514-529geytenbeek 21/8/02 4:15 pm Page 514

514 Key Words , systematic review, evidence-based research, critical appraisal.

by Jenny Geytenbeek Evidence for Effective Hydrotherapy

Summary Purpose The purpose of this study was to search for, appraise the quality of and collate the research evidence Background and Purpose supporting the clinical effectiveness of hydrotherapy. Hydrotherapy practice in physiotherapy has developed from a scientific basis of Method A systematic search of literature was performed hydrodynamic theory. An understanding using ten medical and allied health databases from which of the physical properties of water and the studies relevant to physiotherapeutic hydrotherapy practice physiology of human immersion, coupled were retrieved. Patient trials were critically appraised for with skills to analyse human movement, have helped physiotherapists in using research merit using recognised published guidelines and the hydrotherapy as a tool for facilitating results were collated into clinical, functional and affective movement and restoring function. outcomes for the investigated populations. Although there is a large body of anecdotal evidence, many hypothesised Results Seventeen randomised control trials, two case- benefits remain to be proven with control studies, 12 cohort studies and two case reports were rigorous research designed with minimal sources of bias (McIlveen and Robertson, included in the appraisal. Two trials achieved appraisal scores 1998). Expert opinion and clinical indicating high quality evidence in a subjectively evaluated experience alone do not confirm the merit categorisation. Fifteen studies were deemed to provide effectiveness of treatment (Bithell, 2000), moderate quality evidence for the effectiveness of but combined with clinical reasoning and hydrotherapy. evidence-based research, clinicians, patients and healthcare funders will be better assured of effective hydrotherapy Discussion Flaws in study design and reporting attenuated (Goldby and Scott, 1993; Wakefield, the strength of the research evidence. Recommendations 2000). In compiling their extensive 1997 were made for the future direction of clinical hydrotherapy text entitled Aquatic Rehabilitation, Ruoti research. Randomised controlled trials with larger sample et al commented that their ‘review of sizes, assessor blinding and the use of validated and reliable literature revealed a scarcity of studies outcome measures in subjects with neurological conditions dealing with specific pathologies and functional outcomes’. The evidence for and acute orthopaedic injuries are particularly required. effective ‘ exercise’ was specifically excluded by the Philadelphia Conclusion The balance of high to moderate quality Panel (2001) in developing its evidence- evidence supported benefit from hydrotherapy in pain, based clinical practice guidelines for function, self-efficacy and affect, joint mobility, strength, and the management of low back, cervical, balance, particularly among older adults, subjects with shoulder and knee pain; suggesting the intervention to be of infrequent use rheumatic conditions and chronic low back pain. despite its anecdotal popularity with patients. The purpose of this study was to identify and critically appraise clinical trials of physiotherapeutic hydrotherapy for research merit. The clinical effectiveness Geytenbeek, J (2002). ‘Evidence for effective hydrotherapy’, and outcomes attributable to hydro- Physiotherapy, 88, 9, 514-529. are also examined.

Physiotherapy September 2002/vol 88/no 9 514-529geytenbeek 21/8/02 4:15 pm Page 515

Review 515

Table 1: Levels of evidence professional exercise instruction towards Author achieving therapeutic, rehabilitative or Level of Study design Jenny Geytenbeek evidence habilitative goals in neurological, BAppSc (Physio) musculoskeletal and/or cardiovascular MPhysio (Manipulative) I Systematic review of randomised function were targeted. CertHydro MAPA is a controlled trials The level of evidence provided by the private practitioner in II Randomised controlled trials trial design was identified in accordance Adelaide, Australia. III-1 Pseudo-randomised controlled trials with those described by the National (alternate allocation or some other method) Health and Medical Research Council of This research project III-2 Comparative studies with concurrent Australia (NHMRC, 2000) which recog- was undertaken in controls and allocation is not nises the potential for trial design flaws to partial fulfilment of randomised, cohort studies, case-control introduce biases that may confound the award of Master of studies, or interrupted time series with results and compromise the strength Physiotherapy at the a control group of evidence. Randomised controlled University of South III-3 Comparative study with historical Australia in 2000. control group, two or more single arm trials were appraised for research merit studies, or interrupted time series using the ten-point scale of the Physio- without a parallel control group therapy Evidence Database (PEDro) This article was IV Case-series, either post-test or (http://ptwww.cchs.usyd.edu.au/pedro) received by pre-test/post-test (Sherrington et al, 2000). One point Physiotherapy on Adapted from NHMRC (2000) is awarded for each of the following: May 4, 2001, random allocation to groups, concealed and accepted on allocation to groups, similarity of March 1, 2002. Method measures between groups at baseline, A search strategy was developed to subject blinding, therapist blinding, identify published clinical trials in assessor blinding, complete data hydrotherapy. Anecdotal, expert and collection from more than 85% of Address for clinical opinions were excluded in subjects, intention-to-treat analysis, Correspondence preference to more sophisticated evid- provision of statistics showing between- Ms J Geytenbeek, ence of controlled trials and cohort group differences, and reporting of both PO Box 6, studies with greater potential to provide point measures and the variability, or Cudlee Creek, minimal sources of bias in accordance range, of those measures. The PEDro South Australia 5232. with the ‘hierarchy of evidence’ (Lloyd- scale includes the three items that have E-mail: Smith, 1997). been shown to predict bias in clinical [email protected] Allied health, medical, nursing and trials – concealed allocation to groups, sports science databases were accessed blinding, and adequacy of follow-up including Medline, CINAHL, Current (Moher et al, 1999, cited by Moseley et al, Contents, AMED, EMBASE, the Exp- 2002). The validity of the scale has been anded Academic ASAP, SportsDiscuss, described by Moseley et al (2002). Where PEDro, the Cochrane Library and trials were previously reviewed, scored Ageline. The terms ‘hydrotherapy’, and listed on PEDro, trials were appraised ‘’, ‘aquatic physiotherapy’ blindly, and the scores later compared. and ‘water exercise’ were applied to Scores concurred in all but one case. journal article titles, abstracts and key Case-control and cohort studies were words in the electronic databases. appraised against the observational study Searches covered literature from 1980 to criteria recommended by Crombie October 2001, but were limited to (1996). Parameters included reporting of publications in English. Terms commonly subject eligibility, appropriateness of not captured under the keyword ‘hydro- using a control group, clearly stated aims, therapy’ within the databases but the selection of a study design excluded from this literature search were appropriate for the aims, justification of colonic irrigation, water birth, Kneipp sample size, likelihood of reliable and therapy, therapy, whirlpool therapy, valid measures, omission of relevant immersion in water, contrast baths and outcome measures, adequate description balneology. Trials investigating only of statistical methods, reporting of the physiological responses of subjects occurrence of untoward events, adequate immersed in or exercising in water were description of the data, assessment of also excluded (for example, heart rate, statistical significance, potential for blood pressure, aerobic capacity and renal confounding influences, interpretation function). Thus, hydrotherapy trials with of null findings, comparison of results

Physiotherapy September 2002/vol 88/no 9 514-529geytenbeek 21/8/02 4:15 pm Page 516

516

Table 2: Merit categories

PEDro scores Scores for Scores for pre-test/ Scores for case for randomised case-control studies post-test reports control trials cohort studies (maximum 8/10)* (maximum 18/18) (maximum 19/19)

Level of evidence II to III-1 III-2 III-3 to IV - High quality 7 to 10 Not awarded Not awarded Not awarded Moderate quality 5 to 6 14 to 18 14 to 19 Not awarded Poor quality 0 to 4 10 to 13 10 to 13 Not awarded Very poor quality Not awarded 0 to 9 0 to 9 Awarded to all

* Subject and therapist blinding not possible in hydrotherapy trials

against previous reports, and implications Table 3: Investigated populations for clinical practice. Trials were scored Investigated Number Number twice, at least two months apart, and the population of of average taken of the two scores. Repeat trials subjects scores did not vary by more than two points. 3 280 Case reports were not scored as they Rheumatic diseases 3 83 were considered to provide a very poor Rheumatoid and osteo-arthritis 2 57 level of evidence with a broad scope for Hip osteo-arthritis 2 61 bias. They were included in this review as Fibromyalgia 2 124 a reflection of clinical practice. Ankylosing spondylitis 3 218 Not all appraisal scoring items were Older adults 7 419 considered of equal importance. Equal Low back pain 7 366 scores on the different scales would not Multiple sclerosis 2 14 necessarily reflect equivalent merit. Based Late poliomyelitis 1 30 upon subjective evaluation of the ACL reconstruction 1 20 perceived importance of scale items and Complex regional the strength of trial-types, merit categories pain syndrome 1 103 were devised to describe the strength of Totals 34 1775 evidence that could be yielded from the Average sample size 52.2 trial (table 2). PEDro scores of five or Range of sample sizes 1 to 140 more were noted to reflect moderate to high quality evidence according to Moseley et al (2002). Only randomised along with two case-controlled trials (type controlled trials were considered to III-2), 12 pretest/post-test cohort studies provide potential for high quality (type IV) and two case reports. evidence, while very high scores for case- The most investigated subjects, controlled and cohort studies could represented in 15 trials, were those with receive no higher merit than moderate rheumatic conditions including osteo-, quality. psoriatic and rheumatoid arthritis, Following critical appraisal for research ankylosing spondylitis, fibromyalgia, merit, the outcome measures of all trials scleroderma and systemic lupus were collated. The effectiveness of erythematosis. Other populations in- hydrotherapy on each measure was noted cluded older adults, subjects with low and cross-referenced with the merit of the back pain, multiple sclerosis, complex trial. regional pain syndrome, late poliomyelitis and one study specifying patients being Results rehabilitated after anterior cruciate More than 500 journal articles were ligament reconstruction (table 3). identified from the databases using the Table 4 summarises attributes of the specified keywords and terms of trial design, populations, sample sizes, exclusion. Journal articles were manually control groups, appraisal scores and merit screened for their trial type and relevance categorisation. to this review. Seventeen randomised Two trials achieved the merit of high controlled trials (type II) were included quality. Fifteen trials were deemed to

Physiotherapy September 2002/vol 88/no 9 514-529geytenbeek 21/8/02 4:15 pm Page 517

Review 517 Poor Poor Poor Poor Poor Poor Poor Poor Poor ry poor High High Merit ery poor ery poor ery poor e ery poor ery poor ery poor ery poor category V V V V V V V V Moderate Moderate Moderate Moderate Moderate Moderate Moderate Moderate Moderate Moderate Moderate Moderate Moderate Moderate Moderate f I I I I I I I I I I I I I I I I I I o V V V V V V V – – I I I I I I I I I I I I I I I I I I I I I I IV IV I IV IV IV I I Level III-2 III-2 evidence – – score 3/10 3/19 5/10 5/19 6/10 7/10 4/10 4/10 5/10 4/19 6/19 7/10 4/19 4/10 5/10 4/10 5/10 5/10 5/10 5/10 6/10 7/19 6/10 4/10 9/19 15/18 14/19 14/19 10/19 15/19 11/18 11/19 Appraisal s s s s s s s s s s s s o o o o o o o o o e es e es e es es e e e es e e es e e e e on N N N No N N No No N N No No N No N No Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Reported reliability - s s es es es e es es e Y Y Y Y Y Y Y Cointer ventions s s s s e e es es e e es es es es – – – – – – – – – – – – – – – – – – – – – – – – Y Y Y Y Y Y Y Y Y Y Assessor blinding 0 0 2 8 9 1 8 9 0 4 2 0 4 7 4 4 * 2 24 13 14 18 11 0* 15 18 0* 10 0* 16 0* 13 0* 10 5 0 outs Drop- – – – – – – – – – – – – – – 8 7 8 22 53 32 13 15 68 37 10 10 30 22 12 12 size 23+ group Control 14,15 35,35,35 13,13,13 1 1 1 1 5 1 4 0 7 3 9 8 7 3 0 size 22 8 5 56 37 15 4 3 15 15 67 7 36 35 5 9 10 1 3 17 13 30 1 23 27 12 22 2 group 103 24+ Intervention roup g Control – Untreated – – Untreated symptomatic Untreated symptomatic – – Untreated, age and sex matched – Untreated symptomatic – Symptomatic, alternative intervention Symptomatic, alternative intervention – – Age matched, alternative intervention Symptomatic, alternative intervention, and sham Symptomatic, alternative intervention – – Untreated symptomatic Symptomatic, alternative intervention – Symptomatic, alternative intervention Symptomatic, alternative intervention Untreated symptomatic Untreated, age and sex matched – Age matched, alternative interventions and sham Untreate symptomatic Symptomatic, alternative intervention Untreated symptomatic – s s s s s s s s s s s s s s s s s e e e e e e e e e e e e e e e e e No No No No No No No No No No No No No No No No No trial Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Randomised roup G diagnosis lder adults lder adults heumatoid and ow back pain Older adults Multiple sclerosis Low back pain O Low back pain Fibromyalgia Low back pain O Rheumatic diseases Late poliomyelitis Older adults Low back pain Ankylosing spondylitis Ankylosing spondylitis Older adults L Older adults Rheumatoid arthritis ACL reconstruction Rheumatic diseases Rheumatic diseases Fibromyalgia Hip osteo-arthritis osteo-arthritis Rheumatoid and Hip osteo-arthritis Low back pain Rheumatoid arthritis Low back pain Multiple sclerosis syndrome Older adults Ankylosing spondylitis osteo-arthritis Complex regional pain Rheumatoid arthritis R atanabe eiss able 4: Appraisal summary ovin empleton Peterson Ruoti Roberts Rissel McIlveen Mannerkorpi Lorenzetti Lord Lineker * inferred to be nil LeFort Willen Whitlatch Langridge W Hidding W Helliwell T Hall T Sylvester Green Suomi Smit Gowans (b) Sjogren Gowans (a) Simmons Samsoe Gehlsen Sherry Danneskiold- Bulstrode of trial T Primary Ahern Sandford Smith author

Physiotherapy September 2002/vol 88/no 9 514-529geytenbeek 21/8/02 4:15 pm Page 518

518

provide moderate quality evidence, nine size, even of the more popular outcome were of poor quality and eight were very measures, as it was considered the poor. investigated samples lacked homogeneity The investigated outcomes fell broadly and the intervention was not applied into measures of pain, strength, flexibility, consistently in all trials. functional ability and self-efficacy and Figure 2, which represents only the affect. Figure 1 portrays the number of outcome measures from high and trials of each merit category that moderate quality trials, and the investigated each type of outcome. The appendices may provide readers and appendices summarise the effect of clinicians with insight to the number and hydrotherapy on each outcome measure types of outcome measures researchers selected by researchers. Where have claimed to be effected by researchers concluded a positive effect hydrotherapy. was yielded by the hydrotherapy Eighteen of the 34 trials in this review treatment a + was ascribed in contrast to measured the effect of hydrotherapy on no effect, or no significant effect, which pain. Ten of these were considered to was noted with 0. Not all authors stated provide high to moderate quality evid- the size or the achievement of statistical ence with all but one outcome measure significance for the effects, although failing to record a positive effect. generally, those of poor and very poor Eighteen trials investigated the effect on merit were the most contestable. It was joint mobility with 11 of these providing not possible to summate the actual effect high to moderate quality evidence. More than half of the joint mobility outcome measures in the high to 10 moderate quality trials showed a positive High effect from hydrotherapy. 8 Moderate Poor Six of the 13 trials that assessed the Very poor effect of hydrotherapy on strength were 6 of moderate quality, while one trial was of high quality, with all the outcome

4 measures of these quality trials yielding a beneficial effect. Number of trials Ten out of the 14 trials that examined 2 the effect of hydrotherapy on function were of moderate quality, two were of 0 high quality, and 22 out of 25 functional Pain Function Self-efficacy Strength Joint Balance Other and affect mobility outcome measures yielded a positive result. Fig 1: Number of trials investigatingCt categorical f t outcomes Thirteen trials selected measures of self- efficacy or affect with six of these being of moderate and one of high quality. 30 Insignificant effect '0' Positive effect '+' Eleven of the 14 outcome measures d used by these high to moderate quality 25 trials demonstrated a beneficial effect of hydrotherapy on self-efficacy and affect. 20 Other positive outcomes from high to moderate quality trials included 15 indicators of balance, measures of fitness, medication use and neurological signs. 10 outcome measures investigate f Discussion er o

b The balance of evidence from high to 5 moderate quality trials indicates that Num hydrotherapy offers benefit toward 0 Pain Function Self-efficacy Strength Joint Balance Other improving pain, strength, flexibility, and affect mobility function, self-efficacy and affect, and Category of outcome measures with a lesser representation, balance Fig 2: Hydrotherapy effect on outcome measures in high and moderate and fitness, in patients with generally quality trials chronic conditions such as rheumatic

Physiotherapy September 2002/vol 88/no 9 514-529geytenbeek 21/8/02 4:15 pm Page 519

Review 519

diseases and hip osteo-arthritis, chronic physiotherapy practice of constantly low back pain, and among elderly people. reassessing the patients’ responsive Hydrotherapeutic rehabilitation in neuro- movement in water, facilitation of optimal logical conditions, such as multiple exercise performance and consequent sclerosis, traumatic brain injury, stroke, adjustment in technique. paediatric neurology, and rehabilitation Hands-on techniques like Bad Ragaz, from acute orthopaedic injury have Halliwick or passive joint mobilisation received little attention from researchers (Shepherd and Mickel, 1998), or place- to date. ment and adjustment of assistive and In asking the question ‘Is hydrotherapy resistive devices, were thus generally not effective?’ one must consider what is included in the repertoire of hydro- hydrotherapy, for whom it might be therapy exercises in the trials of this review. effective, and how effectiveness is det- It was not possible to determine the ermined. Synonymous key words of benefit of individually conducted ‘aquatic physiotherapy’, ‘aquatic therapy’ hydrotherapy over hydrotherapy con- and ‘water exercise’ were applied to ducted in a group or class format where the databases in an attempt to extract all participants performed the same evidence of efficacious physiotherapeutic exercises, nor where patients performed hydrotherapy practice. prescribed exercises unsupervised. These Although eligibility criteria were are important distinctions worthy of specified in the selected trials, eligibility future analysis to determine both cost- was usually determined by diagnosis, not effectiveness of the treatment and prof- clinical signs and symptoms. It was essional expertise. Hidding et al (1993) impossible to glean the impact of phys- investigated supervised exercise regimes iotherapists’ assessment skills and their against an unsupervised regime of home- appropriateness for matching patients based exercises, but not unsupervised with the hydrotherapy exercise medium pool-based exercise. Nevertheless, they and exercise selection. concluded the effect was superior with Not all hydrotherapy trials in this review supervision. were conducted by physiotherapists. Also pertinent to cost and benefit, the Other professionals apparently involved frequency and duration of hydrother- in the trials included physical educators, apy were not explicitly investigated. exercise scientists, personal trainers, Researchers failed to argue their choices nurses and chiropractors. It was deemed of treatment frequency or duration. The that the exercises used by other pract- length of treatment ranged from four itioners were also those that physiother- days (Ahern et al, 1995, phase 1) to 36 apists might include in their rehab- weeks (Hidding et al, 1993), with an ilitation programmes. average of 9.9 weeks. The frequency of In terms of professional accountability treatment ranged from daily to weekly and market-place niche, it was not with an average of 2.6 times per week. possible to assess better outcomes from Half of the trials (17 out of 34) were physiotherapists’ over other practitioners’ awarded moderate to high quality (table water-based exercise programmes. 4) which compares with the appraisal Research protocol usually imposed scoring and merit categorisation claimed standardisation of the hydrotherapy for other physiotherapy trials. Moseley et intervention under investigation. In the al (2001) reported that 52% of the 2,376 majority of trials it appeared that all randomised controlled trials conducted subjects within each trial received the across all areas of physiotherapy listed on same programme of exercises. Exercise the Physiotherapy Evidence Database programme content was not audited in were of moderate to high quality, rating this review; in fact it was sometimes five or more on the PEDro scale. omitted from the reports or poorly Uncontrolled trials (type IV) cannot described. Replicating the various truly attribute any observed changes to treatment regimes would be challenging the intervention. However, pre-test/post- from most reported exercise descriptions. test measurements in cohort trial designs The imposition of standardised inter- may accommodate the ethical dilemma vention may well have detracted from of withholding treatment from some the potential to demonstrate effective patients – the would-be control subjects. hydrotherapy in suppressing interactive Failing to control these trials should not

Physiotherapy September 2002/vol 88/no 9 514-529geytenbeek 21/8/02 4:15 pm Page 520

520

altogether devalue the research claims, from immersion (Simmons and Hansen, rather, they can be acknowledged as 1996; Hidding et al, 1993). Outcome providing supportive, albeit contestable, measures of the control groups evidence as subjects may have improved undergoing the sham treatments did not over time regardless of treatment. improve in either trial. Appraisal and scoring of the type IV trials Potential confounding influences were with Crombie’s list (1996) was more present in all trials. No randomised variable, and more prone to value- controlled trial scored more than seven judgements than scoring with PEDro. out of 11 on the PEDro Scale. No trial However, nine of the 12 type IV trials in specified whether the allocation to this review were deemed to provide ‘poor’ treatment and control groups was to ‘very poor’ quality evidence (table 4). concealed from the investigators Seven trials included hydrotherapy (‘concealed allocation’). This criterion treatment with other modalities, perhaps ensures against selection bias where those replicating clinical practice, but confusing allocated to the intervention group might the interpretation of results from either be chosen, consciously or unconsciously, modality. Co-interventions included because they are expected to do well. concurrent home exercise programmes Only 16% of all PEDro listed trials have (Le Fort and Hannah, 1994; Hidding et al, satisfied this criterion (Moseley et al, 1993; Green et al, 1993), a supervised 2002). Only 12% of all PEDro listed trials gym programme (Hidding et al, 1993), have reported on ‘intention-to-treat weight training (Le Fort and Hannah, analysis’. That is, researchers needed to 1994), aerobic and functional exercise state that all subjects received the programmes (Sherry et al, 1999), super- intended treatment protocol, or, where vised therapeutic exercises (Peterson, violations occurred, these were reported 2001), an education programme in- and demonstrated not to prejudice the cluding understanding long-term pain results. Only one trial in this review and strategies to cope with pain (Manner- satisfied this criterion (Hidding et al, korpi et al, 2000) and chiropractic 1993). manipulation with electrical muscle It was not possible to award points for stimulation to relieve pain (Lorenzetti, the blinding of subjects or therapists. By 1999). the nature of exercise-based intervention, Alternative interventions were applied all subjects knew they were undergoing to the control groups of ten type II trials hydrotherapy and all therapists knew what including home exercises (Green et al, intervention was being applied and to 1993), supervised land-based exercises whom. Subjects may show improvements (Watanabe et al, 2000; Sandford Smith et in their conditions simply because they al, 1998; Sjogren et al, 1997; Hall et al, know they are receiving ‘special 1996; Helliwell et al, 1996; Simmons and treatment’, a phenomenon known as the Hansen, 1996; Hidding et al, 1994; Tovin Hawthorne effect (Polgar and Thomas, et al, 1994), supervised sporting activities 2000). Therapists may have instructed (Hidding et al, 1994), progressive subjects in the intervention group relaxation (Hall et al, 1996), supervised differently. While subject and therapist socialisation (playing cards) (Simmons blinding are practicable in drug trials and and Hansen, 1996), and short-wave some physiotherapy trials, (Sylvester, 1989). such is not the case in hydrotherapy trials Hydrotherapy effect was then compared (Moseley et al, 2001). Assessor blinding to the alternative intervention, either of then becomes paramount in hydro- which may be beneficial, but the actual therapy trials to minimise bias where it is effect-size of one of the interventions expected by all that the treated group will possibly blurred in the statistics. That is, perform better. improvements were often measured in Appropriate sample size is not scored both the hydrotherapy group and the on the PEDro scale. Among the studies supervised land-based exercise group, and reviewed, sample size varied from one in occasionally the hydrotherapy group the two case reports (Lorenzetti, 1999; improved significantly more. Sham Peterson, 2001) to 140 (Hall et al, 1996). ‘treatments’ of ‘seated immersion’ were with an average of 52.2 (table 3). included in two trials in an attempt to Obviously, larger samples will have greater distract the effect of warm water exercise power to strengthen research findings.

Physiotherapy September 2002/vol 88/no 9 514-529geytenbeek 21/8/02 4:15 pm Page 521

Review 521

Yet with a relative sparsity of hydrother- merit, and summarising pooled results. apy researchers, the convenience and Critical appraisal by panels of experts expedience afforded in smaller trials such as the Philadelphia Panel (2001) and should not obviate their contribution independent scoring as is the protocol of to the pool of evidence for effective the Physiotherapy Evidence Database, hydrotherapy. Rather, consumers of tempers subjectivity. Systematic review research knowledge must bear this and critical appraisal can occur only after potential confounder in mind in clinical trials have been conducted; a accepting claims of hydrotherapy effect- lengthy process. However, in daily clinical iveness or rejecting an outcome measure- practice, physiotherapists need to draw on ment that fails to yield significant effect. their experiential knowledge and the Appropriate demonstration of validity available research evidence in a critical of measures, reliability of measurement, manner, not always devoid of value and interpretation of results are judgements, to select treatments likely to fundamental issues in producing mean- be effective. Hydrotherapy is a treatment ingful evidence. Only half of the trials in worthy of consideration. this review reported on the reliability of their selected measures, either adequately Conclusion or inadequately. Several cited previously The body of evidence supporting the established reliability, some reported their effectiveness of physiotherapeutic own test-retest, inter-rater and intra-rater hydrotherapy is incomplete. This report reliability (see appendix). Generally, presents the evidence available at a more recent researchers in hydrotherapy specific time. More randomised cont- have adopted recognised and validated rolled trials of improved research merit, measurement tools. Hydrotherapeutic with reporting that defends design effect has been investigated with both self- choices and protocol, are required. assessment scales of pain, function and Neurological populations are under- affect, and more technical objective investigated. The benefit of hydrotherapy measuring instruments including in acute orthopaedic rehabilitation and dynamometry, electromyography (Kelly peripheral joint conditions also lack et al (2000), pedabarography and com- presence among the research evidence. puterised force platforms. Questions pertaining to the cost-benefit Critical appraisal is fundamentally of hydrotherapy remain to be answered, subjective from defining search terms to including the level of physiotherapy screening journal articles for inclusion or supervision, exercise selection, frequency exclusion, to scoring indefinite appraisal and duration of treatment, and sustained criteria, comparing trial types for merit, benefit following cessation of inter- combining trial types with appraisal scores vention. to rank trials into a descriptive category of

Key Messages Clinical evidence of a moderate and with older adults than in quality exists to support the populations with neurological effectiveness of hydrotherapy conditions or acute musculoskeletal treatment on pain, joint mobility, injuries. strength, function, self-efficacy, affect, fitness and balance. More randomised controlled trials with larger samples and conscientious Clinical trials of hydrotherapy have reporting of conduct minimising bias, been conducted more often in defending validity and reliability of populations with rheumatic measures will support assurance of conditions and chronic low back pain the effectiveness of hydrotherapy.

Physiotherapy September 2002/vol 88/no 9 514-529geytenbeek 21/8/02 4:15 pm Page 522

522

Appendix Merit of evidence determining hydrotherapy effect on outcomes

Outcome Reliability Hydro- Merit Level Group Primary measure of therapy category of diagnosis author measure effect evidence of trial

Pain Visual analogue scale of pain Not reported 0 Very poor – Low back pain Lorenzetti McGill pain questionnaire Not reported + High II Rheumatoid arthritis Hall Beliefs in pain control questionnaire Citation + High II Rheumatoid arthritis Hall Visual analogue scale of pain Test-retest + High II Ankylosing spondylitis Hidding Visual analogue scale of pain Not reported + Moderate II Hip osteo-arthritis Green Descriptive pain scale Not reported + Moderate II Hip osteo-arthritis Green Analgesic requirement Not reported + Moderate II Hip osteo-arthritis Green Multidimensional pain inventory Citation +1 Moderate II Fibromyalgia Mannerkorpi McGill pain questionnaire Citation 0 Moderate II Low back pain McIlveen Visual analogue scale of pain Not reported + Moderate II Low back pain Sjogren Visual analogue scale of pain Citation + Moderate II Hip osteo-arthritis Sylvester Visual analogue scale of pain Citation + Moderate III-2 Older adults Lord Pain rating index of McGill pain Citation + Moderate IV Low back pain LeFort questionnaire Visual analogue scale of pain Citation + Moderate IV Rheumatic diseases Lineker Numerical pain rating scale Citation + Moderate IV Rheumatic diseases Lineker Visual analogue scale of pain Inter-rater + Poor II Rheumatoid and Ahern osteo-arthritis Visual analogue scale of pain Test-retest + Poor II Ankylosing spondylitis Helliwell Pain drawing Not reported 0 Poor II Late poliomyelitis Willen Visual analogue scale of pain Citation 0 Poor II Late poliomyelitis Willen Nottingham health profile (pain) Not reported + Poor II Late poliomyelitis Willen Visual analogue scale of pain Citation + Poor IV Low back pain Smit Present pain level Not reported + Very poor IV Low back pain Langridge Pain area score Not reported + Very poor IV Low back pain Roberts Pain intensity score Not reported + Very poor IV Low back pain Roberts Verbal and visual analogue Not reported + Very poor IV Complex regional pain Sherry pain scales syndrome 1-6 pain scale Not reported + Very poor IV Older adults Whitlatch

Function Arthritis impact measurement scales –2 Citation + High II Rheumatoid arthritis Hall Functional index for ankylosing Test-retest + High II Ankylosing spondylitis Hidding spondylitis Health assessment questionnaire for Test-retest + High II Ankylosing spondylitis Hidding spondyloarthropathies Sickness impact profile Test-retest + High II Ankylosing spondylitis Hidding Fibromyalgia impact questionnaire Not reported + Moderate II Fibromyalgia Gowans (a) Modified six-minute walk test Citation + Moderate II Fibromyalgia Gowans (a) Ability to rise from a chair Not reported + Moderate II Hip osteo-arthritis Green Time and number of steps to walk a Not reported + Moderate II Hip osteo-arthritis Green fixed distance Time taken to walk up and down a Not reported + Moderate II Hip osteo-arthritis Green fixed staircase rig Fibromyalgia impact questionnaire Not reported + Moderate II Fibromyalgia Mannerkorpi Six-minute walk test Not reported + Moderate II Fibromyalgia Mannerkorpi Oswestry low back pain Citation + Moderate II Low back pain McIlveen questionnaire Standford health assessment Citation 0 Moderate II Rheumatoid arthritis Sandford Smith questionnaire

Physiotherapy September 2002/vol 88/no 9 514-529geytenbeek 21/8/02 4:15 pm Page 523

Review 523

Merit of evidence determining hydrotherapy effect on outcomes (continued)

Outcome Reliability Hydro- Merit Level Group Primary measure of therapy category of diagnosis author measure effect evidence of trial

Oswestry low back pain disability Not reported + Moderate II Low back pain Sjogren questionnaire Timed 100-metre walk test Test-retest + Moderate II Low back pain Sjogren Oswestry low back pain disability Not reported + Moderate II Low back pain Sylvester questionnaire Pedabarographic maximal vertical Not reported 0 Moderate II Hip osteo-arthritis Sylvester force during gait Pedabarographic stance time during Not reported 0 Moderate II Hip osteo-arthritis Sylvester gait Six-minute walk test Not reported + Moderate IV Rheumatic diseases Gowans (b) Oswestry low back pain disability Test-retest + Moderate IV Low back pain LeFort questionnaire Arthritis impact measurement scales 2 Citation + Moderate IV Rheumatic diseases Lineker Medical outcomes short form 36 Citation + Moderate IV Rheumatic diseases Lineker Need for help from others Not reported + Moderate IV Rheumatic diseases Lineker Use of walking devices Not reported + Moderate IV Rheumatic diseases Lineker Western Ontario and McMaster Citation + Moderate IV Rheumatic diseases Lineker Universities osteo-arthritis index Time to climb four steps Inter-rater + Poor II Rheumatoid and Ahern osteo-arthritis Time to walk 25 m Inter-rater + Poor II Rheumatoid and Ahern osteo-arthritis Lyshom scale (functional Not reported + Poor II ACL reconstruction Tovin questionnaire) Physical activity scale for the elderly Not reported 0 Poor II Late poliomyelitis Willen Walking speed over 30 metres Not reported 0 Poor II Late poliomyelitis Willen Functional status index Citation + Poor IV Rheumatic diseases Templeton Patient evaluation conference system Citation + Very poor – Multiple sclerosis Peterson Change in ease of work Not reported + Very poor IV Low back pain Langridge Activities of daily living Not reported + Very poor IV Low back pain Roberts Verbal scale of dysfunction and Not reported + Very poor IV Complex regional pain Sherry observation of physical function syndrome Medical outcomes short form 36 Not reported 0 Very poor IV Older adults Whitlatch Walking speed over 3 minutes Not reported + Very poor IV Older adults Whitlatch

Self-efficacy and effort Arthritis impact measurement scales - 2 Citation + High II Rheumatoid arthritis Hall Arthritis self-efficacy questionnaire Not reported + Moderate II Fibromyalgia Gowans (a) Fibromyalgia impact questionnaire Not reported + Moderate II Fibromyalgia Gowans (a) Philadelphia (life satisfaction) Not reported 0 Moderate II Hip osteo-arthritis Sylvester questionnaire State/trait anxiety inventory Citation + Moderate II Older adults Watanabe Fibromyalgia impact questionnaire Not reported + Moderate II Fibromyalgia Mannerkorpi Short-form 36 (social functioning and Not reported + Moderate II Fibromyalgia Mannerkorpi general health) Arthritis self-efficacy scales Not reported 0 Moderate II Fibromyalgia Mannerkorpi Arthritis impact measurement scales Not reported + Moderate II Fibromyalgia Mannerkorpi (anxiety and depression) Quality of life questionnaire Not reported + Moderate II Fibromyalgia Mannerkorpi Rosenburg self-esteem scale Test-retest + Moderate IV Low back pain LeFort State/trait anxiety inventory Not reported + Moderate IV Low back pain LeFort Memorial University mood scale Not reported + Moderate IV Low back pain LeFort Centre for Epidemiological Studies Citation Not Moderate IV Rheumatic diseases Lineker Depression scale reported

Physiotherapy September 2002/vol 88/no 9 514-529geytenbeek 21/8/02 4:15 pm Page 524

524

Merit of evidence determining hydrotherapy effect on outcomes (continued)

Outcome Reliability Hydro- Merit Level Group Primary measure of therapy category of diagnosis author measure effect evidence of trial

Zung self-rating depression scale Not reported + Poor II Rheumatoid and Ahern osteo-arthritis Middlesex Hospital questionnaire Not reported Not Poor II Rheumatoid and Ahern reported osteo-arthritis Illness behaviour questionnaire Not reported 0 Poor II Rheumatoid and Ahern osteo-arthritis Arthritis self-efficacy questionnaire Not reported + Poor II Rheumatoid and Ahern osteo-arthritis Frenchay activities index Not reported 0 Poor II Rheumatoid and Ahern osteo-arthritis Nottingham health profile (part 1) Not reported 0 Poor II Late poliomyelitis Willen Visual analogue scale of quality of life Not reported + Very poor IV Low back pain Langridge Health and well being Not reported + Very poor IV Older adults Rissel Scale of affect Not reported + Very poor IV Older adults Rissel Affective questionnaire Not reported + Very poor IV Older adults Weiss Revised Oswestry questionnaire Not reported + Very poor – Low back pain Lorenzetti

Joint mobility Ritchie articular index (joint mobility) Citation + High II Rheumatoid arthritis Hall Duration of morning stiffness Not reported 0 High II Rheumatoid arthritis Hall Active range of wrist and knee flexion Not reported 0 High II Rheumatoid arthritis Hall and extension Thoracolumbar flexion-extension Test-retest + High II Ankylosing spondylitis Hidding Chest expansion Test-retest + High II Ankylosing spondylitis Hidding Cervical rotation Test-retest + High II Ankylosing spondylitis Hidding Visual analogue scale of stiffness Test-retest 0 High II Ankylosing spondylitis Hidding Hip flexion Test-retest 0 Moderate II Ankylosing spondylitis Bulstrode Hip extension with knee in extension Test-retest + Moderate II Ankylosing spondylitis Bulstrode Hip extension with knee in flexion Test-retest + Moderate II Ankylosing spondylitis Bulstrode Single hip abduction Test-retest + Moderate II Ankylosing spondylitis Bulstrode Bilateral hip abduction Test-retest + Moderate II Ankylosing spondylitis Bulstrode Medial rotation of the hip, lateral Test-retest + Moderate II Ankylosing spondylitis Bulstrode rotation of the hip Immobility, stiffness Not reported + Moderate II Hip osteo-arthritis Green Hip internal rotation Not reported + Moderate II Hip osteo-arthritis Green Flexion deformity Not reported + Moderate II Hip osteo-arthritis Green Goniometric active hip joint range Not reported + Moderate II Hip osteo-arthritis Green Shoulder range of motion: 0-4 scale Citation 0 Moderate II Fibromyalgia Mannerkorpi Range of active lumbar flexion – Citation 0 Moderate II Low back pain McIlveen Schober method Range of active lumbar extension Citation 0 Moderate II Low back pain McIlveen Duration of morning stiffness Not reported 0 Moderate II Rheumatoid arthritis Sandford Smith Schober’s test for thoracolumbar Intra-rater 0 Moderate II Low back pain Sjogren mobility Active range of hip abduction Not reported 0 Moderate II Hip osteo-arthritis Sylvester Passive ankle dorsiflexion Citation 0 Moderate III-2 Older adults Lord Visual analogue scale for stiffness Citation + Moderate IV Rheumatic diseases Lineker Visual analogue scale for flexibility Citation + Moderate IV Rheumatic diseases Lineker Morning stiffness Citation + Moderate IV Rheumatic diseases Lineker Pendulum goniometry of shoulder Inter-rater 0 Poor II Rheumatoid and Ahern flexion osteo-arthritis Spondylometry of lumbar flexion Inter-rater 0 Poor II Rheumatoid and Ahern osteo-arthritis

Physiotherapy September 2002/vol 88/no 9 514-529geytenbeek 21/8/02 4:15 pm Page 525

Review 525

Merit of evidence determining hydrotherapy effect on outcomes (continued)

Outcome Reliability Hydro- Merit Level Group Primary measure of therapy category of diagnosis author measure effect evidence of trial

Goniometric active and passive knee Inter-rater 0 Poor II Rheumatoid and Ahern flexion-extension osteo-arthritis Visual analogue scale of stiffness Inter-rater + Poor II Rheumatoid and Ahern osteo-arthritis Goniometric range of movement of Inter-rater 0 Poor II Rheumatoid and Ahern ‘target joints’ osteo-arthritis Supine cervical rotation Test-retest + Poor II Ankylosing spondylitis Helliwell Xiphisternal chest girth (expansion) Test-retest + Poor II Ankylosing spondylitis Helliwell Modified Schober’s test for lumbar Test-retest + Poor II Ankylosing spondylitis Helliwell movement Visual analogue scale of stiffness Test-retest + Poor II Ankylosing spondylitis Helliwell Joint laxity Inter-rater 0 Poor II ACL reconstruction Tovin Goniometric passive range of joint Inter-rater 0 Poor II ACL reconstruction Tovin motion – knee flexion Goniometric passive range of joint Inter-rater 0 Poor II ACL reconstruction Tovin motion – knee extension Thoracolumbar mobility Citation + Poor IV Low back pain Smit Goniometric joint range of motion Inter-rater + Poor IV Rheumatic diseases Templeton Range of movement Not reported + Very poor IV Low back pain Roberts Ranges of shoulder abduction and Not reported + Very poor IV Older adults Whitlatch hyper extension Range of hip flexion Not reported + Very poor IV Older adults Whitlatch

Strength Grip strength Not reported 0 High II Rheumatoid arthritis Hall Power extension maximum Not reported + Moderate II Hip osteo-arthritis Green Power abduction maximum Not reported + Moderate II Hip osteo-arthritis Green Power extension 90% Not reported + Moderate II Hip osteo-arthritis Green Power abduction fatigue Not reported + Moderate II Hip osteo-arthritis Green Power abduction fatigue rate Not reported + Moderate II Hip osteo-arthritis Green Endurance abduction work done Not reported + Moderate II Hip osteo-arthritis Green Endurance extension on target Not reported + Moderate II Hip osteo-arthritis Green Endurance flexion scored time Not reported + Moderate II Hip osteo-arthritis Green Muscle dynamometry – hip Not reported + Moderate II Hip osteo-arthritis Green Muscle dynamometry – hip Not reported + Moderate II Hip osteo-arthritis Green Chair test (lower limb endurance) Citation + Moderate II Fibromyalgia Mannerkorpi Grip strength endurance Citation + Moderate II Fibromyalgia Mannerkorpi Shoulder abductor Citation + Moderate II Fibromyalgia Mannerkorpi Grip strength Not reported + Moderate II Rheumatoid arthritis Sandford Smith Quadriceps strength Citation + Moderate III-2 Older adults Lord Ankle dorsiflexion strength Citation + Moderate III-2 Older adults Lord Total weights lifted Not reported + Moderate IV Low back pain LeFort Sphygmomanometric grip strength Inter-rater Not Poor II Rheumatoid and Ahern reported osteo-arthritis Endurance of shoulder musculature Not reported + Poor II Older adults Ruoti Isometric knee flexion at 85˚ Not reported 0 Poor II ACL reconstruction Tovin Isometric extension at 60˚ Not reported 0 Poor II ACL reconstruction Tovin Isokinetic knee extension through Not reported 0 Poor II ACL reconstruction Tovin 80˚-40˚ at 90˚/s Isokinetic knee flexion through Not reported + Poor II ACL reconstruction Tovin 0˚-70˚ at 90˚/s Thigh girth Inter-rater 0 Poor II ACL reconstruction Tovin

Physiotherapy September 2002/vol 88/no 9 514-529geytenbeek 21/8/02 4:15 pm Page 526

526

Merit of evidence determining hydrotherapy effect on outcomes (continued)

Outcome Reliability Hydro- Merit Level Group Primary measure of therapy category of diagnosis author measure effect evidence of trial

Knee extensor isometric strength Not reported 0 Poor II Late poliomyelitis Willen at 60˚ Knee flexor isometric strength at 60˚ Not reported 0 Poor II Late poliomyelitis Willen Knee extensor isokinetic strength Not reported 0 Poor II Late poliomyelitis Willen at 60˚ and 180˚/s Knee flexor isokinetic strength Not reported 0 Poor II Late poliomyelitis Willen at 60˚ and 180˚/s Knee extensor isometric endurance Not reported 0 Poor II Late poliomyelitis Willen Isometric knee extensor strength Test-retest + Poor III-2 Rheumatoid arthritis Danneskiold- at 60˚ flexion Samsoe Isokinetic knee extensor strength Test-retest + Poor III-2 Rheumatoid arthritis Danneskiold- at 30˚ and 60˚/s Samsoe Isokinetic knee extensor strength at Test-retest 0 Poor III-2 Rheumatoid arthritis Danneskiold- 12˚, 18˚, 24˚ and 300˚/s Samsoe Isometric peak torque of knee Not reported + Poor IV Multiple sclerosis Gehlsen extensors Isometric peak torque of knee flexors Not reported 0 Poor IV Multiple sclerosis Gehlsen Peak torque of knee flexors from Not reported 0 Poor IV Multiple sclerosis Gehlsen 60˚/s to 300˚/s Peak torque of knee extensors from Not reported 0 Poor IV Multiple sclerosis Gehlsen 60˚/s to 300˚/s Total work of knee extensors Not reported + Poor IV Multiple sclerosis Gehlsen Lower extremity fatigue Not reported + Poor IV Multiple sclerosis Gehlsen Biokinetic swim bench for upper Not reported + Poor IV Multiple sclerosis Gehlsen extremity peak force Biokinetic swim bench for upper Not reported + Poor IV Multiple sclerosis Gehlsen extremity speed Total work of upper extremities Not reported + Poor IV Multiple sclerosis Gehlsen Upper extremity fatigue Not reported 0 Poor IV Multiple sclerosis Gehlsen Computerised physical capacity tests Not reported + Very poor – Low back pain Lorenzetti isometric lifts Manual muscle testing Citation + Very poor – Multiple sclerosis Peterson Timed isometric hold in deltoid front Not reported + Very poor IV Older adults Whitlatch raise with weight Number of resisted leg extensions Not reported + Very poor IV Older adults Whitlatch

Balance Total sway area Test-retest + Moderate II Rheumatoid and Suomi osteo-arthritis Sagittal sway standard deviation Test-retest + Moderate II Rheumatoid and Suomi osteo-arthritis Lateral sway standard deviation Test-retest + Moderate II Rheumatoid and Suomi osteo-arthritis Sagittal/lateral sway ratio measure Test-retest 0 Moderate II Rheumatoid and Suomi osteo-arthritis Reaction time to visual stimulus via Citation 0 Moderate III-2 Older adults Lord foot switch Neuromuscular control via repetitive Citation 0 Moderate III-2 Older adults Lord depression of foot switch Body sway via sway meter Citation + Moderate III-2 Older adults Lord Balance questions Citation 0 Moderate IV Rheumatic diseases Lineker Functional reach Citation + Poor II Older adults Simmons Berg balance scale Citation 0 Poor II Late poliomyelitis Willen

Physiotherapy September 2002/vol 88/no 9 514-529geytenbeek 21/8/02 4:15 pm Page 527

Review 527

Merit of evidence determining hydrotherapy effect on outcomes (continued)

Outcome Reliability Hydro- Merit Level Group Primary measure of therapy category of diagnosis author measure effect evidence of trial

Other outcomes C-reactive protein (disease activity) Not reported 0 High II Rheumatoid arthritis Hall Physical fitness/aerobic power Test-retest + High II Ankylosing spondylitis Hidding Patient's global assessment of change Test-retest + High II Ankylosing spondylitis Hidding – visual analogue scale Articular and enthesopathy indices Test-retest + High II Ankylosing spondylitis Hidding Knowledge of fibromyalgia Not reported + Moderate II Fibromyalgia Gowans (a) questionnaire Time of relief of articular gelling Not reported + Moderate II Hip osteo-arthritis Green Overall change score Not reported + Moderate II Hip osteo-arthritis Green Neurological – passive unilateral Citation 0 Moderate II Low back pain McIlveen straight leg raise Neurological – manual muscle Intra- and + Moderate II Low back pain McIlveen strength inter-rater Neurological – grade of reflex Intra- and + Moderate II Low back pain McIlveen inter-rater Neurological – light Intra- and + Moderate II Low back pain McIlveen touch sensation inter-rater Fitness – maximal heart rate – Not reported + Moderate II Rheumatoid arthritis Sandford Smith self-limited exercise test Fitness – maximal rate-pressure Not reported 0 Moderate II Rheumatoid arthritis Sandford Smith product Fitness – duration on treadmill and Not reported + Moderate II Rheumatoid arthritis Sandford Smith peak work load Erythrocyte sedimentation rate Not reported + Moderate II Rheumatoid arthritis Sandford Smith Active joint count Not reported + Moderate II Rheumatoid arthritis Sandford Smith Medication use Not reported + Moderate II Low back pain Sjogren Fitness – recovery pulse rate after Not reported + Moderate IV Low back pain LeFort exercise Change in health status Not reported + Moderate IV Rheumatic diseases Lineker Visits to health professionals Not reported + Moderate IV Rheumatic diseases Lineker Use of medications Not reported + Moderate IV Rheumatic diseases Lineker Standford health assessment Not reported Not Poor II Rheumatoid and Ahern questionnaire reported osteo-arthritis Bone density Not reported + Poor II Older adults Ruoti Percentage body fat Not reported 0 Poor II Older adults Ruoti Heart rate response to walking in Not reported + Poor II Older adults Ruoti water Maximum oxygen consumption on Not reported + Poor II Older adults Ruoti treadmill Residual lung volume Not reported + Poor II Older adults Ruoti Resting heart rate Not reported + Poor II Older adults Ruoti Heart rate at watt load of peak work Not reported + Poor II Late poliomyelitis Willen level Oxygen uptake and anaerobic Not reported 0 Poor II Late poliomyelitis Willen threshold Astrand submaximal aerobic capacity Not reported + Poor III-2 Rheumatoid arthritis Danneskiold- – bicycle test Samsoe Medication use Not reported 0 Poor IV Low back pain Smit Overall status Not reported + Poor IV Low back pain Smit Number of doctor visits Not reported + Very poor IV Low back pain Langridge Cost of medicines Not reported + Very poor IV Low back pain Langridge Self-reported fitness level Not reported + Very poor IV Older adults Rissel Blood pressure Not reported + Very poor IV Older adults Whitlatch

Physiotherapy September 2002/vol 88/no 9 514-529geytenbeek 21/8/02 4:15 pm Page 528

528

References Hidding, A, van der Linden, S, Gielen, X, de Witte, L, Kester, A, Dijkmans, B and Ahern, M, Nicholls, E, Simionato, E, Clark, M Moolenburgh, D (1994). ‘Continuation of and Bond, M (1995). ‘Clinical and group is necessary in psychological effects of hydrotherapy in ankylosing spondylitis’, Arthritis Care and rheumatic diseases’, Clinical Rehabilitation, 9, 7 204-212. Research, , 2, 90-96. Bithell, C (2000). ‘Evidence-based Kelly, B T, Roskin, L A, Kirkendall, D T and physiotherapy: Some thoughts on best Speer, K P (2000). ‘Shoulder muscle activation evidence’, Physiotherapy, 86, 2, 58-60. during aquatic and dry land exercises in non- impaired subjects’, Journal of Orthopedic Sports Bulstrode, S J, Barefoot, J, Harrison, R A and Physical Therapy, 30, 4, 204-210. Clarke, A K (1987). ‘The role of passive stretching in the treatment of ankylosing Langridge, J C and Phillips, D (1988). ‘Group spondylitis’, British Journal of Rheumatology, 26, exercises for chronic back pain sufferers’, 40-42. Physiotherapy, 74, 6, 269-273. Crombie, I K (1996). The Pocket Guide to Critical LeFort, S M, and Hannah, E (1994). ‘Return to Appraisal, BMJ Publishing Group, London. work following an aquafitness and muscle strengthening programme for the low back Danneskiold-Samsoe, B, Lynberg, K, Risum, T injured’, Archives of Physical Medicine and and Telling, M (1987). ‘The effect of water Rehabilitation, 75, 1247-55. exercise given to patients with rheumatoid arthritis’, Scandinavian Journal of Rehabilitation Lineker, S C, Badley, E M, Hawker, G and Medicine, 19, 31-35. Wilkins, A (2000). ‘Determining sensitivity to change in outcome measures used to evaluate Gehlsen, G M, Grisby, S A and Winant, D M hydrotherapy exercise programmes for people (1984). ‘Effects of an aquafitness programme with rheumatic diseases’, Arthritis Care and on the muscular strength and endurance of Research, 13, 1, 62-65. patients with multiple sclerosis’, Physical Therapy, 64, 5, 653-657. Lloyd-Smith, W (1997). ‘Evidence-based practice and ’, British Goldby, L J and Scott, D L (1993). ‘The way Journal of Occupational Therapy, 60, 474-777. forward for hydrotherapy’, British Journal of Rheumatology, 32, 9, 771-773. Lord, S, Mitchell, D Williams, P (1993). ‘Effect of water exercise on balance and related Gowans, S E, deHuech, A, Voss, S and factors in older people’, Australian Journal of Richardson, M (1999a) . ‘A randomised Physiotherapy, 39, 3, 217-222. controlled trial of exercise and education for individuals with fibromyalgia’, Arthritis Care Lorenzetti, D P (1999). ‘Rehabilitation of a and Research, 12, 2, 120-128. lumbar disc injury with concomitant spondylolisthesis and scoliosis: Case report, Gowans, S E, deHueck, A and Voss, S (1999b). Sports Chiropractic and Rehabilitation, 13, 3, ‘Six minute walk test: A potential outcome 107-110. measure for hydrotherapy’, Arthritis Care and Research, 12, 3, 208-211. Mannerkorpi, K, Nyberg, B, Ahlmen, M and Ekdahl, C (2000). ‘Pool exercise combined Green, J, McKenna, F, Refern, E J and with an education programme for patients Chamberlain, M A (1993). ‘Home exercises with fibromyalgia syndrome: Prospective are as effective as outpatient hydrotherapy randomised study’, Journal of Rheumatology, 27, for osteo-arthritis of the hip’, British Journal 10, 2473-81. of Rheumatology, 32, 812-815. McIlveen, B and Robertson, V J (1998). ‘A Hall J, Skevington, S M, Maddison, P and randomised controlled study of the outcome Chapman, K (1996). ‘A randomised and of hydrotherapy for subjects with low back or controlled trial of hydrotherapy in rheumatoid back and leg pain’, Physiotherapy, 84, 1, 17-26. arthritis’, Arthritis Care and Research, 9, 3, 206-215. Moseley, A M, Herbert, R D, Sherrington, C and Maher, C G (2002). ‘Evidence for Helliwell, P S, Abbott, C A and physiotherapy practice: Survey of the Chamberlain, M A (1996). ‘A randomised trial Physiotherapy Evidence Database (PEDro)’, of three different physiotherapy regimes Australian Journal of Physiotherapy, 48, 1, 43-49. in ankylosing spondylitis’, Physiotherapy, 82, 2, 85-90. National Health and Medical Research Council (2000). ‘How to use the evidence: Assessment Hidding, A, van der Linden, S, Boers, M, and application of scientific evidence’, Biotext, Gielen, X, de Witte, L, Kester, A, Dijkmans, B Canberra. and Moolenburgh, D (1993). ‘Is group physical therapy superior to individual therapy in Peterson, C (2001). ’Exercise in 94˚F water for ankylosing spondylitis?’ Arthritis Care and a patient with multiple sclerosis’, Physical Research, 6, 3, 117-125. Therapy, 81, 4, 1049-58.

Physiotherapy September 2002/vol 88/no 9 514-529geytenbeek 21/8/02 4:15 pm Page 529

Review 529

Philadelphia Panel (2001). ‘Evidence-based Smit, T and Harrison, R (1991). clinical practice guidelines on selected ‘Hydrotherapy and chronic lower back pain: rehabilitation interventions: Overview and Pilot study’, Australian Journal of Physiotherapy, methodology’, Physical Therapy, 81, 10, 36, 3, 229-246 . 1629-40. Suomi, R and Koceja, D M (2000). ‘Postural Polgar, S and Thomas, S A (2000). Introduction sway characteristics in women with lower to Research in the Health Sciences, Churchill extremity arthritis before and after an aquatic Livingstone, Sydney, 4th edn. exercise intervention’, Archives of Physical Rissel, C (1987). ‘Water exercises for the frail Medicine and Rehabilitation, 81, 780-785. elderly: Pilot programme’, Australian Journal of Sylvester, K L (1989). ‘Investigation of the Physiotherapy, 33, 4, 226-232. effects of hydrotherapy in the treatment of Roberts, J and Freeman, J (1995). osteo-arthritic hips’, Clinical Rehabilitation, 4, ‘Hydrotherapy management of low back pain: 223-228. Quality improvement project’, Australian Templeton, M S, Booth, D L, and O’Kelly, W D Journal of Physiotherapy, 41, 3, 205-207. (1996). ‘Effects of aquatic therapy on joint Ruoti, R G, Morris, D M, and Cole, A J (1997). flexibility and functional ability in subjects with Aquatic Rehabilitation, Lippincott-Raven, rheumatic disease’, Journal of Sports and Philadelphia. Physical Therapy, 23, 6, 376-381. Sandford Smith, S, Mackay-Lyons, M and Tovin, B J, Wolf, S L, Greenfield, B H, Nunes-Clement, S (1998). ‘Therapeutic benefit Crouse, J and Woodfin, B A (1994). of aquarobics for indiviuals with rheumatoid ‘Comparison of the effects of exercise in water arthritis’, Physiotherapy Canada, 50, 1, 40-46. and on land on the rehabilitation of patients with intra-articular anterior cruciate ligament Shepherd, J and Mickel, C (1998). ‘Towards reconstructions’, Physical Therapy, 74, the localisation of the lumbar-posterior 8, 710-719. mobilisation technique in water in the treatment of low back pain: Clinical note’, Wakefield, A (2000). Evidence-based , 3, 3, 162-163. physiotherapy: The case for pragmatic randomised controlled trials’, Physiotherapy, 86, Sherrington, C, Herbert, R D, Maher, C G and 8, 394-396. Moseley, A M (2000). ‘PEDro: A database of randomised trials and systematic reviews in Watanabe, E, Takeshima, N, Okada, A and physiotherapy’, Manual Therapy, 5, 223-226. Inomata, K (2000). ‘Comparison of water- and land-based exercise in the reduction of state Sherry, D D, Wallace, C A, Kelley, C, Kidder, M anxiety among older adults’, Perceptual and and Sapp, L (1999). ‘Short- and long-term Motor Skills, 91, 97-104. outcomes of children with complex regional pain syndrome type 1 treated with exercise Weiss, C R, Jamieson, N B (1987). ‘Affective therapy’, Clinical Journal of Pain, 15, 218-223. aspects of an age-integrated water exercise programme’, The Gerontologist, 27, 4, 430-433. Simmons, V and Hansen, P D (1996). ‘Effectiveness of water exercise on postural Whitlatch, S and Adema, R (1996). ‘Functional mobility in the well elderly: Experimental benefits of a structured hot water group study on balance enhancement’, Journal of exercise programme’, Activities, Adaptation and Gerontology, 51A, 5, M233-M238. Aging, 20, 3, 75-85. Sjogren, T, Long, N, Storay, I and Smith, J Willen, C, Sunnerhagen, K S and Grimby, G (1997). ‘Group hydrotherapy versus land-based (2001). ‘Dynamic water exercise in individuals treatment for chronic low back pain’, with late poliomyelitis’, Archives of Physical Physiotherapy Research International, 2, 4, Medicine and Rehabilitation, 82, 66-72. 212-222.

Physiotherapy September 2002/vol 88/no 9