abstracts sourced from more than one database

were removed On closer review of full text articles many did not meet the inclusion criteria

and were excluded based on aquatic-based rehabilitation occurring in an outpatient setting or

being poorly described and unable to be distinguished from land therapy Four articles were

sourced that described inpatient orthopaedic rehabilitation after hip or knee joint arthroplasty

(THA or TKA) These included one high quality randomized controlled trial (RCT)

(Rahmann et al 2009) and two moderate quality prospective cohort randomized design studies

(Giaquinto et al 2009(a) Giaquinto et al 2009(b) scoring 1b to 2b on the OEBM scale A low

quality single case study describing a cardiopulmonary compromised elderly patient

recovering from THA was also included (Costa et al 2004) From these four studies benefit

in lower limb strength self-reported pain and functional measures and trends in range of

motion limb girth and improved patient satisfaction were attributed to the adjunct of aquatic

physiotherapy to routine care (Rahmann et al 2009 Giaquinto et al 2009(a) Giaquinto et al

2009(b) Costa et al 2004) Particularly in a geriatric population the authors suggest aquatic

physiotherapy be considered after joint arthroplasty surgery as a safe and effective alternative

to routine or additional land-based therapy The benefit of aquatic physiotherapy post joint

arthroplasty as a stand-alone treatment remains unclear

One control case matched study was sourced that investigated an inpatient neurological

population post spinal cord injury (SCI) (Kesiktas et al 2004) Hydrotherapy was added as an

adjunct to the rehabilitation programme of participants who had not reached their functional

targets due to spasticity Compared to a control group patients participating in hydrotherapy

had a statistically significant reduction in spasticity severity and decreased medication use

OEBM scoring is 3b and the study is of low quality due to the small convenience sample size

(n=20) and non-randomization

Representing the lowest level of available evidence (OEBM 4-5) two further case studies

were sourced for clinical interest and completeness One study described the post-operative

spinal surgery rehabilitation in a patient with significant comorbidities and orthopaedic


weight-bearing restriction (Fragala-Pinkham et al 2009) The authors concluded that the

integration of an aquatic programme positively impacted on client participation and

motivation level of activity and general body function There was no statistical analysis and

overall quality was low a reflection of single case study design Taylor (2003) undertook a

retrospective case study of a ventilated Guillain Barre Syndrome patient undergoing aquatic

physiotherapy in the acute setting Despite anecdotal improvements in muscle size and

strength lack of structured methodology and valid and reliable outcomes means we are unable

to draw clear recommendations for the application of hydrotherapy in the wider critical care

population

As evidence of further methodological and quality assessment for all of the above studies

Table 2 indicates the yesno response to sixteen short answer questions from Law et al‟s

(1998) Critical Review Form- Quantitative Studies A ldquoyesrdquo answer indicates the study met

the domain criteria with a higher overall number of ldquoyesrdquo answers reflecting stronger

methodological quality Where applicable PEDro scores for Randomised Control Trials

(CEBP 1999) are presented in Table 3

A summary of each study‟s main findings including outcome measures assessment and

details of the aquatic program are included in Table 4

DISCUSSION

Aquatic physiotherapy in the early stages after surgery injury illness neurological event or

disease is largely understudied Conducting research in an inpatient rehabilitation setting may

be confounded by difficulty in sourcing large numbers of homogenous patient groups and

complex interventions often not suitable for application in the generic group setting

(Geytenbeek 2008) Potential constraints to study recruitment and retention include medical

unsuitability or short hospital length of stay meaning descriptive and comparative case studies

may be more readily undertaken than high quality research trials

Despite physiotherapy and aquatic intervention being treatments of choice by clinicians the

acute phase following joint arthroplasty is one of the most understudied aspects in the

literature with wide variance in the modes of service delivery (Harmer et al 2009 Lawson

2009 Naylor et al 2006 Roos 2003) With growing disability from osteoarthritis contributing


to increasing incidence of joint replacement surgery in Australia and worldwide there is

increasing pressure to contain costs reduce hospital length of stay and establish the most

efficient and effective clinical pathways for patients recovering from joint replacement

surgery in the inpatient setting (Rahmann et al 2009)

Rahmann et al (2009) designed a prospective randomised controlled trial to evaluate the

effect of inpatient aquatic physiotherapy in addition to usual ward physiotherapy Outcome

measures were evaluated relating to strength function and gait speed at baseline and at day

14 90 and 180 after total hip or knee replacement surgery The number of different and

validreliable outcome measurements assessor blinding and use of a general ldquowater exerciserdquo

control contributes methodological strength to this article Main findings were a significant

increase in hip abductor strength at day 14 after aquatic physiotherapy compared to additional

ward treatment or water exercise This is clinically significant in the context that hip abductor

weakness was the most common muscle weakness post THA that can result in ipsilateral

trunk flexion during stance phase and a Trendelenberg gait (Bhave et al 2007 in Costa et al

2009) Secondary outcome measures of length of stay and occasions of physiotherapy service

were analysed without significant difference when comparing the aquatic with the ward or

water exercise groups No adverse events occurred with early aquatic intervention There

was a trend towards reduced swelling and knee circumference that was not statistically

different A justified sample of 65 patients were recruited for this study yet small group

numbers (n=20-24) and an increasing loss to follow-up of 26 by day 180 may lessen the

power calculation and quality of this article

Giaquinto et al (2009) in two separate studies(a)(b) used a prospective randomised design to

follow up of a cohort of patients who underwent TKA and THA Using the same

methodology patients were randomly allocated to a conventional gym treatment or

hydrotherapy group and interviewed with Western-Ontario McMasters Universities

Osteoarthritis Index (WOMAC) the gold standard for self-perceived functional status in OA

and total joint arthroplasty (Bellamy et al 2005 in Giaquinto et al 2009(a) Scores were

obtained at admission to a rehabilitation unit at discharge and 6 months later Both studies

reported subjective improvement in pain stiffness and function in both intervention groups

with WOMAC sub-scales significantly lower for all patients undergoing hydrotherapy

Benefits gained at discharge still remained at the 6 month follow-up mark


Weaknesses of both Rahmann et al‟s (2009) and Giaquinto et al‟s (2009) two studies is the

lack of control for confounding factors in the 6 month period post discharge In Giaquinto et

al (2009) there was no intention-to-treat analysis and a loss to follow up of 17 (1270) in

study(b) compared to 9 (674) in study(a) casting doubt on the internal validity of the TKA

trial(b) in particular using PEDro‟s (CEBP 1999) scoring criteria Assessor blinding and

group randomisation lends strength to these studies however unlike Rahmann et al‟s (2009)

comprehensive physiotherapy exercise prescription there was a lack of clear description of

either water or land therapy in Giaquinto et al‟s (2009) two studies making the intervention

difficult to replicate in a clinical setting Participants in Giaquinto et al‟s (2009) hydrotherapy

groups received 20 minutes of passive joint motion followed by 40 minutes of treatment in

water The control groups received land therapy followed by a bdquoneutral‟ massage on the hip

or knee scar for 20 minutes The inclusion of massage and joint mobilisation could be seen as

a source of co-intervention which may confound results Yoshida et al (2008) cited in

Rahmann et al (2009) suggest that the multi-faceted disability from osteoarthritis means a

single outcome measure or domain is likely to be inadequate for measuring the true nature of

post-operative recovery The use of only a single qualitative outcome measure and no

physical measures is a limitation to interpretation and wider application of the findings in

Giaquinto et al‟s (2009) randomised cohort trials and a potential source of measurement bias

(Law et al 1998)

While providing low quality evidence as far as research methodology and widespread

application case studies give an insight into the role of aquatic therapy in often complex

clinical scenarios Costa et al‟s (2009) single case study of a cardiopulmonary compromised

patient who underwent THA supports the use of early aquatic intervention in the acute

rehabilitation setting Improvement was demonstrated in range of motion strength girth and

pain The authors conclude that in the geriatric population with comorbidities aquatic

intervention may be well tolerated less painful than land therapy and can lead to earlier

functional improvements and patient satisfaction As cited in Costa et al (2009) their findings

are consistent with Hall and Brody‟s (1999) assertion that aquatic therapy as an alternative to

land-based therapy may be more tolerable in post-operative patients who are deconditioned

The lack of cardiopulmonary complication on immersion is supported by Perk et al‟s (1996)

study of a cohort of non-hypoxaemic normotensive chronic obstructive pulmonary disease

patients who were able to exercise sub-maximally in a hydrotherapy environment safely and

without desaturation arrhythmia or discomfort that was deemed clinically relevant In Costa


et al‟s (2009) case study there was an attempt to use reliable and valid outcome measures

although no statistical analysis was performed and there was no intention to control for

confounding factors High motivation and high pre-morbid activity may also have

contributed to patientbdquos improvement A conclusion cannot be drawn as to the benefit of land

versus aquatic intervention

Aquatic exercise is often recommended as an adjunct to land based therapy as part of an

integrated rehabilitation programme A review of lower limb orthopaedic literature found that

when used together water and land based interventions are more effective in treating lower

extremity injuries than land based treatment alone (Fappiano and Gangaway 2008) Findings

of improved strength (Rahmann et al 2009) and functional measures (Giaquinto et al 2009(a)

Giaquinto et al 2009(b) Costa et al 2009) with the addition of aquatic physiotherapy is a

finding not always consistent with orthopaedic and musculoskeletal literature Investigations

of aquatic exercise compared to land based intervention in outpatient studies often yield

similar results or no added benefit raising doubt about the cost-effectiveness of offering

particularly in-house aquatic intervention (Geytenbeek 2008 Harmer et al 2009) While

aquatic intervention may be better tolerated in TKR and OA it has also been demonstrated

that exercise in water compared to land may not be as effective in regaining maximal muscle

performance in ACL rehabilitation (Tovin et al 1994) or in improving strength and pain in

knee OA (Lund et al 2008) Variable expert opinion means it is increasingly necessary to

justify aquatic intervention with sound clinical reasoning and improve the specificity and

intensity of exercises using the unique properties of water to replicate the strength gains

achievable on land Improving reporting quality of aquatic exercise in the literature is a

promising trend that will aid replication in the clinical setting

A case series by Fragala-Pinkham et al (2009) investigated the effect of inpatient orthopaedic

aquatic rehabilitation and the feasibility of treating a participant with a complex history A 19

year old obese participant had undergone L1sacrum spinal fusion on a background of Prader-

Willi Syndrome and a history of multiple spinal surgeries and complications After a period

of bed-rest due to orthopaedic non-weight-bearing (NWB) restriction the patient was cleared

to participate in upright standing activities in water and an intensive aquatic programme was

initiated A variety of valid and reliable outcome measures were used and reported in

measures of Minimal Important Difference (MID) and Mean Detectable Change (MDC)

Intervention was well described and resulted in a clinically significant improvement in


functional mobility as well as improved walking endurance pain scores and lower extremity

strength on manual muscle testing Obvious limitations of the study were lack of statistical

analysis and co-intervention of land and aquatic therapy from 12 weeks post-operatively

meaning no conclusions could be drawn as to the relative benefit of either intervention

Single case studies have inherently very poor applicability to wider populations and offer low

quality evidence to the research pool

Despite having a vital role in functional recovery in the neurological population (Kesiktas

2004) Geytenbeek (2008) highlights that this is one area where there is a need for quality

aquatic physiotherapy research Single case studies in SCI and traumatic brain injury have

demonstrated that aquatic physiotherapy contributes to improvement in long term functional

outcomes as part of neurological rehabilitation (Degano et al 2009 Stowell et al 2001) Noh

et al (2007) found that when compared to conventional therapy outpatient stroke survivors

participating in aquatic physiotherapy participants showed improved balance and strength in

the hemi-paretic leg With the bulk of neurological aquatic research conducted in outpatient

post-acute rehabilitation settings only 2 studies were found describing aquatic intervention in

the inpatient setting in this current review

Kesiktas et al (2004) conducted a control case matched study to compare the effects of

hydrotherapy on spasticity and functional independence measures (FIM) in twenty patients

with SCI While both control and hydrotherapy intervention groups made significant

improvement in functional scores the hydrotherapy group made a larger improvement

(plt00001) and demonstrated a significant decrease in oral baclofen use and muscle spasm

severity (plt002) Both groups gained significant improved in spasticity as measured by the

Ashworth Scale Lack of blinding and randomisation through bdquoconvenience sampling‟ as well

as the small number of participants make it difficult to generalise findings to the wider SCI

population although reduced medication use is a positive trend consistent with previous SCI

literature (Giesecke 1997)

In a Single Case Study Taylor (2003) described a detailed protocol requiring combined

medical nursing and physiotherapy staff cooperation to facilitate the treatment of an intensive

care ventilated Guillain Barre Syndrome patient in the water 2-3 times per week for 7 months

The purpose of the intervention was to benefit morale facilitate graduated weight bearing and

improve muscle strength and range of motion in an otherwise highly physically dependent


patient A lack of valid or reliable outcomes measures makes it difficult to draw conclusions

and wider recommendations from this study Furthermore costbenefit analysis would assist

in determining whether the benefit of reducing Intensive Critical Care Unit (ICCU) length of

stay is offset by the intensive staff requirements to allow treatment to take place Interestingly

the author purports that due to the high per patient costs in an ICCU environment facilitating

early ventilator weaning so as to reduce length of stay by only 1-2 weeks could be seen as cost

effective compared to long-term ventilator dependence

CONCLUSION

A comprehensive database search yielded 7 studies describing aquatic physiotherapy taking

place in an inpatient population Level 1b to 2b moderate to high quality evidence from three

randomised control trials supports the use of aquatic physiotherapy in the early post-operative

phase after lower limb joint arthroplasty as a safe and effective modality for consideration

(Rahmann et al 2009 Giaquinto et al 2009(a) Giaquinto et al 2009(b) Early improvement in

lower limb strength compared to land based or general water exercise has been demonstrated

on physical measures (Rahmann et al 2009) Qualitative self-reported data of pain stiffness

and function can be positively influenced in geriatric patients who underwent total hip or knee

joint arthroplasty compared to land based (Giaquinto et al 2009(a) Giaquinto et al 2009(b)

Aquatic intervention contributes to less post exercise soreness improved pain and functional

measures and a reduction in swelling and lower limb girth in the orthopaedic population

(Costa et al 2009 Fappiano and Gangaway 2008 Giaquinto et al 2009(a) Giaquinto et al

2009(b) McClintock 1995 Rahmann et al 2009 Tovin et al 2009) It may be a preferred

mode of treatment where pain comorbidities severe debility or weight-bearing restriction

make it difficult for a patient to exercise on land (Babb and Simelson-Warr 1994 Costa et al

2009 Fragala-Pinkham et al 2009 Taylor 2003)

Low level 3b evidence supports the use of aquatic physiotherapy to reduce spasticity severity

decrease medication use and improve functional independence scores in SCI (Kesiktas et al

2004) Very low quality evidence from case studies investigate the application of aquatic

intervention in a cardiopulmonary individual status post THA a young orthopaedic patient

with bilateral weight bearing restrictions post spinal fusion surgery and a ventilated patient

with severe neuromuscular weakness secondary to Guillain Barre Syndrome (Costa et al

2009 Fragala-Pinkham et al 2009 Taylor 2003) These individual studies are important in


their capacity to describe complex clinical scenarios in detail with good aquatic exercise

specificity and description Individual case studies demonstrate that even in an acute

population recovering from orthopaedic surgery neuromuscular insult or with

cardiorespiratory compromise aquatic physiotherapy can be a safe and effective mode of

treatment There is particular scope for application in functional rehabilitation of geriatric

deconditioned patients with benefit in strength range of movement and morale paving the

way for further research into the area (Costa et al 2009 Giaquinto et al 2009(a) Giaquinto et

al 2009(b)

To my knowledge there are no studies to date that investigate the cost effectiveness of

operating an in-house hydrotherapy pool for inpatient use There is little investigation and no

significant findings on the potential for inpatient aquatic rehabilitation to contribute to earlier

obtainment of functional goals less physiotherapy occasions of service or reduced length of

hospital stay More high quality studies are needed comparing land versus aquatic therapy in

the inpatient setting in a wide population of patients Attention to true randomisation

increased patient numbers assessor blinding using general water exercise as a control and

the use of a battery of tests for reliable and valid outcome measures will improve the quality

of available evidence in this area


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Ahlqvist J (2002) Hydrotherapy has had and has a rationale Rheumatology (Oxford) 41 p

1070-1071

Babb R Simelson-Warr A (1994) Manual techniques of the lower extremities in aquatic

physical therapy Journal of Aquatic Physical Therapy 74710-19

Bartels EM Lund H Hagen K B Dagfinrud H Christensen R Danneskiold-Samsoe B (2009)

Aquatic exercise for the treatment of knee and hip osteoarthritis Cochrane Database of

Systematic Reviews 2007 Issue 4 art No CD005523

Boxall A Sayers A Kaplan GA (2004) A cohort study of 7 day a week physiotherapy on an

acute orthopedic ward Journal of Orthopedic Nursing 8(2) 96-102

Costa B Wilmarth MA Glynn PE (2009) Rehabilitation of a cardiopulmonary compromised

individual status-post total hip arthroplasty utilizing a combined land and aquatic based

program a case report Journal of Aquatic Physical Therapy 17(2) 12-19

Degano AC Geigle PR (2009) Use of aquatic physical therapy in the treatment of balance and

gait impairments following traumatic brain injury A case report Journal of Aquatic Physical

Therapy 17(1) 16-21

Fappiano M Gangaway JMK (2008) Aquatic physical therapy improves joint mobility

strength and edema in lower extremity orthopedic injuries The ournal of Aquatic Physical

Therapy 16(1) 10-15

Fragala-Pinkham MA Dumas HM Barlow CA Pasternak A (2009) An aquatic physical

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21(1) 68-78

Freburger JK (2000) An analysis of the relationship between the utilization of physical

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Therapy 80(5) 448-58


Geytenbeek J (2002) Evidence for effective hydrotherapy Physiotherapy 88(9)514-529

Geytenbeek J (2008) Aquatic Physiotherapy Evidence-Based Practice Guide National

Aquatic Physiotherapy Group Australian Physiotherapy Association

Giaquinto S Ciatola E Dall‟Armi V Margutti F (2009)(a) Hydrotherapy after total hip

arthroplasty A follow-up study Archives of Gerontology and Geriatrics 5092-95

Giaquinto S Ciatola E Dall‟Armi V Margutti F (2009)(b) Hydrotherapy after total knee


Giaquinto S Ferdinando M (2004) A special pool project for rehabilitation of hip and knee

arthroprosthesis Franco Romano Disability amp Rehabilitation 26(19) 1158-1162

Giesecke C (1997) Aquatic rehabilitation of clients with spinal cord injury In Ruoti RG

Morris DM Cole J eds Aquatic Rehabilitation Hagerstown MD Lippincott Williams and

Wilkins pp 125-50

Kesiktas N Paker N Erdogen N Gulsen G Bicki D and Yilmaz H (2004) The Use of

Hydrotherapy for the Management of Spasticity Neurorehabilitation and Repair 18(4) 268-

273

Kirk-Sanchez NJ Roach KE (2001) Relationship between duration of therapy services in a

comprehensive rehabilitation program and mobility at discharge in patients with orthopedic

problems Physical Therapy 81(3) 888-95

Law M Stewart D Pollicj N Letts L Bosch J Westmorland M (1998) Critical Review Form-

Quantitative Studies McMaster University

httpfhsmcmastercarehabebppdfquanreviewpdf [Accessed October-November 2010]


Lawson D (2009) Comparing outcomes of patients following total knee replacement does

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study Acute Care Perspectives June 2009

Lund H Weile U Christensen R Rostock B Downey A Bartels EM Danneskiod-Samsoe B

Bliddal H (2008) A Randomized Controlled Trial of Aquatic and land based exercise in

participants with knee osteoarthritis J Rehabil Med 40 137-144

McAvoy R (2009) Aquatic and Land Based Therapy vs Land Therapy on the Outcome of

Total Knee Arthroplasty A Pilot Randomized Clinical Trial Journal of Aquatic Physical

Therapy 17(1) 8-15

McClintock A Kirkley PJ (1995) Prospective randomized clinical trial of standard

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Clinical Journal of Sports Medicine 5(4)

Moffet H Collet J-P Shapiro SH Paradis G Marquis F Roy L (2004) Effectiveness of

intensive rehabilitation on functional ability and quality of life after first total knee

arthroplasty a single-blind randomized controlled trial Archives of Physical Medicine amp

Rehabilitation 85546-56

Munin MC Rudy TE Glynn NW Crossett LS Rubash HE (1998) Early inpatient

rehabilitation after elective hip and knee arthroplasty JAMA Mar 18279(11)847-52

Naylor J Harmer A Fransen M Crosbie J Innes L (2006) Status of physiotherapy

rehabilitation after total knee replacement in Australia

Physiotherapy Research International 11(1)35-47

Noh DK Lim JY Shin HI Paik NJ (2008) The effect of aquatic therapy on postural balance

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Rehabilitation 22(10-11)966-76

OCEBM (2001) Oxford Centre for Evidence-based Medicine Levels of Evidence (May 2001)

httpwwwcebmnetindexaspxo=1025 [Accessed October-November 2010]


Oldmeadow LB McBurney H and Robertson VJ (2002) Hospital stay and discharge

outcomes after knee arthroplasty Implications for physiotherapy practice Australian Journal

of Physiotherapy 48 117-121

PEDro Scale (Updated 1999) Centre for Evidence-Based Physiotherapy Musculoskeletal

Division The George Institute for Global Health Affiliated with the University of Sydney

Available httpwwwpedroorgauenglishdownloadspedro-scale [Accessed October-

November 2010]

Perk J Perk L and Boden C (1996) Cardiorespiratory adaptation of COPD patients to physical

training on land and in water European Respiratory Journal 9 248-252

Rahmann AE Brauer SG Nitz JC (2009) A specific inpatient aquatic physiotherapy program

improves strength after total hip or knee replacement surgery a randomized controlled trial

Archives of Physical Medicine amp Rehabilitation 90(5)745-55

Roach KE Ally D Finnerty B Watkins D et al (1998) The relationship between duration of

physical therapy services in the acute care setting and change in functional status in patients

with lower-extremity orthopedic problems Physical Therapy 78(1) 19-24

Roos EM (2003) Effectiveness and practice variation of rehabilitation after joint replacement

Current Opinion in Rheumatology Rehabilitation medicine in rheumatic diseases 15(2)160-

162

Stalzer S Wahoff M Scanlan M (2006) Rehabilitation Following Hip Arthroscopy Clinics in

Sports Medicine 25(2)337-57

Stowell T Fuller R Fulk G (2001) An Aquatic and Land-Based Physical Therapy

Intervention to Improve Functional Mobility for an Individual After an Incomplete C6 Spinal

Cord Lesion Journal of Aquatic Physical Therapy 9(1)27-32

Taylor S (2003) The ventilated patient undergoing hydrotherapy a case study Australian

Critical Care 16(3)111-5


Tovin B Wolf S Greenfield B Crouse J Woodfin B (1994) Comparison of the effects of

Exercise in Water and on Land on the rehabilitation of patients with intra-articular anterior

cruciate ligament reconstructions Physical Therapy 74(8)

Watts KE Gangaway JMK (2007) Evidence-Based treatment of Aquatic Physical Therapy in

the Rehabilitation of Upper-Extremity Othopaedic Injuries The Journal of Aquatic Physical

Therapy 15(1)19-26

Weigl M Angst F Stucki G Lehmann S Aeschlimann A (2004) Inpatient rehabilitation for

hip or knee osteoarthritis 2 year follow up study Ann Rheum Dis 63360ndash368

Zuckerman JD (1998) Inpatient rehabilitation after total joint replacement JAMA

279(11)880

Table 1 Oxford Centre for Evidence-based Medicine Levels of Evidence (March 2009)

Level

1a Systematic review of RCTs (with homogeneity)

1b Individual RCT with narrow confidence intervals

1c All or none case series

2a Systematic review of cohort studies (with homogeneity)

2b Individual cohort study (including low quality RCT eg lt80 follow up)

2c Outcomes Research

3a Systematic Review of case-control studies (with homogeneity)

3b Individual Case-Control Study

4 Case-series and poor quality cohort and case-control studies

5

Expert opinion without explicit critical appraisal or based on physiology

bench research or first principles


nothing

Rahmann et al (2009)

Giaquinto et al (2009) TKA(b)

Giaquinto et al (2009) THA(a)

Kesiktas et al (2004)

Fragala-Pinkham et al (2009)

Taylor (2003)

Costa et al (2009)

Level of Evidence Based on The Oxford Centre for Evidence-based Medicine Levels of Evidence (OCEBM March 2009)

Moderate to High 1b or 2b (less than 80 follow up (fup) at 612 Small sample lt 20group contributing to wider CI

Moderate 2b (lower follow up 83 CI SD not reported)

Moderate to High 1b or 2b (good follow up 91 CISD not reported)

LowPoor 3b (small convenience sample)

Very Poor 4 (Single sample CI 90)

Very Poor 5 (expert opinion no sensitivity analysis)

Very Poor 5 (no sensitivity analysis)

Purpose Clearly Stated Yes Yes Yes Yes Yes Yes Yes

Background Literature Reviewed

Yes Yes Yes Yes Yes Yes Yes

Design Pragmatic Randomised Controlled Trial (RCT) blinded 6 month fup

Cohort Prospective Randomised Design


Control Case Matched Study

Case Series Single case study

Single Case Study (retrospective)

Single Case StudyReport

Number of Subjects 65 70 74 20 1 (adult inpatient) 3 (paediatric outpatients)

1 1

Sample Described in Detail Yes Yes

Yes

Yes Yes Yes Yes

Sample Size Justified Yes No No No NA NA NA

Reliable Outcome Measures Yes Yes Yes Yes Yes NA

Not discussed

Table 2 Adapted from Law et al (1998) Critical Review Form- Quantitative Studies

NB Abbreviations used Confidence interval (CI) Standard Deviation (SD) Intraclass correlation coefficient (ICC Minimal Detectable Change (MDC) Minimal

Important Difference (MID)



Giaquinto et al (2009) (b)TKA

Giaquinto et al (2009) (a)THA



Taylor (2003)

Costa et al (2009)

Valid Outcome Measures Yes Yes Yes Yes Yes NA Not discussed

Intervention Described in Detail

Yes No No No Yes Yes Yes

Contamination Avoided Yes Yes Yes Yes NA NA NA Co-intervention Avoided Yes (not

controlled gtday 14 primary end point)

NoUnclear- massage and passive joint motion included


Yes No No No

Results Reported in Statistical Significance

Yes Yes Yes Yes No Clinically significance SD ICC MDCMID reported

No No

Analysis Methods Appropriate

Yes Yes Yes Yes Yes NA NA

Clinical Importance Reported Yes Yes Yes Yes Yes Yes Yes

Drop-Outs Reported Yes- 5 lost to fup (8) ExcludedWithdrew =12 Total 1765=26

Yes- 12 lost to follow up (17)


NA NA NA NA

Conclusions Appropriate Yes Yes Yes Yes Yes Yes Yes

Total ldquoyesrdquo answers14 14 11 11 9 7 6 6

Table 2 continued


PEDro SCALE 10





1 eligibility criteria were specified Yes Yes Yes Yes

2 subjects were randomly allocated to groups (in a crossover study subjects were randomly allocated an order in which treatments were received)

Yes Yes Yes No included for comparison only

3 allocation was concealed Yes Yes Yes No

4 the groups were similar at baseline regarding the most important prognostic indicators NB Abbreviation used for The

Western Ontario and McMaster

Universities Arthritis Index

(WOMAC)

Yes Yes Yes WOMAC= functionpainstiffness Significant difference in stiffness plt001

Yes

5 there was blinding of all subjects No No No No

6 there was blinding of all therapists who administered the therapy

No No No No

7 there was blinding of all assessors who measured at least one key outcome

Yes Yes Yes No

8 measures of at least one key outcome were obtained from more than 85 of the subjects initially allocated to groups

No No Yes Yes

9 all subjects for whom outcome measures were available received the treatment or control condition as allocated or where this was not the case data for at least one key outcome was analysed by ldquointention to treatrdquo

Yes No No Yes

10 the results of between-group statistical comparisons are reported for at least one key outcome

Yes Yes Yes Yes

11 the study provides both point measures and measures of variability for at least one key outcome

Yes No Confidence Interval (CI) reported No point measure

No CI reported No point measure

Yes

SCORE 710 510 610 510

Table 3 PEDro SCALE 10 (CEBP 1999) for Randomized Controlled Trials



Giaquinto et al (2009)(b)

Giaquinto et al (2009)(a)



Taylor (2003) Costa et al (2009)

Type of Patient

Recent Total Hip Replacement (THR) or Total Knee Replacement (TKR)

Italian Recent TKA less than 10 days post op

Italian Recent THA less than 10 days post op

New established Spinal Cord Injury (SCI) Inpatients 7-9 month post injury- not yet reached rehabilitation targets owing to spasticity

Adolescent inpatient Prader-Willi syndrome sp spinal fusion L1-sacrum with limited WB restrictions ho multiple spinal surgeries obesity 3 paediatric outpatient (2 Cerebral Palsy (CP) 1 Juvenile Idiopathic Arthritis (JIA)- not discussed here)

Elderly Asian Guillain Barre Syndrome (GBS) ventilated patient in intensive care unit

THA with cardiopulmonary comorbidities

Description of intervention

11 land general water or aquatic physiotherapy additional intervention

Inpatient rehabilitation- land vs water


Usual passive exercises 2xday matched for oral baclofen 1052 + hydrotherapy in study group

Usual land based rehabilitation with addition of aquatic therapy when seated and upright postures allowed post op 452

Usual intensive care and addition of hydrotherapy with a team of medical nursing and physiotherapy staff patient remaining intubated and ventilated

7 days land-based inpatient rehabilitation with adjunct of aquatic treatment on days 4-7

Table 4 Summary of aquatic intervention outcomes assessment and clinical implications








Type of aquatic exercise

Fast paced 80-88bpm Walking forwardsbackwardssideways hip abductionadductionflexionextension squats heel raises progress to step ups supported in corner scissors hip extension with float resist leg kick cycling knee flexionextension in sitting trunk stability with arm swings-double-single

Walking while supported with a ceiling tracking hoist Gait analysed with video recordingclear panels for therapist observation


Full immersion water exercises in study group +- floatation devices to assist them Floats (rings for trunkextremities) paddle boards slippers parallel bars and weighted stools or chairs used during sessions

Upright in water Partial Weight Bear (PWB) from 952 post op Sit-stand transfers Active Range of Motion (AROM) 4 limbs in standing gait-stable to unstable (treadmill) Progression of WB depth and reduced Upper Extremity (UE) support described

Supine floats or supported seated postures Water familiarisation Upper Limb (UL) and Lower Limb (LL) buoyancy assisted resisted and counterbalanced Range of Motion (ROM) exercises

95 degree water 10668cm depth Warm up therapeutic exercises functional activities cool down Incorporating buoyancy assisted and resisted hip strengthening and stretching performed in the frontal and sagittal plane within limits of hip precautions avoiding IR adduction past midline and flexion greater than 90 degrees

Frequency Duration of intervention

Once daily additional land or water based intervention from Day 4 post operative

40 min pool session after 20 min passive joint motion 6 timesweek for 3 weeks


20mins water exercise 3xweek

Aquatic activity 1-xday 5Xweek 45 min duration 18 week total hospital stay gt50 sessions in pool

30 min sessions 2-3Xweek over 7 months

1 hourday 3 days total 2X10 repetitions each exercise




Giaquinto et al (2009) (a)




Land physiotherapy

All participants received once daily usual ward physiotherapy

Not in Hydrotherapy Group (HTG) Land group received usual therapy and a 20 minute bdquoneutral‟ massage on the knee scar

Not in HTG Land group received usual therapy and a 20 minute bdquoneutral‟ massage on the hip scar

Conventional rehabilitation and study programs were continued

Yes Active and passive limb exercises in bed first 852 Brief Weight Bear (WB) pivot transfer on land from week 12 Ambulation from week 14

Routine Intensive care physiotherapy including passive calf stretches limb ROM exercises splints tilt table and sitting out of bed in chair

15 hours of land intervention on days 12 and 3 Half hour on days 4-7 Including therapeutic exercise bed mobility transfergait stairstanding balance and family training Frequency repssets documented in table format

Outcomes Strength gait speed and functional ability

Self-perceived Pain stiffness function


Baclofen intake spasm severity function

Mobility Pain muscle strength walking endurance Single Leg Stancce (SLS)

Anecdotal limb range of motion muscle size strength psychological well-being functional improvement in water towards supported standing and walking postures

Range of motion (ROM) strength girth and pain








Outcome Measures Used

Hand-held dynamometry (HHD) 10m walk test WOMAC index

WOMAC WOMAC Functional Independence Measure (FIM) Scores Ashworth Scores-weekly

Pediatric Evaluation of Disability Inventory (PEDI) Functional Skills (FS) Mobility scaled score PEDI mobility caregiver assistance (CA) scaled score Manual Muscle testing (MMT) Numerical pain Scale (NPS)

NA Manual Muscle Break Test Verbal Pain Scale 0-10 Functional Assessment Girth

Main Outcome

Significantly greater hip abduction strength after aquatic physiotherapy than additional ward treatment or water exercise No other outcomes clinically significant but positive trends favouring aquatic group

HTG better treatment than land-Kinesis since pain stiffness and function were significantly lower than for non-hydrotherapy group (NHTG) Results are maintained for 6 months post operative (op)

HTG better treatment than land-Kinesis since pain stiffness and function were significantly lower than for NHTG Results are maintained for 6 months post op

Statistically significant results in hydrotherapy group compared to controls- reduced plasticity and oral baclofen dose increased FIM scores Small study numbers

Clinical improvement all re-tested areas Clinical significant improvement functional mobility MDC function pain strength wee1 to discharge Also improvements in activity initiation motivation attendance participation independence

Anecdotal uarr muscle sizestrengthfunction psychological benefit enjoymentmorale Progressed exercise regime Speculated uarr respiratory muscle function successful wean from ventilation Nil adverse outcomes

Steady functional improvement uarr right hip knee ankle ROM lower extremity (LE) strength standing balance Pain darr from 810 to 010 in water Remarkable improvement in girth measurements right versus left LE oedema








Assessment

Day 14 post op day 90 180 (not controlled)

WOMAC administered at admission discharge and telephone at 6 months


Weekly 1052 period

Week 1 Week 9 discharge

Intervention at 6 months into disease process Impressions Day 1 post immersion No further assessment

ROM muscle strength girth and functional assessment recorded on Day 1 and Day 7 Daily Pain verbal score recorded

Clinical Study implication

Early safe application of aquatic physiotherapy in post-operative population after joint arthroplasty for recovery of hip strength

Early implementation of aquatic exercise in TKA population Hydrotherapy is recommended after TKA in a geriatric population More focussed randomised studies warranted to clarify most suitable costeffective rehabilitation program

Early implementation of aquatic exercise in THA population More focussed randomised studies warranted to clarify most suitable costeffective rehabilitation program

Hydrotherapy as an adjunct to usual rehabilitation post SCI can improve function reduce spasticity severity and decrease medication dose -often associated with side effectsfatigue

Successful addition of aquatic physiotherapy to a rehabilitation programme at a paediatric hospital for children and adolescents with a variety of physical disabilities and orthopaedic restrictions

Hydrotherapy successfullysafely included as part of an exercise regimen in a medically stable mechanically ventilated Intensive Critical Care Unit (ICCU) patient Difficult to establish cost benefit with large staff numbers time demands equipment required vs potential to reduce length of stay (LOS)

Aquatic therapy (AT) important in the rehab of post op THA in acute setting No conclusion in effects of aquatic vs land intervention In geriatric population with comorbidities AT may be well tolerated less painful lead to earlier functional improvements and patient satisfaction compared to land therapy


2002 Geytenbeek 2008 Bartels et al 2009) In osteoarthritis gold level evidence supports

the use of aquatic therapy for short term slight improvement in pain and function (Bartels et al

2007) while benefits in disability strength range of motion pain flexibility balance well-

being cost-effectiveness heath status and quality of life are also demonstrated (Geytenbeek

2002 Geytenbeek 2008) Scientific grounds and evidence from outpatient studies support the

use of aquatic physiotherapy in post-surgical rehabilitation and orthopaedic injury (Ahlqvist

2002 Fappiano and Gangaway 2008 Watts and Gangaway 2007) It has been demonstrated

that aquatic intervention can facilitate early initiation of exercise improve self-reported pain

and function and contribute to greater range of motion strength proprioception and decreased

risk of further injury (Fappiano and Gangaway 2008 Watts and Gangaway 2007 McAvoy

2009) In anterior cruciate ligament (ACL) rehabilitation aquatic physiotherapy has been

attributed to reduced joint effusion and earlier gains in range of motion (McClintock and

Kirkley 1995 Tovin et al 1994) In a reduced weight bearing environment which minimises

joint stress it is likely that the physiological and thermal properties of water including

hydrostatic pressure and buoyancy effect enable early initiation of exercise and increased

activity tolerance

Limited evidence exists to support the use of aquatic physiotherapy in inpatient populations

including acute orthopaedic rehabilitation (Geytenbeek 2008) Land-based studies of

intensive rehabilitation programmes and additional physiotherapy in the hospital setting

clearly demonstrate a positive relationship between physiotherapy service and positive patient

outcomes Increased intensity and frequency of physiotherapy intervention has been shown to

benefit parameters of functional mobility and total hospital cost including discharge

destination and reduced length of stay (Boxall 2004 Freburger 2000 Kirk-Sanchez 2001

Lawson 2006 Moffet 2004 and Roach 1998 Weigl 2003) In the post-operative recovery of

high risk patients undergoing elective hip or knee arthroplasty early inpatient rehabilitation

(day 3 instead of 7) was well tolerated and contributed to earlier obtainment of functional

goals at less overall cost (Munin et al 1998) Considering that aquatic physiotherapy is

indicated where land based activity is contraindicated due to pain or acute injury (Babb and

Simelson-Warr 1994) it is possible that aquatic physiotherapy could be used as a substitute

for land-based rehabilitation The inpatient setting provides a unique opportunity to explore

the use of aquatic physiotherapy in hospital patients recovering from surgery injury illness or

disease This review of the literature aims to investigate what evidence exists to support the
































RESULTS





































population









DISCUSSION































































(Law et al 1998)
























































































CONCLUSION
































al 2009(b)











REFERENCES


1070-1071













Therapy 17(1) 16-21



Therapy 16(1) 10-15



21(1) 68-78



Therapy 80(5) 448-58













Wilkins pp 125-50



273
















Therapy 17(1) 8-15

























November 2010]











162














Therapy 15(1)19-26




279(11)880


Level










5




nothing






Taylor (2003)

Costa et al (2009)




















1 1


Yes

Yes Yes Yes Yes



Not discussed










Taylor (2003)

Costa et al (2009)








Yes No No No



No No







NA NA NA NA



Table 2 continued


PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period











































RESULTS





































population









DISCUSSION































































(Law et al 1998)
























































































CONCLUSION
































al 2009(b)











REFERENCES


1070-1071













Therapy 17(1) 16-21



Therapy 16(1) 10-15



21(1) 68-78



Therapy 80(5) 448-58













Wilkins pp 125-50



273
















Therapy 17(1) 8-15

























November 2010]











162














Therapy 15(1)19-26




279(11)880


Level










5




nothing






Taylor (2003)

Costa et al (2009)




















1 1


Yes

Yes Yes Yes Yes



Not discussed










Taylor (2003)

Costa et al (2009)








Yes No No No



No No







NA NA NA NA



Table 2 continued


PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period















RESULTS





































population









DISCUSSION































































(Law et al 1998)
























































































CONCLUSION
































al 2009(b)











REFERENCES


1070-1071













Therapy 17(1) 16-21



Therapy 16(1) 10-15



21(1) 68-78



Therapy 80(5) 448-58













Wilkins pp 125-50



273
















Therapy 17(1) 8-15

























November 2010]











162














Therapy 15(1)19-26




279(11)880


Level










5




nothing






Taylor (2003)

Costa et al (2009)




















1 1


Yes

Yes Yes Yes Yes



Not discussed










Taylor (2003)

Costa et al (2009)








Yes No No No



No No







NA NA NA NA



Table 2 continued


PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period





















population









DISCUSSION































































(Law et al 1998)
























































































CONCLUSION
































al 2009(b)











REFERENCES


1070-1071













Therapy 17(1) 16-21



Therapy 16(1) 10-15



21(1) 68-78



Therapy 80(5) 448-58













Wilkins pp 125-50



273
















Therapy 17(1) 8-15

























November 2010]











162














Therapy 15(1)19-26




279(11)880


Level










5




nothing






Taylor (2003)

Costa et al (2009)




















1 1


Yes

Yes Yes Yes Yes



Not discussed










Taylor (2003)

Costa et al (2009)








Yes No No No



No No







NA NA NA NA



Table 2 continued


PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period































































(Law et al 1998)
























































































CONCLUSION
































al 2009(b)











REFERENCES


1070-1071













Therapy 17(1) 16-21



Therapy 16(1) 10-15



21(1) 68-78



Therapy 80(5) 448-58













Wilkins pp 125-50



273
















Therapy 17(1) 8-15

























November 2010]











162














Therapy 15(1)19-26




279(11)880


Level










5




nothing






Taylor (2003)

Costa et al (2009)




















1 1


Yes

Yes Yes Yes Yes



Not discussed










Taylor (2003)

Costa et al (2009)








Yes No No No



No No







NA NA NA NA



Table 2 continued


PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period































(Law et al 1998)
























































































CONCLUSION
































al 2009(b)











REFERENCES


1070-1071













Therapy 17(1) 16-21



Therapy 16(1) 10-15



21(1) 68-78



Therapy 80(5) 448-58













Wilkins pp 125-50



273
















Therapy 17(1) 8-15

























November 2010]











162














Therapy 15(1)19-26




279(11)880


Level










5




nothing






Taylor (2003)

Costa et al (2009)




















1 1


Yes

Yes Yes Yes Yes



Not discussed










Taylor (2003)

Costa et al (2009)








Yes No No No



No No







NA NA NA NA



Table 2 continued


PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period





















































































CONCLUSION
































al 2009(b)











REFERENCES


1070-1071













Therapy 17(1) 16-21



Therapy 16(1) 10-15



21(1) 68-78



Therapy 80(5) 448-58













Wilkins pp 125-50



273
















Therapy 17(1) 8-15

























November 2010]











162














Therapy 15(1)19-26




279(11)880


Level










5




nothing






Taylor (2003)

Costa et al (2009)




















1 1


Yes

Yes Yes Yes Yes



Not discussed










Taylor (2003)

Costa et al (2009)








Yes No No No



No No







NA NA NA NA



Table 2 continued


PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period




















































CONCLUSION
































al 2009(b)











REFERENCES


1070-1071













Therapy 17(1) 16-21



Therapy 16(1) 10-15



21(1) 68-78



Therapy 80(5) 448-58













Wilkins pp 125-50



273
















Therapy 17(1) 8-15

























November 2010]











162














Therapy 15(1)19-26




279(11)880


Level










5




nothing






Taylor (2003)

Costa et al (2009)




















1 1


Yes

Yes Yes Yes Yes



Not discussed










Taylor (2003)

Costa et al (2009)








Yes No No No



No No







NA NA NA NA



Table 2 continued


PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period




















CONCLUSION
































al 2009(b)











REFERENCES


1070-1071













Therapy 17(1) 16-21



Therapy 16(1) 10-15



21(1) 68-78



Therapy 80(5) 448-58













Wilkins pp 125-50



273
















Therapy 17(1) 8-15

























November 2010]











162














Therapy 15(1)19-26




279(11)880


Level










5




nothing






Taylor (2003)

Costa et al (2009)




















1 1


Yes

Yes Yes Yes Yes



Not discussed










Taylor (2003)

Costa et al (2009)








Yes No No No



No No







NA NA NA NA



Table 2 continued


PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period




















al 2009(b)











REFERENCES


1070-1071













Therapy 17(1) 16-21



Therapy 16(1) 10-15



21(1) 68-78



Therapy 80(5) 448-58













Wilkins pp 125-50



273
















Therapy 17(1) 8-15

























November 2010]











162














Therapy 15(1)19-26




279(11)880


Level










5




nothing






Taylor (2003)

Costa et al (2009)




















1 1


Yes

Yes Yes Yes Yes



Not discussed










Taylor (2003)

Costa et al (2009)








Yes No No No



No No







NA NA NA NA



Table 2 continued


PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period













REFERENCES


1070-1071













Therapy 17(1) 16-21



Therapy 16(1) 10-15



21(1) 68-78



Therapy 80(5) 448-58













Wilkins pp 125-50



273
















Therapy 17(1) 8-15

























November 2010]











162














Therapy 15(1)19-26




279(11)880


Level










5




nothing






Taylor (2003)

Costa et al (2009)




















1 1


Yes

Yes Yes Yes Yes



Not discussed










Taylor (2003)

Costa et al (2009)








Yes No No No



No No







NA NA NA NA



Table 2 continued


PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period
























Wilkins pp 125-50



273
















Therapy 17(1) 8-15

























November 2010]











162














Therapy 15(1)19-26




279(11)880


Level










5




nothing






Taylor (2003)

Costa et al (2009)




















1 1


Yes

Yes Yes Yes Yes



Not discussed










Taylor (2003)

Costa et al (2009)








Yes No No No



No No







NA NA NA NA



Table 2 continued


PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period





















Therapy 17(1) 8-15

























November 2010]











162














Therapy 15(1)19-26




279(11)880


Level










5




nothing






Taylor (2003)

Costa et al (2009)




















1 1


Yes

Yes Yes Yes Yes



Not discussed










Taylor (2003)

Costa et al (2009)








Yes No No No



No No







NA NA NA NA



Table 2 continued


PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period



















November 2010]











162














Therapy 15(1)19-26




279(11)880


Level










5




nothing






Taylor (2003)

Costa et al (2009)




















1 1


Yes

Yes Yes Yes Yes



Not discussed










Taylor (2003)

Costa et al (2009)








Yes No No No



No No







NA NA NA NA



Table 2 continued


PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period


















Therapy 15(1)19-26




279(11)880


Level










5




nothing






Taylor (2003)

Costa et al (2009)




















1 1


Yes

Yes Yes Yes Yes



Not discussed










Taylor (2003)

Costa et al (2009)








Yes No No No



No No







NA NA NA NA



Table 2 continued


PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period













nothing






Taylor (2003)

Costa et al (2009)




















1 1


Yes

Yes Yes Yes Yes



Not discussed










Taylor (2003)

Costa et al (2009)








Yes No No No



No No







NA NA NA NA



Table 2 continued


PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period


















Taylor (2003)

Costa et al (2009)








Yes No No No



No No







NA NA NA NA



Table 2 continued


PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period













PEDro SCALE 10












(WOMAC)


Yes



No No No No


Yes Yes Yes No


No No Yes Yes


Yes No No Yes


Yes Yes Yes Yes




Yes

SCORE 710 510 610 510









Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period



















Type of Patient















































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period










































Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period



















Land physiotherapy



























Main Outcome















Assessment




Weekly 1052 period
























Main Outcome















Assessment




Weekly 1052 period



















Assessment




Weekly 1052 period












Documents

AQUATIC PHYSIOTHERAPY IN THE INPATIENT SETTING · Aquatic Physiotherapy in the Inpatient Setting Sarah Guille 2002, Geytenbeek 2008, Bartels et al 2009). In osteoarthritis, gold level