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Evidence for Effective Hydrotherapy

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Evidence for Effective Hydrotherapy 514-529geytenbeek 21/8/02 4:15 pm Page 514 514 Key Words Hydrotherapy, 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 ‘swimming pool 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. therapy 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 therapy’, ‘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, spa 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. Rheumatoid arthritis 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
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