Rheumatological disorders: Joint, tissue, and motor pain (Part 2 of 2)

Part 1 made the case from physics. Part 2 asks the harder question: what happened when researchers actually put people with rheumatologic disorders in the water?

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II. Scientific research 

Although the beginnings of a solid case can be made based on hydrodynamic principles alone, there has also been some research that has examined whether aquatic therapy can increase flexibility, strength, and movement quality/quantity in rheumatology patients.

Dial and Windsor examined the combined effects of an 8-week health education/water exercise class for 12 adults with rheumatoid arthritis. ^[1]  Self-report tools indicated that the subjects had improved in functional status, pain, mobility, tenderness in joints, joint movement, number of recent flare-ups and treatment expectations. There was no significant improvement in ADL outlook. Objective findings showed significant improvement in the following: shoulder, elbow and wrist AROM, ability to flex digits to palmar crease, hip and knee AROM, and timed tests for arise-walk-sitting, walking 50-feet times, and donning/removal of shirt. The subjects did not show significant improvement in grip strength, morning stiffness, ankle AROM or MCP extension.

In a study by Danneskiold-Samsoe et al, subjects diagnosed with functional class II or III participated in an aquatic exercise program 2x/week for 2 months. ^[2]  After 2 months of exercise participation, maximal isometric and isokinetic strength of the quadriceps increased by 38 percent and 16 percent, respectively.

Bacon et al examined the effects of an aquatic exercise program on individuals diagnosed with JRA (functional class I-III). ^[3]  There were significant ROM improvements in bilateral hip internal rotation, and right hip flexion with knee extended. Trends toward increased plantar flexion ROM were also noted but not significant. There were no significant improvements in balance or timed tasks. There were no significant differences (although a trend was evident) toward increased gait cadence, velocity and stride length.

Templeton et al examined the objective changes in joint flexibility and functional ability in rheumatologic populations after participation in an aquatic therapy program. ^[4] Measurements of joint ROM and functional ability measured by the Functional Status Index (FSI) were determined pre- and post-aquatic exercise. Psychosocial factors were emphasized by encouraging members to share benefits, joys, and accomplishments prior to each class session. Following the eight-week aquatic program, joint ROM measurements and functional ability (FSI) significantly improved. Aquatic therapy was identified as an effective treatment for improving quality of life in this population. There was no significant improvement in the subjects' ratings of "need for assistance" with daily functional tasks.

Stenstrom et al examined the effects of a 1x/week aquatic exercise class for 30 subjects with class II RA over a 4-year span. ^[5] After four years of training 1x/week, the following significant improvements were evident in the training group: grip strength, frequency of exercise and frequency of hospitalization in the department of internal medicine. Additionally, the control group attended supplemental physiotherapy visits more often than the training group (34 visits and 21 visits, respectively). At the two-year follow-up, the training group remained significantly more active and more likely to exercise than the control group. A majority of the training group continued to independently perform intensive, dynamic water training even though this was not offered as a service through the study. All but one subject in the training group rated the long-term benefits of the 1x/week training as "important" or "rather important."

Jentoft et al ^[6] examined the effects of pool-based (PE) and land-based (LE) exercise programs on patients with fibromyalgia. The outcomes were assessed by the Fibromyalgia Impact Questionnaire, the Arthritis Self-Efficacy Scale, and tests of physical capacity. After 20 weeks, greater improvement in grip strength was seen in the LE group compared with the PE group, although both improved. The results were mainly unchanged at 6 months follow-up.

Green and colleagues ^[7] assessed the treatment effectiveness of home exercise alone versus the effectiveness of home exercises plus hydrotherapy for osteoarthritis of the hip. The authors examined range of motion (goniometry), muscle strength (dynamometry), and functional abilities (transfer times, walking speed and number of steps required for a fixed distance, and stair climbing/descent speeds). Weeks 0-6 were used to establish a baseline. There was no significant difference of any parameters over this period. Weeks 9-12 were used to examine treatment effects compared to the baseline information. Subjects in both group 1 and 2 showed highly significant improvement in the combination of parameters tested. Final visit: This improvement continued over the next 6 weeks and the final assessment (week 18) showed marked improvement over control values for both the land only and the aquatic-plus-land groups. The elements most affected by both interventions were joint stiffness, hip external rotation, hip abduction power/endurance, the number of steps necessary to travel a distance and to ascend/descend a set of steps. The authors found no significant difference in the treatment results obtained by the self-treatment group and the self-treatment plus hydrotherapy group. However, this was not a comparative study.

Conclusion 

This column attempts to establish the beginning of a hydrodynamic and scientific basis for the use of aquatic therapy to improve the strength, flexibility and quality and quantity of movement in patients with rheumatology disorders. Part III will examine the beneficial effects of aquatic therapy on decreasing pain and muscle spasms.

For education only; not a substitute for individual clinical judgment.