Effectiveness of Aquatic Exercise and Balneotherapy: A Summary of Systematic Reviews Based on Randomized Controlled Trials of Water Immersion Therapies.

0.12 MB·English

by  Kamioka, Hiroharu

J Epidemiol 2010;20(1):2-12
doi:10.2188/jea.JE20090030
Review Article
Effectiveness of Aquatic Exercise and Balneotherapy:
A Summary of Systematic Reviews Based on Randomized
Controlled Trials of Water Immersion Therapies
Hiroharu Kamioka1, Kiichiro Tsutani2, Hiroyasu Okuizumi3, Yoshiteru Mutoh4, Miho Ohta5,
Shuichi Handa3, Shinpei Okada6, Jun Kitayuguchi7, Masamitsu Kamada7,
Nobuyoshi Shiozawa8, and Takuya Honda4
1FacultyofRegionalEnvironmentScience,TokyoUniversityofAgriculture,Tokyo,Japan
2DepartmentofDrugPolicyandManagement,GraduateSchoolofPharmaceuticalSciences,TheUniversityofTokyo,Tokyo,Japan
3MimakiOnsen(Spa)Clinic,Tomi,Nagano,Japan
4DepartmentofPhysicalandHealthEducation,GraduateSchoolofEducation,TheUniversityofTokyo,Tokyo,Japan
5LaboratoryofAqua,Health,andSportsMedicine,Sapporo,Japan
6PhysicalEducationandMedicineResearchFoundation,Tomi,Nagano,Japan
7PhysicalEducationandMedicineResearchCenterUnnan,Unnan,Shimane,Japan
8DepartmentofLongevityandSocialMedicine,OkayamaUniversityGraduateSchoolofMedicine,
DentistryandPharmaceuticalSciences,Okayama,Japan
ReceivedFebruary19,2009;acceptedJuly2,2009;releasedonlineOctober31,2009
ABSTRACT
Background: Theobjectiveofthisreviewwastosummarizefindingsonaquaticexerciseandbalneotherapyandto
assess the quality of systematic reviews based on randomized controlled trials.
Methods: Studieswereeligibleiftheyweresystematicreviewsbasedonrandomizedclinicaltrials(withorwithout
ameta-analysis)thatincludedatleast1treatmentgroupthatreceivedaquaticexerciseorbalneotherapy.Wesearched
thefollowingdatabases:CochraneDatabaseSystematicReview,MEDLINE,CINAHL,WebofScience,JDreamII,
and Ichushi-Web for articles published from the year 1990 to August 17, 2008.
Results: We found evidence that aquatic exercise had small but statistically significant effects on pain relief and
related outcome measures of locomotor diseases (eg, arthritis, rheumatoid diseases, and low back pain). However,
long-term effectiveness was unclear. Because evidence was lacking due to the poor methodological quality of
balneotherapy studies, we were unable to make any conclusions on the effects of intervention. There were frequent
flawsregardingthedescriptionofexcludedRCTsandtheassessmentofpublicationbiasinseveraltrials.Twoofthe
present authors independently assessed the quality of articles using the AMSTAR checklist.
Conclusions: Aquatic exercise had a small but statistically significant short-term effect on locomotor diseases.
However, the effectiveness of balneotherapy in curing disease or improving health remains unclear.
Key words: systematic review; aquatic exercise; randomized controlled trial; balneotherapy
facilitate muscle relaxation. In addition, the hydrostatic
INTRODUCTION
effect may relieve pain by reducing peripheral edema5 and
Aquatic exercise has been referred to as pool therapy, by dampening sympathetic nervous system activity.6
hydrotherapy, and, in earlier literature, sometimes even as Bathing in water (balneotherapy or spa therapy) without
balneotherapy.1 Exercise in warm water, usually called exercisehasalsobeenfrequentlyusedinalternativemedicine
hydrotherapy or aquatic therapy, is a popular treatment for as a disease cure. Spa therapy is a very popular form
many patients with painful neurologic or musculoskeletal of treatment for all types of arthritis in many European
conditions.2 The warmth and buoyancy of water may block countries, as well as in Israel and Japan.7,8 In addition,
nociception by acting on thermal receptors and mechano- recent reports have demonstrated that comprehensive health
receptors,thusinfluencingspinalsegmentalmechanisms.3,4In education, which includes lifestyle education and exercise in
addition, warm water may enhance blood flow, which is combinationwithspabathing,haspositiveeffectsformiddle-
thought to help in dissipating algogenic chemicals, and aged and elderly people.9,10
Addressforcorrespondence.Dr.HiroharuKamioka,Ph.D,FacultyofRegionalEnvironment,TokyoUniversityofAgriculture,Sakuragaoka1-1-1,Setagaya-ku,
Tokyo,Setagaya156-8502,Japan(e-mail:[email protected]).
Copyright©2009bytheJapanEpidemiologicalAssociation
2
Kamioka H,et al. 3
Although many studies have reported the effects of water (IV) Search I or II or III
exercise and balneotherapy, there is no review of systematic (V) Search I or II or III Limits: systematic reviews/meta-
reviews of evidence from randomized controlled trials. The analysis
objective of this review was to summarize evidence for the Only keywords related to intervention were used for
effectiveness of aquatic exercise and balneotherapy and to searching. First, titles and abstracts of identified published
assessthequality ofsystematicreviews based on randomized articles were reviewed to determine the relevance of the
controlled trials of these therapies. articles.Next,thereferencesinrelevantreviewsandidentified
randomized controlled trials (RCTs) were screened.
Reference checking and hand searching
METHODS
We did not check the references of included studies, nor did
Criteria for study inclusion we perform any hand searches or contact institutions,
Types of studies societies, specialists with expertise in aquatic exercise or
Systematic reviews based on randomized clinical trials (with balneotherapy, or the authors of included studies to identify
or without a meta-analysis) were eligible. any additional published or unpublished data.
Types of participants
Studies were not excluded based on the disease status of Review methods
participants (ill vs healthy people). Selection of trials
Types of intervention and language Forthefinalselectionofstudiesforthisreview,2authors(HK
Studies that included at least 1 treatment group in which and TH) independently applied all criteria to the full text of
aquatic exercise or balneotherapy were included. A study of the articles that had passed the initial eligibility screening
anytype ofexercise usedinatherapeuticindoor pool orbath (Figure 1). Disagreements and uncertainties were resolved by
(rangeofmotionexercise,dynamicexercise,aerobicexercise, discussion between the authors.
immersion only, etc.) was acceptable. Studies had to include Studieswereselectedwhen(1)thedesignwasasystematic
information on use of medication, alternative therapies, and review of RCTs, and (2) one of the interventions was a
lifestyle changes, and these had to be comparable among form of aquatic exercise or balneotherapy. Effectiveness of
groups.Whencomparingdifferentprograms,typeofexercise, cure or health improvement was used as a primary outcome
type of water, water depth, and water temperature were measure. Health improvement was defined broadly, and
considered.Therewasnorestrictiononthebasisoflanguage. encompassed improvements in blood pressure, serum lipid
profile,immunity,andqualityoflife.Weexcludedsystematic
Methods used to identify studies reviewsofnon-RCTsorobservationalstudies.Trialsthatwere
Bibliographic database excluded are shown, along with the reason for exclusion, in
We searched the following databases: Cochrane Database the Appendix.
Systematic Review, MEDLINE via PubMed from 1990, Quality assessment of included studies
CINAHL from 1990, Web of Science from 1990, JDream II Toensurethatvariationwasnotcausedbysystematicerrorsin
(inJapanese)from1990,andIchushi-Web(inJapanese)from study design or execution, 2 review authors (MK and HK)
1990,forarticlespublisheduptoAugust17,2008.Thesearch independently assessed the quality of articles. A full quality
was limited to studies published in or after 1990, the time appraisal of these papers was made using the AMSTAR,11
period during which the systematic review methodology which was developed to assess the methodological quality of
became accepted. All searches were performed by 2 hospital systematic reviews. Disagreements and uncertainties were
librarians who were qualified in medical information resolved by discussion between the review authors.
management and were highly trained in the retrieval of Summary of studies and data extraction
clinical trials. One author (HK) selected the summary from each of the
Search strategies structured abstracts and extracted the results for statistical
The search strategies used for all databases contained the analysis. The primary outcome measurement was always
following elements and terms: chosen for analysis.
(I) Search“aquatictherapy”or“aquaticexercise”or“water Benefits and harms
exercise” The GRADE Working Group12 reported that the balance
(II) Search (“water”[Majr] or “swimming”[Majr]) and betweenbenefitsandharms,qualityofevidence,applicability,
exercise therapy/methods and the probability of baseline risk were all considered in
(III) Search “water gymnastic” or “water training” or “water judgments of the strength of recommendations. Adverse
aerobics” or “pool exercise” or “pool therapy” events and withdrawals are particularly important for
or “aerobic aquatics” or “hydrotherapy” or researchers and users of clinical practice guidelines, and
“thalassotherapy” or “aquatics” or “balneotherapy” or we present this information with the description of each
“spa therapy” article.
J Epidemiol 2010;20(1):2-12
4 Effectivenessof Aquatic Exerciseand Balneotherapy
Potentially relevant abstracts
(n=111)
Excluded
Not relevant (n=76)
Retrieved for detailed evaluation
(n=35)
Appendix
.
Not SR (n=7)
Excluded .
Not SR based on RCTs (n=12)
.
Not SR based on water therapy (n=7)
.
Not reviewed according to protocol (n=2)
Systematic reviews meeting inclusion
criteria (n=7)
Figure 1. Flowchart oftrial process
SR: systematic review.RCT: randomizedcontrolled trial.
and6.6%relativereductionfrombaselinewerefoundforpain
RESULTS
(P<0.05; SMD, 0.19; 95% CI, 0.04 to 0.35; n=638). No
Study characteristics statistically significant differences were found for walking
The literature searches identified 111 potentially relevant ability or stiffness.
articles (Figure 1). Abstracts from those articles were Next,weexaminedtheeffectivenessofaquaticexercisefor
assessed and 35 studies were retrieved for further evaluation pain relief.2 Aquatic exercise was significantly inversely
(assessment of relevant literature). Twenty-eight publications associated with pain (P<0.05; SMD, −0.17; 95% CI,
were excluded either because they were not a systematic −0.33 to −0.01; n=594). However, meta-analysis showed
review (SR), not an SR based on RCTs, not an SR in which no differences between aquatic exercise and land exercise
waterwasafactor,orwerenotreviewedaccordingtoprotocol (P=0.56; SMD, 0.11; 95% CI, −0.27 to 0.50; n=103).
(see Appendix). Seven trials1,2,13–17 met all inclusion criteria We then examined the effectiveness of spa therapy
(Tables 1 and 2). These included 3 SRs on aquatic exercise (with physiotherapy) and balneotherapy for treating low
(spa therapy)1,2,16 and 5 SRs on balneotherapy13–17; one of back pain.16 Pain was assessed using a 100-mm VAS. Spa
these concerned both balneotherapy and spa therapy (with therapy was significantly inversely associated with pain
physiotherapy). The target diseases and disorders included (P<0.001; SMD, 26.6; 95% CI, 20.4 to 32.8; n=442), as
knee and hip osteoarthritis,1,14,15 rheumatoid arthritis,13 low was balneotherapy (P<0.001; SMD, 18.8; 95% CI, 10.3 to
back pain,16 and neurologic or musculoskeletal disease 27.3; n=138). Results on the Schober index and assessment
(ie, rheumatoid arthritis, fibromyalgia, low back pain, and of lumbar flexibility suggested there were no significant
osteoarthritis), along with a number of other diseases intergroup differences.
and disorders.2 Studies on health improvement were also
included.17 The SRs of aquatic exercise showed a curative Withdrawals and adverse events
effect in all studies; however, the SRs of balneotherapy Withdrawals (dropouts) were reported in 3 studies, and
provided no clear evidence of curative effect (Table 3). adverse events were reported in 4 studies (Table 4). No fatal
accidents or serious adverseeffects were noted instudiesthat
Results of meta-analysis reported adverse events.
Only3SRs1,2,16provideddatathatweresuitableforstatistical
pooling. Regarding the effectiveness of aquatic exercise for Quality assessment
the treatment of knee and hip osteoarthritis,1 there was a A list of excluded studies (3 trials, 43%) and the use of
small but statistically significant favorable effect for aquatic graphic aids to assess publication bias (1 trial, 14%) were
exercise on function (P<0.001; weighted standardized mean evaluated by using the AMSTAR checklist (Table 5).
difference[SMD],0.26;95%confidenceinterval[CI],0.11to
0.42; n=648), quality of life (P<0.05; SMD, 0.32; 95% CI,
DISCUSSION
0.03 to 0.61; n=599), and mental health (P<0.05; SMD,
0.16; 95% CI, 0.01 to 0.32; n=642) measured immediately We identified only 7 published SRs on aquatic exercise and
after the intervention period. Pain was assessed using a 100- balneotherapy, which indicates that there is little evidence
mm visual analogue scale (VAS). A 3% absolute reduction demonstratingtheeffectivenessofthewarmth,buoyancy,and
J Epidemiol 2010;20(1):2-12
Kamioka H,et al. 5
Dataextraction/Datacollectionandanalysis Tworeviewauthorsindependentlyselectedtrialsforinclusion,assessedtheinternalvalidityofincludedtrialsandextracteddata.Pooledresultswereanalyzedusingstandardizedmeandifferences(SMD). Twoauthorsindependentlyassessedqualityandextracteddata.Disagreementsweresolvedbyconsensus. Twoauthorsindependentlyassessedqualityandextracteddata.Disagreementsweresolvedbyconsensus.Intheeventofclinicalheterogeneityorlackofdatatheyrefrainedfromstatisticalpooling. :Continuedonnextpage
Selectioncriteria/periodofintervention Randomizedcontrolledtrialsorquasi-randomizedclinicaltrials.Thedurationofinterventionswasfrom6weeksto12months. Selectioncriteria:randomizedcontrolledtrialscomparingbalneotherapywithanyotherinterventionorwithnointervention.IncludedpatientsfiwereallsufferingfromdeniteorclassicalrheumatoidarthritisfiasdenedbytheAmericanRheumatismAssociationCriteriaorbythecriteriaofSteinbrocker.AtleastoneoftheWHO/ILARcoresetofendpointsforRAclinicaltrialshadtobeamongthemainoutcomemeasures.Thedurationofinterventionswasfrom14weeksto6monthsand4weeks. Randomizedcontrolledtrials(RCT)comparingbalneotherapywithanyinterventionornointervention.Atleast90%ofthepatientpopulationhadtobediagnosedwithosteoarthritis;durationofinterventionswasfrom15daysto27weeks.
Datasource/Searchstrategy MEDLINEfrom1949,EMBASEfrom1980,CENTRAL(Issue2,2006),CINAHLfrom1982,WebofSciencefrom1945,alluptoMay2006.Therewasnolanguagerestriction. TheysearchedthefollowingdatabasesuptoOctober2006:CENTRAL(Issue3,2006),PubMed,CINAHL,thedatabasefromtheCochrane“RehabilitationandRelated”TherapiesFieldandPedro,andperformedreferencecheckingandpersonalcommunicationswithauthorstoretrieveeligiblestudies. TheysearchedthefollowingdatabasesuptoOctober2006:EMBASE,PubMed,the“CochraneRehabilitationand”RelatedTherapiesFielddatabase,PEDro,CENTRAL(Issue3,2006),andperformedreferencecheckingandcommunicatedwithauthorstoretrieveeligiblestudies.
e
aimandmethods) Aim/Objective Tocomparetheeffectivenessandsafetyofaquaticexerciseinterventionsinthetreatmentofkneandhiposteoarthritis. Toassesstheeffectivenessofbalneotherapyforrheumatoidarthritis. Toassesstheeffectivenessofbalneotherapyforpatientswithosteoarthritis(OA).
( e
s hd
structuredabstract Title Aquaticexerciseforttreatmentofkneeanhiposteoarthritis. Balneotherapyforrheumatoidarthritis. Balneotherapyforosteoarthritis.
n e e e
basedo ear;Vol.; Databas D005523.h) Databas D000518.h) Databas D006864.h)
maryofarticles JournalYPage. etal.CochraneSystRev2007;4:C(inEnglis P,etal.CochraneSystRev2008;3:C(inEnglis P,etal.CochraneSystRev2007;4:C(inEnglis
m M, A A
1.Su uthor artelsE erhagen erhagen
e A B V V
Tabl No. 1 13 14
J Epidemiol 2010;20(1):2-12
6 Effectivenessof Aquatic Exerciseand Balneotherapy
Dataextraction/Datacollectionandanalysis Theyusedachecklistfispecicallydesignedtoevaluatetheinternalvalidityofnonpharmacologicaltrials.Externalvalidityandthequalityofthestatisticalanalysiswerealsoevaluated. Dataabstractionwasperformedsystematicallyandindependentlyaccordingtodesign,quality,samplesize,intervention,watercharacteristics,results,adverseeventsandconcomitanttreatment. Informationontheparticipants,interventions,andoutcomeswasextractedfromtheincludedstudies.QualityappraisalwasassessedusingtheScottishIntercollegiateGuidelinesNetworkcriteriaforRCTs. Thequalityofindividualarticleswasevaluatedona13-pointfimodiedPEDroscalethatwasconstructedbyaddingthreeterms,representingthenumberofsubjects,theobservationperiod,andwatercharacteristicstothe10-pointPEDroscale.
Selectioncriteria/periodofintervention Studiesthatcomparedcrenobalneotherapytootherinterventionsortonointerventionwereconsidered.Massage(usuallyanintegralpartofspaprograms)isnotfispecictospatherapyandthereforewasnotstudiedhere.Onlystudiesofpatientswithosteoarthritisoftheknee,hip,and/orhandswereselected.Thedurationofinterventionswasfrom16daysto1yearand3months. Alltrialsreportingthatthesequenceofallocationwasrandomized(RCTs).Testingbalneotherapyorspatherapyfortreatingpatientswithlowbackpainwereincluded.Trialsreportedinduplicatewereexcluded.Thedurationofinterventionswasfrom3weeksto4weeks. Randomizedcontrolledtrials(RCTs)thatincludedadultswithneurologicormusculoskeletaldisease,painasanoutcomemeasure,andexerciseinwaterwereincluded.Thedurationofinterventionswasfrom4weeksto12months. Keywordsforstudyselection“wererandomizedcontrolled”“”trialandspaor“”balneotherapy.Nocriteriaweresetupconcerningthenumberofsubjects,theobservationperiod,orthekindofdiseasestudied.Thedurationofinterventionswasfrom3weeksto12months.
Datasource/Searchstrategy TheysearchedtheMedlinedatabase.TheyalsoreviewedthereferencelistsofarticlesretrievedbytheMedlinesearch.ThestudieshadtobewritteninEnglishorFrench. SystematicsearcheswereconductedonMedline,Embase,AmedCochraneCentral,theUKNationalResearchRegisterandClincalTrials.gov(alluntilJuly2005). Asystematicliteraturesearchof14databaseswasexaminedforresearchonaquaticexerciseovertheperiodfromJanuary1980toJune2006. TheysearchedthePubMeddatabasetwice:inSept.2004andinApril2005.Articlespublishedafter1990andwritteninEnglishweresearched.
Aim/Objective Toconductasystematicliteraturereviewoncrenobalneotherapyforlimbosteoarthritisandtodiscussthestudymethodsusedtoevaluatethistreatmentmodality. Toassesstheevidencefororagainsttheeffectivenessofspatherapyandbalneotherapyfortreatinglowbackpain. Toevaluatetheliteratureontheeffectivenessofaquaticexerciseinrelievingpaininadultswithneurologicormusculoskeletaldisease. Toreviewrandomizedcontrolledtrialsoftheeffectsoftreatmentinspas,therebyclarifyingtherapeuticeffectsofthesetreatmentsonindividualdiseases,anditshealth-promotingeffects.
Title Crenobalneotherapyforlimbosteoarthritis:Systematicliteraturereviewandmethodologicalanalysis. Spatherapyandbalneotherapyfortreatinglowbackpain:meta-analysisofrandomizedtrials. Doesaquaticexerciserelievepaininadultswithneurologicormusculoskeletaldisease?Asystematicreviewandmeta-analysisofrandomizedcontrolledtrials. Asystematicreviewofrandomizedcontrolledtrialsonthetherapeuticandhealth-promotingeffectsofspas.
JournalYear;Vol.;Page. JointBoneSpine–2008;75:138148.(inEnglish) Rheumatol–2006;45:880883.(inEnglish) ArchPhysMedRehabil–2008;89:873883.(inEnglish) JJpnSocBalneolClimatolPhysMed–2006;69:155166.(inJapanesewithEnglishabstract)
R,etal. H,etal. al. H,etal.
:ntinued Author Forestier PittlerM HallJ,et Kamioka
Co No. 15 16 2 17
J Epidemiol 2010;20(1):2-12
Kamioka H,et al. 7
Conclusion fiAquaticexerciseappearstohavesomebenecialshort-termeffectsforpatientswithhipand/orkneeOA;nolong-termeffectsweredocumented.Thecontrolledandrandomizedstudiesinthisareaarestilltoofewtogivefurtherrecommendationsonhowtoapplythetherapy,andstudiesofficlearlydenedpatientgroupswithlong-termoutcomesareneeded. Silverlevelevidencewasfoundforonestudyinfavorofmineralbathscomparedtodrugtreatmentfifiateightweeks.Insufcientevidencewasfoundforallothercomparisons.Howeverthescienticfi“evidenceisinsufcientbecauseofpoormethodologicalquality.Therefore,thenotedpositivefi”ndingsshouldbeviewedwithcaution. fiTheyfoundsilverlevelevidenceconcerningthebenecialeffectsofmineralbathscomparedtonotreatment.Regardingallotherbalneologicaltreatments,nocleareffectswerefound.However,thefiscienticevidenceisweakbecauseofthepoormethodologicalqualityandtheabsenceof“fi”adequatestatisticalanalysisanddatapresentation.Thenotedpositivendingsshouldbeviewedwithcaution. Althoughtheconsistencyoftheresultssuggestsatherapeuticeffectofcrenobalneotherapyinlimbosteoarthritis,availablestudiesaremethodologicallyinadequateandsamplesizestoosmalltofiallowdenitiveconclusions.Theysuggestanumberofsolutionstotheseshortcomings.Carefullydesignedstudiesinlargerpatientpopulationsareneededtodeterminetheroleofcrenobalneotherapyinkneeosteoarthritis. Eventhoughthedataarescarce,thereisencouragingevidencesuggestingthatspatherapyandbalneotherapymaybeeffectivefortreatingpatientswithlowbackpain.Thesedataarenotcompellingbutwarrantrigorouslarge-scaletrials. Thereissoundevidencethattherearenodifferencesinpain-relievingeffectsbetweenaquaticandlandexercise.Comparedwithnotreatment,aquaticexercisehasasmallpain-relievingeffect;however,thesmallnumberofgood-qualitystudiesandinconsistencyofresultsmeansthatfifiinsufcientevidencelimitsrmconclusions. “”Theydeviseda3-layermodelofevidencetobeaccumulatedinbalneotherapyandconcludedthatRCTquality,evidencelevel,andexpectationofgoodresultswerehighfor,indescendingorder,pain-relievingeffect,functionalrecoveryandimprovementinqualityoflife,andhealth-promotingeffects.
ofarticlesbasedonstructuredabstracts(resultsandconclusion) Mainresults Intotal,sixtrials(800participants)wereincluded.Attheendoftreatmentforcombinedkneeandfihiposteoarthritis,therewasasmall-to-moderateeffectonfunction(SMD0.26,95%condenceinterval(CI)0.11to0.42)andasmall-to-moderateeffectonqualityoflife(SMD0.32,95%CI0.03to0.61).Aminoreffectofa3%absolutereduction(0.6fewerpointsona0to20scale)and6.6%relativereductionfrombaselinewasfoundforpain.Onlytwostudiesreportedadverseeffects,thatis,theinterventionsdidnotincreaseself-reportedpainorsymptomscores. Oneextrastudyisincludedinthisupdate.Nowseventrials(412patients)wereincludedinthisfireview.Mosttrialsreportedpositivendingsontheirmainoutcomes,butweremethodologicallyfl‘’awedtosomeextent.Aqualityoflifeoutcomewasreportedbytwotrials.Noneofthetrialsperformedanintention-to-treatanalysisandonlytwoperformedacomparisonofeffectsbetweengroups.Poolingofthedatawasnotperformedbecauseofheterogeneityofthestudies,multiplefifioutcomemeasurements,andtheoverallpoordatapresentation.WefoundasignicantbenetofmineralbathscomparedtoCyclosporineAateightweeksonpaininonestudy(RR=2.4;95%CI:fi1.4,3.8).Overallthereisinsufcientevidencethatbalneotherapyismoreeffectivethannotreatment,thatonetypeofbathismoreeffectivethananother,orthatonetypeofbathismoreeffectivethanmudpacks,exercise,orrelaxationtherapy. Seventrials(498patients)wereincludedinthisreview.Twostudiescomparedspatreatmentwithnotreatment.Onestudyevaluatedbathsasanadd-ontreatmenttohomeexerciseandtheauthorcomparedthermalwaterfromCserkeszolowithtapwater(placebo).ThreestudiescomparedsulphurorDeadSeabathswithnotreatmentormineralbathswithtapwaterbathsornotreatment.Onlyoneofthetrialsperformedanintention-to-treatanalysisandtwostudiesprovidedenoughdata‘’toperformourownintention-to-treatanalysis.Aqualityoflifeoutcomewasreportedbyonetrial. Crenobalneotherapywasassociatedwithimprovementsintheevaluationcriteria(pain,function,andqualityoflife)comparedtobaseline.However,inadequateinternalvalidityprecludedtheestablishmentofacausallinkbetweentheseimprovementsandcrenobalneotherapy.Externalfifivaliditywasoftenpoorlydened.Somestudiesfoundnosignicantdifferenceswiththecontrolgroupbutfailedtoincludeasample-sizecalculation,suggestinginadequatestatisticalpowerasapossibleexplanationfortheresult.Inseveralstudies,theuseofmultipleevaluationcriteriaandmeasurementsledtoahighriskofTypeIerror. Fiverandomizedclinicaltrialsmetallinclusioncriteria.Quantitativedatasynthesiswasperformed.fiThedataforspatherapy,assessedona100-mmvisualanaloguescale(VAS),suggestsignicantfibenecialeffectscomparedwithwaitinglistcontrolgroups(weightedmeandifference26.6mm,fi–n95%condenceinterval20.432.8,=442)forpatientswithchroniclowbackpain.Forfibalneotherapy,thedata,assessedona100-mmVAS,alsosuggestbenecialeffectscomparedfi–withcontrolgroups(weightedmeandifference18.8mm,95%condenceinterval10.327.3,n=138). Nineteenstudiesmettheinclusioncriteria;8hadamoderate-to-lowriskofbias,and5ofthesehaddatasuitableformeta-analyses.Thisshowedthataquaticexercisehasasmallposttreatmenteffect−Pinrelievingpaincomparedwithnotreatment(=.04;standardizedmeandifference[SMD],.17;fi−−fi95%condenceinterval[CI],.33to.01),butitisnotpossibletodrawarmconclusionbecauseofthelackofconsistencyofevidenceacrossstudies.Comparablepain-relievingeffectswerefound−Pbetweenaquaticandland-basedexercise(=.56;SMD=.11;95%CI,.27to.50). Atotalof17articleswerereviewed.Diseasesstudiedinthesearticlesweremostlylocomotor’disorders,withpainasamainsymptom:rheumatism,osteoarthritis,lumbago,Parkinsonsdisease,fivaricosis,psoriasis,andhealth-promotion.Themeanscoreonthe13-pointmodiedPEDroscalewas7.5(SD,2.3),withaminimumscoreof2pointsandamaximumscoreof12points.Inadditiontobalneotherapy,exercisetherapy,mudpacktreatment,anddouchemassagewereemployedinnumerousstudies.Improvementsintheindicatorswerealwaysmoremarkedinbalneotherapyinterventiongroupsthanincontrolgroups,irrespectiveofthediseasestudied.
e2.Summary Author BartelsEM,etal. VerhagenAP,etal. VerhagenAP,etal. ForestierR,etal. PittlerMH,etal. HallJ,etal. KamiokaH,etal.
Tabl No. 1 13 14 15 16 2 17
J Epidemiol 2010;20(1):2-12
8 Effectivenessof Aquatic Exerciseand Balneotherapy
Table 3. Briefsummaryof7systematicreviews
No. Author Yearofpublication Interventiontype Meta-analysis Objectdisease Effectsnoted
1 BartelsEM,etal. 2007 Aquaticexercise Performed Hipandknee Short-termeffects
Osteoarthritis
13 VerhagenAP,etal. 2008 Balneotherapy Notperformed Rheumatoidarthritis Unclear,buteffectsin
sometrials
14 VerhagenAP,etal. 2007 Balneotherapy Notperformed Osteoarthritis Unclear,buteffectsin
sometrials
15 ForestierR,etal. 2008 Balneotherapy Notperformed Limbosteoarthritis Unclear,buteffectsin
sometrials
16 PittlerMH,etal. 2006 Balneotherapyand Performed Lowbackpain Effectforboth
aquaticexercise interventions
2 HallJ,etal. 2008 Aquaticexercise Performed Neurologicor Smalleffect
musculoskeletal
disease
17 KamiokaH,etal. 2006 Balneotherapy Notperformed Locomotordiseaseand Unclear,buteffectsin
healthimprovement sometrials
Table 4. Descriptionofadverseeventsandwithdrawalsinarticles
Withdrawals Adverseevents
No. Author Title
(dropouts)described? described?
1 BartelsEM,etal. Aquaticexerciseforthetreatmentofkneeandhip Yes Yes
osteoarthritis
14 VerhagenAP,etal. Balneotherapyforrheumatoidarthritis Yes Yes
15 VerhagenAP,etal. Balneotherapyforosteoarthritis Yes Yes
16 ForestierR,etal. Crenobalneotherapyforlimbosteoarthritis:Systematic Yes No
literaturereviewandmethodologicalanalysis
17 PittlerMH,etal. Spatherapyandbalneotherapyfortreatinglowbackpain: No Yes
meta-analysisofrandomizedtrials
2 HallJ,etal. Doesaquaticexerciserelievepaininadultswith Yes Yes
neurologicormusculoskeletaldisease?Asystematic
reviewandmeta-analysisofrandomizedcontrolledtrials
18 KamiokaH,etal. Asystematicreviewofrandomizedcontrolledtrialsonthe No No
therapeuticandhealth-promotingeffectsofspas
hydrostatic effects of water for curing disease or improving during water immersion. This suggests that an intervention
health.OnereasonforthelimitednumberofSRsmaybethat requiring exercise is more effective for the treatment of
aquatic exercise and balneotherapy are similar practices and musculoskeletal diseases, as compared to balneotherapy,
distinguishing between them in RCTs is thus difficult. In which involves passive immersion. However, it should be
addition,participantsmayfindtheinterventionprocess,which noted that this was only the immediate effect of intervention,
requires them to undress and wear a swimsuit, to be and not the long-term result. The intervention period ranged
troublesome. Furthermore, it is difficult to perform meta- from 3 weeks to 12 months in aquatic exercise studies, and
analyses because, in the case of balneotherapy, the chemical from 15 days to 12 months in studies of balneotherapy.
contentandtemperatureofthewatersstudieddifferinvarious This might reflect the difficulty of maintaining long-term
countries and the data are therefore not easily integrated. participation in an RCT. Whatever the case, the long-term
effects are not clear.
Aquatic exercise versus balneotherapy (without We did not pool data from SRs of balneotherapy13–15,17
exercise) because of their heterogeneity, multiple and varied outcome
Wedistinguishedbetweenaquaticexerciseandbalneotherapy measurements,andpooroverallquality.SRsofbalneotherapy
to determine which was more effective, because many suggestedthatthescientificevidencewasinsufficientbecause
studies do not do so. Aquatic exercise had a small but ofthepoormethodologicalqualityofRCTsofbalneotherapy.
statistically significant effect on pain, function, QOL and Thus, it is difficult to determine the independent effect of
mental health, and included more voluntary movements balneotherapy without exercise.
J Epidemiol 2010;20(1):2-12
Kamioka H,et al. 9
(%) (100)(0)(0)(0) (86)(0)(14)(0) (71)(29)(0)(0) (100)(0)(0)(0) (43)(57)(0)(0) (100)(0)(0)(0) (100)(0)(0)(0) (100)(0)(0)(0) (71)(14)(14)(0) (14)(86)(0)(0) (71)(29)(0)(0)
n 7000 6010 5200 7000 3400 7000 7000 7000 5110 1600 5200
e e e e e e e e e e e
erbl erbl erbl erbl erbl erbl erbl erbl erbl erbl erbl
wa wa wa wa wa wa wa wa wa wa wa
er anspplic anspplic anspplic anspplic anspplic anspplic anspplic anspplic anspplic anspplic anspplic
nsw eso’antota eso’antota eso’antota eso’antota eso’antota eso’antota eso’antota eso’antota eso’antota eso’antota eso’antota
A YNCN YNCN YNCN YNCN YNCN YNCN YNCN YNCN YNCN YNCN YNCN
11EvaluationofthequalityofsystematicreviewsbyusingtheAMSTARchecklist Items ‘’Wasanaprioridesignprovided?Theresearchquestionandinclusioncriteriashouldbeestablishedbeforetheconductofthereview. Wasthereduplicatestudyselectionanddataextraction?Thereshouldbeatleasttwoindependentdataextractorsandaconsensusprocedurefordisagreementsshouldbeinplace. Wasacomprehensiveliteraturesearchperformed?Atleasttwoelectronicsourcesshouldbesearched.Thereportmustincludeyearsanddatabasesused(e.g.,Central,EMBASE,andMEDLINE).Keywordsand/orMESHtermsmustbestatedandwherefeasiblethesearchstrategyshouldbeprovided.Allsearchesshouldbesupplementedbyficonsultingcurrentcontents,reviews,textbooks,specializedregisters,orexpertsintheparticulareldofstudy,andbyreviewingthereferencesinthestudiesfound. Wasthestatusofpublication(i.e.,greyliterature)usedasaninclusioncriterion?Theauthorsshouldstatethattheysearchedforreportsregardlessoftheirpublicationtype.Theauthorsshouldstatewhetherornottheyexcludedanyreports(fromthesystematicreview),basedontheirpublicationstatus,languageetc. Wasalistofstudies(includedandexcluded)provided?Alistofincludedandexcludedstudiesshouldbeprovided. Werethecharacteristicsoftheincludedstudiesprovided?Inanaggregatedformsuchasatable,datafromtheoriginalstudiesshouldbeprovidedontheparticipants,interventionsandoutcomes.Therangesofcharacteristicsinallthestudiesanalyzede.g.,age,race,sex,relevantsocioeconomicdata,diseasestatus,duration,severity,orotherdiseasesshouldbereported. fiWasthescienticqualityoftheincludedstudiesassessedanddocumented?‘’Apriorimethodsofassessmentshouldbeprovided(e.g.,foreffectivenessstudiesiftheauthor(s)chosetoincludeonlyrandomized,double-blind,placebocontrolledstudies,orallocationconcealmentasinclusioncriteria);forothertypesofstudiesalternativeitemswillberelevant. fiWasthescienticqualityoftheincludedstudiesusedappropriatelyinformulatingconclusions?fiTheresultsofthemethodologicalrigorandscienticqualityshouldbeconsideredintheanalysisandtheconclusionsofthereview,andexplicitlystatedinformulatingrecommendations. fiWerethemethodsusedtocombinethendingsofstudiesappropriate?Forthepooledresults,atestshouldbedonetoensurethestudieswerecombinable,toassesstheirhomogeneity(i.e.Chi-squaredtestforhomogeneity).Ifheterogeneityexistsarandomeffectsmodelshouldbeusedand/ortheclinicalappropriatenessofcombiningshouldbetakenintoconsideration(i.e.,isitsensibletocombine?). Wasthelikelihoodofpublicationbiasassessed?Anassessmentofpublicationbiasshouldincludeacombinationofgraphicalaids(e.g.,funnelplot,otheravailabletests)and/orstatisticaltests(e.g.,Eggerregressiontest). flWastheconictofintereststated?Potentialsourcesofsupportshouldbeclearlyacknowledgedinboththesystematicreviewandtheincludedstudies.
5.
ble No. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
a
T
J Epidemiol 2010;20(1):2-12
10 Effectivenessof Aquatic Exerciseand Balneotherapy
Table 6. Overallevidenceandfutureresearchagenda
Intervention Evidence Specificagenda Commonagenda
Aquaticexercise Smallbutsignificanteffect 1.Long-termeffect 1.Randomizedcontrolledtrialsforvarious
(nodifferencesbetweenaquatic 2.Typeofdose diseases
exerciseandlandexercise) (intensity,frequencyandduration) 2.Cost-benefitanalysis
3.Descriptionofadverseeffects
Balneotherapy Poor/Unclear Satisfactorymethodology
(intention-to-treatanalysis,blinding,
adequatecontrolgroup,etc.)
Quality assessment complex review “from scratch” even if there are existing
Seven of the included SRs were published after 2006 and, reviews?
hence, relatively recent. We used the AMSTAR checklist
because its content validity is high and the number of Study limitations
articles reviewed to evaluate SR quality was as few as 11. There were several limitations to the present study. Some
The requirements of the AMSTAR checklist were generally selection criteria were common to the studies, as described
satisfied; however, an assessment of publication bias was above; however, bias remained due to differences in the
frequentlyomitted.TheAMSTARrequiresthatanassessment eligibility for participation in each study.
ofpublicationbias includeacombinationofgraphic aids(eg, Publicationbiaswasalsoalimitation.Althoughwedidnot
funnel plot other available tests). One important publication limit our search to English language articles, we found no
reported that authors were more likely to publish RCTs in an articles published in other languages. Also, we were not able
English-language journal if the results were statistically to check references by means of hand searches. Nor were we
significant.18 English language bias may therefore be present able to contact institutions, societies, or specialists with
in reviews and meta-analyses that include only trials reported expertise in aquatic exercise or balneotherapy or authors of
in English. included studies to identify any additional published or
There were few lists of excluded studies: only 3 Cochrane unpublished data. Another limit of the study was that we
Reviews1,13,14 reported this information. If the format of SRs were not able to search the PEDro database, which is used in
adheres to that of the Cochrane Review, recording omissions fields such as rehabilitation medicine and physiotherapy.
would be minimal. However, many scientific journals limit In terms of quality assessment, disagreements and
the length of submissions, so such descriptions may not uncertainties were resolved by discussion between 2
be published. We believe it is necessary to include a list authors; discussions with a third expert and contact with
of excluded studies in order to improve the certainty and authors for the purpose of clarification were not allowed.
transparency of studies.
Conclusion
Overall evidence and future research agenda There were relatively few SRs of RCTs on aquatic exercise
Table 6showstheoverallevidenceandfutureresearchagenda andbalneotherapy.Wefoundthataquaticexercisehadasmall
foraquaticexerciseandbalneotherapy.Aquaticexercisehada but statistically significant effect on pain relief and related
small but statistically significant effect. Future RCTs should outcome measurements for locomotor diseases. However, the
investigate the long-term effectiveness of aquatic exercise long-term effectiveness of these treatments remains unclear.
or its effectiveness with respect to type or duration of Because there was insufficient evidence due to the
exercise. Then, SRs based on such RCTs can be conducted. poor methodological quality of balneotherapy studies,
Regardingbalneotherapy,RCTsbasedonappropriateresearch we are unable offer any conclusions about the effects of
methodologyareneededbecausenocleareffectwasfoundin this intervention. Common flaws included an inadequate
thepresentstudy. Acommon problem with RCTs isthat they description of excluded RCTs and insufficient assessment of
donotproperlyevaluateadverseeffects;futurestudiesshould publication bias.
include these data.
Arecentstudy suggestedthatthemostimportantquestions
ACKNOWLEDGEMENTS
that authors of systematic reviews face are as follows19: (1)
Howcanincorporatingexistingreviewsintonewworkadhere This study was supported by Health and Labour Sciences
to the principles of comprehensive, transparent, and unbiased Research Grants (Research on Health Security Control:
methods required for systematic reviews? (2) If an effort is ID No. H20-007) from the Japanese Ministry of Health,
made to incorporate existing reviews, will it save time and Labour and Welfare in 2008. We would like to express our
resources? (3) Are there instances where an independent, appreciationtoM.Makishi, Y.Yamada,andS.Moriyama for
critical assessment of the evidence warrants conducting a their assistance in this study.
J Epidemiol 2010;20(1):2-12
Kamioka H,et al. 11
Appendix. Studiesexcludedinthepresentreview
No. Author.Journal(Year) Title Reasonforexclusion
E1 CardosoJR,etal.CochraneDatabaseSystcRev Aquatictherapyexercisefortreatingrheumatoidarthritis Notrevieweddueto
(2008) (Protocol) protocol
E2 BeamonS,etal.CochraneDatabaseSystRev Hydrotherapyforasthma(Protocol) Notrevieweddueto
(2008) protocol
E3 DziedzicK,etal.BestPracticeResearchClin Land-andwater-basedexercisetherapiesfor NotSR
Rheumatol(2008) musculoskeletalcondition
E4 GetzM,etal.ClinRehabili(2006) Effectsofaquaticinterventionsinchildrenwithneuromotor NotSRbasedonRCTs
impairments:asystematicreviewoftheliterature
E5 TejirianT,etal.DiseasesColonRectum(2005) Sitzbath:whereistheevidence?Scientificbasisofa NotSR
commonpractice
E6 HermanPM,etal.BMCComplementaryAlternative Iscomplementaryandalternativemedicine(CAM)cost- NotSRbasedonwater
Med(2005) effective?asystematicreview
E7 KaragulleMZ,etal.ForschKomplementarmed Balneotherapyandspatherapyofrheumaticdiseasesin NotSRbasedonRCTs
KlassNaturheilkd(2004) Turkey:asystematicreview(inGerman)
E8 MeremikwuM,etal.CochraneDatabaseSystRev Physicalmethodsfortreatingfeverinchildren NotSRbasedonwater
(2008)
E9 LiaoWC.IntJNursingStudies(2002) Effectsofpassivebodyheatingonbodytemperatureand NotSRbasedonRCTs
sleepregulationintheelderly:asystematicreview
E10 PennickVE,etal.CochraneDatabaseSystRev Interventionsforpreventingandtreatingpelvicandback NotSRbasedonwater
(2007) paininpregnancy
E11 TeschendorfME,etal.AmJMaternal/ChildNursing Hydrotherapyduringlabor:anexampleofdevelopinga NotSRbasedonRCTs
(2000) practicepolicy
E12 VerhagenAP,etal.JRheumatol(1997) Takingbaths:theefficacyofbalneotherapyinpatientswith NotSRbasedonRCTs
arthritis.Asystematicreview
E13 SimJ,etal.ClinJPain(2002) Systematicreviewofrandomizedcontrolledtrialsof NotSRbasedonwater
nonpharmacologicalinterventionsforfibromyalgia
E14 RosiminiC,etal.JAmAcademyNurse Benefitsofswimtrainingforchildrenandadolescentswith NotSRbasedonRCTs
Practitioners(2003) asthma
E15 SchiltenwolfM,etal.Schmerz(2008) Physiotherapy,exerciseandstrengthtrainingandphysical NotSRbasedonRCTs
therapiesinthetreatmentoffibromyalgiasyndrome
(inGerman)
E16 ToumaireM,etal.eCAM(2007) Complementaryandalternativeapproachestopainrelief NotSR
duringlabor
E17 BouchamaA,etal.CriticalCare(2007) Coolingandhemodynamicmanagementinheatstroke: NotSRbasedonRCTs
practicalrecommendations
E18 IarustovskaiaOV,etal.VoprKurotolFizioterLech Thermocontrasthydrotherapyinthetreatmentof NotSRbasedonRCTs
FizKult(2006) neuroendocrinedisordersinfemalesofreproductiveage
(inRussian)
E19 BalintG,etal.OrvHetil(2006) Rehabilitationandbalneotherapy,wellness2004 NotSRbasedonRCTs
(inHungarian)
E20 AdilovVB,etal.VoprKurotolFizioterLechFizKult Mineralwatersforexternal(balneological)application. NotSR
(2006) Guideforphysicians(inRussian)
E21 MarkelW.WienKilnWochenschr(2006) Cantheeffectsofradontherapybescientifically NotSR
substantiated?(inRussian)
E22 GetenbrunnerC.WienKlinWochenschr(2006) Couldbalneologyandmedicalclimatologyhavemorethan NotSR
historicimportanceinthetherapyofchronicdiseases?
(inRussian)
E23 DavydovaDB,etal.VoprKurotolFizioterLechFiz Hydrobalneotherapyofpatientswithcardiovascular NotSR
Kult(2006) disease.Manualforphysicians(inRussian)
E24 HodgsonS.ClinOrthopaedicsRelatedResearch Proximalhumerusfracturerehabilitation NotSRbasedonRCTs
(2006)
E25 LiuY,etal.CurrentOpinionRheumatol(2004) Recentadvancesinthetreatmentofthe NotSRbasedonwater
spondyloarthropathies
E26 WattsR,etal.IntJNursingPractice(2003) Nursingmanagementoffeverinchildren:asystematic NotSRbasedonwater
review
E27 PengelHM,etal.ClinRehabili(2002) Systematicreviewofconservativeinterventionsfor NotSRbasedonwater
subacutelowbackpain
E28 ConstantF,etal.BullSocSciMedGrandDuche Criticalbibliographicanalysisofinternationalmedical NotSRbasedonRCTs
Luxemb(1995) literatureinthedomainofthermalresearch
J Epidemiol 2010;20(1):2-12