Aquatic Physiotherapy Evidence-Based Practice Guide

Jenny Geytenbeek

National Aquatic Physiotherapy Group Australian Physiotherapy Association

2008

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ACKNOWLEDGEMENTS The Aquatic Physiotherapy Evidence-Based Practice Guide was initiated by the National Aquatic Physiotherapy Group and supported by the Special Purpose Fund of the Australian Physiotherapy Association. Special thanks is afforded to Johan Lambeck for his generous co-operation in identifying bibliographic material, Sophie Heywood for her recruitment and co-ordination of reviewers and assistance in sourcing bibliographic material, Ricki Deane for locating private archival material, and reviewers Heather Bond, Dianna Howell, Kimberly Tennant, Joanne Schwarzman, and Juni Ong. Sincere thanks are also offered to all authors and researchers of aquatic exercise whose work has assisted in the evolution of evidence-based practice. REFERENCING References to articles appearing in this review are shortened to the name of the primary author and year of publication only. Secondary and subsequent authors are acknowledged in the full reference list appearing at the end of this report.

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TABLES

Table 1. Level I and II Evidence 3 Table 2. Evidence and Outcomes 5 Table 3. Trials Investigating Pre or Post Operative 21

Hip or Knee Replacement

CONTENTS Acknowledgments i Referencing i Tables ii

Contents ii Overview iv

1. Introduction 1

Purpose 1 Definitions 1 Method 2 Results 2 Discussion and Further Research 9

2. Musculoskeletal Aquatic Physiotherapy 12 Osteoarthritis 12 Rheumatoid Arthritis 16 Osteo- and Rheumatoid- Arthritis 19 Arthroplasty 20 Ankylosing Spondylitis 25 Fibromyalgia 26 Low Back 30 Upper Limbs 36 Lower Limbs 38

3. Aquatic Physiotherapy in Neurology 42

Stroke 42 Acquired Brain Injury and Intellectual Disability 43 Adult Cerebral Palsy 44 Multiple Sclerosis 46 Spinal Cord Injury 46 Guillain Barre Syndrome 47 Post-polio Disease 48

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4. Paediatric Aquatic Physiotherapy 49

Autism 49 Cerebral Palsy 50 Complex Regional Pain Syndrome 53 Juvenile Idiopathic Arthritis 54 Rett Syndrome 56 Spinal Muscular Atrophy 57

5. Aquatic Physiotherapy in Women’s Health 58 Pregnancy-related Wellbeing 58 Pregnancy-related Back Pain 60 Labour-related Pain 61 Post-menopausal Wellbeing 62 Breast cancer related lymphodema 64 Osteoporosis 64 Obesity 67

6. Cardiorespiratory Aquatic Physiotherapy 69

Heart Disease and Failure 69 Chronic Obstructive Pulmonary Disease 72

7. Aquatic Physiotherapy in Sports and Training 75

Deep Water Running 75 Plyometric Training 78 Sport-specific Training and Rehabilitation 80

8. References 83

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OVERVIEW In response to increasing physiotherapist and consumer demand, the Management Committee of the Aquatic Physiotherapy Group sought funding from the APA Special Purpose Fund in 2007 to develop the APEBPG. A substantial systematic review was undertaken using the phrases “aquatic physiotherapy”, “hydrotherapy”, “aquatic therapy” and “water exercise” over electronic databases including CINAHL, MEDLINE, EMBASE, PEDro, AMED, Ageline, Sports Discuss and The Cochrane Library. A personal bibliographic database was created to store and manage the 154 research papers retrieved that met the inclusion criteria of recency of publication (from 1997 to 2007), publication in English, availability in full-text-format, and not balneotherapy, whirl pool, passive immersion or spa. Evidence was catalogued into clinically useful areas of practice; musculoskeletal, neurological, paediatric, women’s health, cardiorespiratory and sports physiotherapy practice. Data extracted pertained particularly to answer three questions; (1) what evidence - relating to research-design and level of evidence, (2) what intervention - with particular emphasis on reporting in detail the aquatic therapies and exercise programs in order to guide clinicians in replicable practice , and (3) what effect – reporting on outcome domains including effect on function, ambulation, strength, range of movement, flexibility, pain, balance, well-being, depression, quality of life, health status, activity and participation, athletic performance, body composition, cardiac and respiratory function, fitness, spasticity, medication use and cost-effectiveness. Evidence was documented to support aquatic physiotherapy in the management of osteoarthritis, rheumatoid arthritis, joint arthroplasty, fibromyalgia, ankylosing spondylitis, back pain and dysfunction, upper- and lower- limb disorders, stroke, acquired brain injury, spinal cord injury, multiple sclerosis, Guillain Barré syndrome, post-polio syndrome, adult cerebral palsy, juvenile rheumatoid arthritis, muscular dystrophy, spinal muscular atrophy, cerebral palsy, autism, Rett syndrome, maternal peri-natal health, post-menopausal health, osteopenia, obesity, lymphodema, chronic obstructive pulmonary disease, heart failure, and sports-specific rehabilitation.

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1 Introduction PURPOSE In a systematic review of hydrotherapy trials, the balance of evidence from high to moderate quality trials indicated that hydrotherapy offered benefit toward improving pain, strength, flexibility, function, self-efficacy and affect, balance and fitness in patients with general chronic conditions such as rheumatic diseases and hip osteoarthritis, chronic low back pain, and among elderly people (Geytenbeek 2002). The review included trials from 1987 to 2001. It recognized a need for evidence to support the practice of aquatic physiotherapy in neurological and acute orthopaedic conditions, and commented that exercise program content was sometimes omitted from the reports or poorly described. The purpose of this review was to develop a guide to clinicians, identifying contemporary evidence of aquatic physiotherapy efficacy, and to report particularly on the varied treatment descriptions to facilitate both clinical and research replication. Assessment of the status of the evidence-base for aquatic physiotherapy practice in the areas of neurology and paediatrics was of particular interest. DEFINITIONS “Aquatic Physiotherapy” refers to the special practice of physiotherapy, with therapeutic intent toward the rehabilitation or attainment of specific physical and functional goals of individuals using the medium of water. It differs from the more generic term “hydrotherapy” which connotes any water-based therapy conducted by an array of professional specialties, including immersion in warm water, immersion in mineralized water (balneotherapy and spa therapy), immersion in mechanically turbulent warm water (spa therapy), application of pressurized water to the external body (whirlpool), application of warm water into the colon (colonic irrigation), the application of water of various temperatures and pressures via showers and towels (kneipp therapy), and movement-based therapy in water (hydrokinesiotherapy). “Aquatic therapy” similarly refers to water-based activity of therapeutic intent, is common among American literature, and includes the practice of physical therapists, exercise therapists, nurses and exercise instructors. “Aquatic exercise” has the intention of fitness training in both healthy and symptomatic individuals, and “water exercise” is its synonym. In this evidence-based practice guide, the terms aquatic physiotherapy, hydrotherapy, aquatic therapy, aquatic exercise and water exercise are used as they were published in the relevant citations. The author’s judgment and experience in Australian aquatic physiotherapy practice has been applied in the use of and inclusion of reference material relating to generic hydrotherapy, aquatic therapy, aquatic exercise and water exercise where the descriptions of the practice was deemed to be reflective of or useful to the Australian aquatic physiotherapist. Balneotherapy, spa therapy, whirlpool, colonic irrigation and kneipp therapy were deemed not to be among the repertoire or purpose of Australian aquatic physiotherapy practice.

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METHOD A systematic review of aquatic physiotherapy literature was undertaken applying the search phrases of “aquatic physiotherapy”, “hydrotherapy”, “aquatic therapy”, “aquatic exercise” and “water exercise” to electronic databases including CINAHL, MEDLINE, EMBASE, PEDro, AMED, Ageline, Sports Discuss and The Cochrane Library. A date of publication limit was set at 10 years, covering the years from 1997 to 2007. The search was filtered for publication in English. The search was not limited by level of research evidence and thus included systematic reviews, clinical trials and clinical opinions. A personal database of search returns was created for the management and storage of research reports in electronic and hard formats. The articles were appraised by a primary reviewer and corroborated by one of a team of secondary reviewers in most cases. Articles were categorized into clinically useful groupings, or areas of practice under headings of musculoskeletal, neurology, paediatrics, women’s health, cardiorespiratory, and sports and training. Appraisal included screening for trial type and level of evidence, subjects, frequency and duration of intervention, description of the intervention and outcome measures. Appraisal results were tabulated and transposed to text, specifically answering three questions; 1) what evidence, 2) what treatment, and 3) what effect? RESULTS One hundred and fifty four articles were sourced for appraisal. Eleven systematic reviews, 42 randomised controlled trials, and 101 reports of lower levels of evidence were included. This represented evidence obtained from 3227 patients. Level 1 and 2 evidence is outlined in Table 1.

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Table 1. Level I and II Evidence

Level I Level II Level III-1 Diagnostic Group or Systematic Randomised Psuedo-random Subject Heading Reviews Controlled Trials Controlled Trials

Acquired Brain Injury Driver (2004, n=16) Arthroplasty Ackerman (2004) Gilbey (2004, n= 57). Ankylosing Van der Linden (2004) Dagfinrud (2007) Spondylitis Back Pengel (2002) Sjogren (1997, n=60)

Liddle (2004) McIlveen (1998, n= 109) Guzmán (2005) Schrepfer (2000, n=49) Hettinga (2007)

Cerebral Palsy Hutzler (1998, n=46)

Getz (2007, n=22)

Chronic Obstructive Chavannes (2006) O’Brien (2003, n=12) Wadell (2004, n=43) Pulmonary Disease Deep Water Running Davidson (2001, n=10) Fibromyalgia Gowans (2007) Assis (2006, n=60)

Gusi (2006, n= 34) Jentoft (2001, n=34) Mannerkorpi (2000, n=58) de Melo Vitorino (2006, n=50)

Heart Failure Volakis (2007, n=34)

Cider (2003, n=25)

Juvenile Idiopathic Arthritis Epps (2005, n=78)

Labour-Related Pain Nikodem VC (2002) Benfield (2001, n=18)

Lower limbs Petrick (2001, n=53) Obesity Gappmaier (2006, n=38)

Nagle (2007, n=44) Osteoarthritis Belza (2002, n=249)

Cochrane (2005, n=312) Foley (2003, n=105) Hinman (2007, n=79) Patrick (2001, n=249) Sterner-Victorin (2004, n=245) Wang (2007, n=38)

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Level I Level II Level III-1 Diagnostic Group or Systematic Randomised Psuedo-random Subject Heading Reviews Controlled Trials Controlled Trials

Osteo- & Rheumatoid- arthritis Suomi (1997, n=27)

Suomi (2000, n= 24) Suomi (2003, n= 30)

Osteoporosis Ay (2003, n= 41) Ay (2005, n=62)

Plyometric Training Robinson (2004, n=32)

Martel (2005, n=19) Miller (2002, n=40)

Post-Polio Syndrome Willen (2001, n=28) Post-menopausal Wellbeing Devereaux (2005, n= 50)

Tsourlou (2006, n=22)

Pregnancy-Related Pennick (2007) Kihlstrand (1999, n=258). Back Pain Pregnancy-Related Parker (2007) Poleman (2007, n=66) Wellbeing

Rheumatoid Arthritis Sandford-Smith (1998, n=24)

Bilberg (2005, n= 46) Eversden (2007, n=115)

Stroke Chu (2004, n=12).

Table 2 depicts the volume and level of evidence in each category and diagnostic grouping. Outcomes from aquatic intervention is indicated by ‘outcome domain’ where support was found in the research trials, and, where that support was obtained from higher levels of evidence, the outcome domain is highlighted in bold type.

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Table 2. Evidence and Outcomes

Diagnostic Group or Papers Levels of Subjects Outcome Domains Subject Heading Evidence

Musculoskeletal Aquatic Physiotherapy Osteoarthritis 11 II, III-1, V 1196 func, amb, strgth, pain, ROM, QoL, wellB, Hlth, depr, Actv,

fitn, cost eff Rheumatoid Arthritis 5 II, V 216 func, amb, Strgth, pain, ROM, HQoL, Hlth, Dis Act Osteo- & Rheumatoid Arthritis 4 II, III-3 297 strgth, flex, ROM, bal, compliance

Arthroplasty 9 I, II, III-3, IV 176 func, amb, strgth, pain, ROM

Ankylosing Spondylitis 3 I, II 120 func, pain, QoL, WellB, dis act Fibromyalgia 9 I, II, III-3 236 func, amb, strgth, pain, QoL, WellB, Health, depr, fit Back Pain 14 I, II, III-3, IV, V 252 func, amb, strgth, Pain, med, RTW

Lower Limb Conditions 4 III-1, III-3, IV 106 amb, strgth, ROM, bal

Upper Limb Conditions 10 III-2, III-3, IV, V 7 func, strgth, ROM Aquatic Physiotherapy in Neurology Stroke 3 II, IV 18 func, amb, strgth, fit, UL movt

Spinal Cord Injury 4 III-2, IV 48 func, amb, strgth, resp Fx, spast

Acquired Brain Injury & Intellectual Disability 3 II, III-3, IV 20 strgth, ROM, fit, wellB, body comp Adult Cerebral Palsy 4 III-3, IV 57 func, amb, strgth, ROM, self perception

Multiple Sclerosis 2 III-3, IV 20 func, strgth, QoL, fatigue

Guillain Barré Syndrome 1 V 1

Post-Polio Syndrome 2 III-1, V 28 pain, fit

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Diagnostic Group or Papers Levels of Subjects Outcome Domains Subject Heading Evidence

Paediatric Aquatic Physiotherapy Cerebral Palsy 4 III-1, IV, V 68 resp Fx, wat skill, Soc comp, soc acc

Chronic Regional 1 IV 103 func, pain Pain Syndrome

Juvenile Idiopathic Arthritis 2 II, III-3 88 func, strgth, fit, dis act, ptt sat Rett Syndrome 3 IV, V 1 amb, bal, anx, UL movt

Autism 1 V 0 strgth, bal, soc comp

Spinal Muscular Atrophy 3 IV 1 maintained weight

Aquatic Physiotherapy in Womens Health Pregnancy-related Wellbeing 4 I, II, IV, V 208 stress, mood, discf, body img

Pregnancy-related Back Pain 2 I, II 258 pain, absnt

Post-menopausal Wellbeing 3 II, IV 88 bal, QoL, strgth, amb, flex, body comp

Labour-related Pain 3 I, II, V 18 pain, anx, med

Osteoporosis 3 II, IV 180 flex, co-ord, agility, strgth, endur, bone hrm, bone US Breast cancer related lymphodema 1 IV 3 limb volume, strgth, endur, wellB

Obesity 2 II 82 body wt, body fat, fit, flex, strgth, HQoL Cardiorespiratory Aquatic Physiotherapy Chronic Obstructive 6 I, III-1, III-2, III-3 109 amb, fit, activity, HQoL, resp Fx, card Fx Pulmonary Disease

Heart Failure 7 II, III-3, V 138 resp Fx, card Fx, body comp, blood lipids, QoL, amb, strgth

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Diagnostic Group or Papers Levels of Subjects Outcome Domains Subject Heading Evidence

Aquatic Physiotherapy in Sports and Training Deep Water Running 12 I, II, III-3, IV, V 155 fit, athl perf

Plyometric Training 4 II, V 81 fit, athl perf, strgth, exs-induced pain

Sport-specific Training 4 II, V 23 athl perf, balance and Rehabilitation

Total 151 3227

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Key to Outcome Domains Outcome Domains in bold type indicate those supported by Level II evidence. (Absnt) Absenteeism, (Actv) Activity, (Aglty) Agility, (Amb) Ambulation, (Anx) Anxiety, (Athl Perf) Athletic Performance, (Bal) Balance, (Body Comp) Body Composition, (Body Img) Body Image, (body wt) Body weight, (Body Fat) Body Fat, (Bone Hrm) Bone Hormones, (Bone US) Bone Ultrasound, (Card Fx) Cardiac Function, (Co-ord) Co-ordination, (Cost) Cost Effectiveness, (Depr) Depression, (Dis Act) Disease Activity, (Discf) Discomfort, (Endr) Endurance, (Fit) Fitness, (Flex) flexibility, (Func) Function, (Hlth) Health, (HQoL) Health Related Quality of Life, (Med) Medication Use, (Mood) Mood, (Pain) Pain, (Ptt Sat) patient satisfaction, (QoL) Quality of Life, (Resp Fx) Respiratory Function, (ROM) Range of Movement, (Soc Acc) Social Acceptance, (Soc Comp) Social Competence, (Spast) Spasticity, (Stress) Stress, (Strgth) Strength, (UL movt) Upper limb movement, (Wtr Skill) Water Skills, (WellB) Well Being. Bold type indicates outcomes supported by level I and II evidence.

Key to Levels of Evidence I Evidence obtained from a systematic review of all relevant randomized controlled trials II Evidence obtained from at least one properly designed randomized controlled trial III-1 Evidence obtained from well-designed pseudo randomized controlled trials (alternate allocation or some other method) III-2 Evidence obtained from comparative studies (including systematic reviews of such studies) with concurrent controls and allocation not randomized (cohort studies), case control studies, or interrupted time series with a control group III-3 Evidence obtained from comparative studies with historical control, two or more single arm studies, or interrupted time series without

parallel control group IV Evidence obtained from a case series, either post-test or pre-test and post-test V Evidence obtained from clinical peers, as referenced literature reviews, or as clinical opinion Adapted from: National Health and Medical Research Council of Australia (1999). A Guide to the Development, Implementation and Evaluation of Clinical Practice Guidelines. NHMRC: Canberra

Subject Tally The subjects tally excludes those cited in systematic reviews. Subject numbers from clinical trials include both intervention and control groups.

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DISCUSSION AND FUTURE RESEARCH The evidence-base for aquatic physiotherapy practice continues to grow and improve in quality. An earlier systematic review of evidence for hydrotherapy included 17 randomised controlled trials (level II and III-1), 12 cohort studies (level III-3 and IV) and 2 case reports published between 1987 and 2001(Geytenbeek 2002). In this subsequent review, an additional 35 randomized controlled trials were sourced. The descriptions of interventions were noted, qualitatively and quantitatively, to be more thorough and more amenable to replication by both researchers and clinicians. Similarly, the outcome measures selected by researchers were of reported reliability and validity, a deficiency noted in half of the measures tabulated by Geytenbeek (2002). The intensity of exercise performance appears to have been standardised or measured in a greater proportion of trials published since 2000 with many researchers utilizing underwater telemetry, heart rate monitoring, or ratings of perceived exertion. Study of aquatic exercise in the area of musculoskeletal practice remains the most prolific. Sixty-nine of 151 articles (45%) and 2606 of 3227 subjects (81%) in this systematic review were categorized as musculoskeletal aquatic physiotherapy practice. This proportion may reflect the clinical use of aquatic exercise for this patient group, the perceived benefits for this group by the participants themselves or the service providers, or, the ease of investigation of this group where larger subject numbers are accessible, the intervention programs appear to be established, and are group delivered. However, limited comparison has been made against other therapies, patient compliance and cost effectiveness, especially considering the degenerative nature of the arthritic conditions captured under the grouping of musculoskeletal practice. Studies by Cochrane (2005) and Patrick (2000) into cost-effectiveness are detailed and comprehensive, however with differing conclusions. Many aquatic interventions for arthritic conditions were delivered by exercise instructors, and where these yielded benefit, the concern for physiotherapists wishing to occupy market-place may be that their additional knowledge, skill and professional cost may not offer additional efficacy, until, that is, such investigation proves otherwise. A similarly bold research contest would be to compare aquatic physiotherapist performance against patient-self-treatment by way of instructional exercise cards. As Geytenbeek (2002) found, the area of acute orthopaedic rehabilitation is understudied perhaps in comparison to anecdotal opinion on the usefulness and practice of musculoskeletal aquatic physiotherapy in conditions such as post upper- or lower limb- fracture, rotator cuff lesions, joint instability and muscle imbalance, acute back pain and paediatric orthopaedics. Where acute rehabilitation is multi-phased, including weight bearing graduations, and multimodal, including manual physiotherapy and land-based exercise, the inclusion of aquatic physiotherapy has not been investigated. Reports of aquatic physiotherapy for the neck, Parkinson’s Disease, lymphodema and oncology were not revealed from the search method applied in this review

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(excluding Katrak 2003, and Tidhar 2004). This contrasted anecdotal opinion and contemporary clinical experience of merit of aquatic physiotherapy for these patient groups. Individual, one-to-one, or manual aquatic physiotherapy practice remains understudied. Thus, the professionally skilled applications of Halliwick, Watsu and Bad Ragaz Methods, passive joint mobilisation, therapist observation and correction of preferred movement patterns, and therapist modifications to prescribed movements based on hydrodynamic variations and patient performance, is not captured in the evidence-base to date. It would appear that a serious constraint to such investigation is the non-standard and variable delivery of one-to-one and manual therapies from practitioner to practitioner and from moment to moment as the subject responds to the movement therapies applied. This remains as a challenge to aquatic physiotherapy efficacy and may, in the immediate future, be best documented in descriptive and comparative case-studies. Assessment of the body of evidence supporting aquatic physiotherapy in neurology was an intention of this review. Nineteen articles of 192 subjects comprised lower levels of evidence for aquatic interventions in neurology. However, for reasons outlined above, their contribution to the body of evidence for aquatic physiotherapy is both highly commendable and embryonic in its genesis as evidenced-based practice. Similarly, the evidence from 14 paediatric articles covering 261 subjects will be enhanced by the attention from researchers recognizing the challenges before them. Aquatic physiotherapy as best-practice, best-evidence or compared with other interventions has been notionally investigated by way of, most commonly, comparison with land-based exercise, and often unfortunately by systematic review. Evidence for exercise therapy in many conditions confronting the physiotherapist is well-established. Translating that evidence to the aquatic medium requires the confidence in knowledge that the critical elements of exercise are retained or even enhanced by the medium. Skilfully, this requires knowledge of the physiological effects of immersion, kinesiology in water and measurement of exercise intensity. A number of studies have attempted to measure the same movement or exercise performed in water or on land, failing to control for increased effort imbued by viscosity, or finding similarly paced movements, by metronome, are harder, and conflict in heart-rate monitoring of effort by measuring an increase with exercise and a decrease by immersion. Nevertheless, most aquatic exercise investigations yield outcomes similar to land-based exercise, that are often better tolerated by subjects, including the obese (Nagle 2007), pregnant (Poleman 2007), arthritic (Wyatt 2003) and plyometrically trained (Martel 2005). Systematic reviews of conditions for which hydrotherapy was compared to other interventions have resulted in less than encouraging commendations. Conclusions regarding hydrotherapy have often been drawn from just one or two trials, and, by way of necessarily strict inclusion and exclusion criteria, have omitted significant

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detail or context, not the least of which is exercise prescription, thereby reducing the comparison to one of exercise medium rather than method. Extensive discussion is offered below by diagnostic grouping or area of practice including descriptions of the aquatic interventions investigated. Clinicians are encouraged to scrutinize the aquatic interventions, consider the restraints of research in aquatic programs, replicate programs with proven merit, enhance outcome with innovation in practice and measurement, and further the evidence-base by recommending to researchers of anecdotally clinically superior methods.

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2 Musculoskeletal Aquatic Physiotherapy OSTEOARTHRITIS Hip and knee joint disease over osteoarthritic involvement in the spine, shoulders or other joints, was the defining inclusion in all trials where diseased joints were specified. What evidence? Eleven articles were identified reporting on the effects of aquatic therapy for patients with osteoarthritis. Randomised controlled trials have been published by Belza (2002, n=249), Cochrane (2005, n=312), Foley (2003, n=105), Hinman (2007, n=79), Patrick (2001, n=249), Sterner-Victorin (2004, n=245), Wang (2007, n=38) and Wyatt (2001, n=45). Non-randomised controlled trials were undertaken by Lin (2004, n=106) and Norton (1998, n=17). A literature review was presented by Simmonds (2005). What treatment? Aquatic therapy for patients with osteoarthritis was delivered in a group format in all the trials presented, with the same exercise program applied to all group members. Some individualization appeared apparent in progression of exercises by repetitions, sets and the addition of resistance devices. In nine of the eleven trials the water based exercise was led by instructors, certified or having completed 10 to 12 hours instruction in exercise class leadership. One exception was the trial of Hinman (2007) in which “an experienced aquatic physical therapist individually instructed participants… Quality of movement was emphasized and the therapist palpated the lower limb musculature to ensure appropriate contraction throughout the exercises… A neutral spine position was also taught; feedback was provided on posture and transversus abdominis muscle contraction and trunk control. Individual progression to subsequent phases of the program was clinically determined by the therapist and occurred on completion of the prior phase with either no or minimal symptom exacerbation.” Across all the trials for osteoarthritis, aquatic therapy sessions ranged from 30 to 60 minutes long, were conducted twice or three times weekly, and the length of trials varied from 5 to 52 weeks. Several researchers measured the effect on osteoarthritis by water exercise programs devised for Arthritis Foundations (Belza 2002, Norton 1997, Patrick 2001, Sterner-Victorin 2004 and Wang 2007). Most refer to exercise class manuals for details of their programs. Belza (2002) and Patrick (2001), who appear to report on the same study cohort with 249 participants, describe their intervention briefly: “Participants engage in gentle upper and lower body exercises to help increase joint flexibility and range of motion to maintain muscle strength.” Studies by Norton (1997) and Suomi (1999, 2002 and 2003) who included subjects with osteo- and rheumatoid arthritis, report on similar programs, respectively: “sixty eight range-of-motion and muscle strengthening exercises, with an optional endurance segment lasting up to a maximum of 10 minutes. The PLUS program includes all of the activities in the

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regular program, plus 5 to 20 minutes of endurance-building activities, and additional muscle strengthening exercises” and “this program consists of 68 aquatic exercises designed to promote strength, range of motion, and mobility for persons with arthritis. … Providing additional physical resistance in moving a body part is not allowed, and the use of resistive devices such as fins, plastic hand paddles, or webbed gloves to increase the workload is not permitted. Instructors leading these classes are to encourage participants to exercise at their own rate, to use good form, and to maintain correct posture when performing the aquatic exercises.” Sterner-Victorin (2004) describe “The hydrotherapy was performed in small groups of 1 to 3… the program consisted of warming up, mobility and strengthening exercises for the muscles around the pelvis and stretching exercises.” The most recent study of the Arthritis Foundation Aquatic Program (Wang, 2007) provides useful program detail in tabulation in six sections from warm-up to flexibility- , endurance- , upper-body- and lower-body- training, to cool-down, minutes of each exercise phase, and exercises by name and sufficient description. Foley (2003) detail their intervention for osteoarthritis: “The warm up in the water based group consisted of walking forwards, sideways and backwards through the water. The strengthening exercises included hip flexion and extension, hip abduction and adduction, knee flexion and extension and knee cycling. One set of 10 repetitions was increased to 3 sets of ten repetitions for each exercise, usually within the first week. Once 3 sets of 15 repetitions could be performed, weighted gaiters were fastened around ankles to provide additional resistance. At this point, repetitions were dropped back to 10 and then increased to 15 as tolerated.” Lin (2004) follows these themes of exercise intent with “a standard exercise protocol specifically designed for this group based on a progressive five-phase plan…. A standard warm up period and exercises included; joint range of motion, muscle strengthening, balance and co-ordination and cardiovascular fitness.” Wyatt (2003) believe they applied the same exercises to their land and water exercise groups as, “The Exercises consisted of the following: 2 sets of manual resistance (both land-based and aquatic) knee extension and knee flexion, 4-way straight leg raises, mini-squats, and walking 800 feet.” What effect? Function, disability, pain, strength, range of movement, flexibility, balance, quality of life, well-being, health status and cost effectiveness were measured to be positively influence in subjects with osteoarthritis undertaking aquatic therapy. The Physical Function score of the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) was improved in the studies of Cochrane (2005) and Hinman (2007). This result was paralleled with the Short Form 36 physical role (Cochrane 2005, and Foley 2003) and Arthritis Impact Measurement Scale (AIMS2) physical function (Norton 1997). The Disability Rating Index of Sterner-Victorin (2004) was enhanced by aquatic therapy. Suomi (2003) utilized a Functional Activities of

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Daily Living (ADL) capacity questionnaire modified from Jette with positive result and a Functional Fitness Assessment (sit-and-reach-test, ‘soda pop’ hand-eye co-ordination test, strength: repeated biceps curl). Improved ambulatory function was indicated by tests of timed stair-ascent and stair descent (4 steps, no turning) (Cochrane 2005, and Lin 2004), walking speed and distance (Foley 2003), Six Minute Walk Test (Hinman 2007), 1 mile walk (Wyatt 2003), Eight-foot walk (Cochrane 2005) and a Summary Physical Function Scale (timed 8-foot walk, ascend/descend stairs, chair test, knee/hip flexibility, lower limb strength) (Lin 2004). However, the 880 yard walk test was insensitive to change in the trial by Suomi (2003), as was the Timed Up & Go Test in the study of (Hinman 2007). Also of contrast to the results of the studies above was the insignificant change in WOMAC function by Foley (2003). Measures of activity participation were unyielding (Adelaide Activities subscales (Foley 2003), and Physical Activity Scale for the Elderly (Hinman 2007)). Pain scores improved in subjects with osteoarthritis receiving aquatic therapy as measured by WOMAC (Cochrane 2005, Hinman 2007, Lin 2004, and Foley 2003), and the Short Form 36 (Cochrane 2005). Visual Analogue Scales (VAS) of pain yielded relief (Hinman 2007, Wyatt 2003, and Sterner-Victorin 2004). Sterner-Victorin (2004) differentiated pain related to motion, and pain related to load, night ache and day ache, all diminished by aquatic therapy management. However, the pain scores in the trial by Belza (2002) did not significantly change. Variable strength improvements between and within trials were often postulated in discussions as product of non-specific targeting of strength by exercise selections. Thigh girth was used to indicate improvement in knee strength (Wyatt 2003). Improvement in isometric strength, measured by hand-held dynamometry, occurred in the trials of Hinman (2007) for hip abduction but not knee extension, Foley (2003) for left quadriceps but not right, Suomi (1997) for hip abduction but not shoulder abduction, and Suomi (2003) for shoulder abduction and left hip abduction but not right. No gain was recorded for isometric hamstrings and quadriceps strength at knee flexion 90o by Cochrane (2005), nor quadriceps strength by Lin (2004). Dynamometric grip strength did not improve by Norton (1997). Suomi (2003) crudely but gainfully assessed upper-limb strength with a repeated biceps-curl test. Range-of-motion and flexibility were enhanced in osteoarthritic subjects by aquatic therapy as measured by WOMAC Stiffness (Hinman 2007), general mobility, knee and hip flexibility (Lin 2004), goniometric hip abduction (Suomi 1997), goniometric knee flexion and extension (Wyatt 2003), and the Sit-and-Reach-Test (Suomi 2003). However, goniometric ROM of shoulder, knee and interphalangeal joints were insignificantly changed (Norton 1997), as with shoulder abduction (Suomi 1997). Balance in arthritic subjects was of particular interest to Suomi (2000) who measured improvements in lateral sway and total sway, with and without vision, and sagittal sway without vision. Hinman (2007) also attempted to measure balance with a dynamic test, the step test involving the repeated placement of a foot on an off a

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step, however, without significant improvement post-aquatic intervention. Similarly, a balance and agility test applied by Suomi (2003) was immutable by the treatment. Quality of life and general health status were improved in subjects with osteoarthritis by aquatic therapy. Evidence for this was found by measurement of Arthritis Quality-of-Life (Belza 2002), Short Form 36 (Cochrane 2005), Health Related Quality of Life (Hinman 2007), Current Health Desirability Rating (Patrick 2000), Health Assessment Questionnaire (Belza 2002, Patrick 2000), and Perceived Quality of Life Scale–physical domain score (Patrick 2000). Well-being was improved by aquatic therapy as indicated by measure of the Centre for Epidemiological Studies Depression Scale (Belza 2002, Patrick 2000) and AIMS2 psychosocial well-being domain (Norton 1997). The Quality of Well-being Scale was insensitive to change in the trials by Patrick (2000) and Belza (2002). The psychosocial function component of the Short Form 36 was insignificantly altered in Cochrane (2005). Measures of “global effect” record parameters of function, disability, health and psychosocial status. Among the trials of aquatic therapy for osteoarthritis, positive changes in scores of global effect were recorded with the Health Assessment Questionnaire (Belza 2002), Revised Arthritis Impact Measurement Scale (AIMS2) (Norton 1997, Lin 2004), WOMAC (Lin 2004), and the Global Self-Rating Index (Sterner-Victorin 2004). Cost effectiveness of aquatic therapy for individuals with osteoarthritis was the subject of investigations by Cochrane (2005) and Patrick (2000), however with differing conclusions, probably indicative of definitional and measurement disparities. The British study of Cochrane (2005) investigated societal cost-effectiveness using the “EuroQol-based utility” by tracking “impact on work, hip or knee replacement, medications, hospital usage, family health services, community services, services from professions allied to medicine, aids and adaptations to home or lifestyle, and personal, friends or family costs associated with osteoarthritis.” Societal cost-benefit was measured by unitizing cost against changes in the WOMAC pain index. Their result ascribes positive cost effect and benefit from aquatic therapy for osteoarthritis as a cost saving of £123-£175 per patient per year, a cost saving of £3838-£5951 per quality-adjusted-life-year, and a net reduction in pain at a net saving of £135-£175 per patient per year (Cochrane 2005). The American study of Patrick (2000) also recorded costs of services sought for traditional and non-traditional health professionals, medical goods, drugs, aids and devices, including canes, walkers, wheelchairs, special utensils, removable splints, bathroom aids, and appliances for grip and reach, and arthritis-related household or chore worker help. Water exercise class costs included time and travel, class fees, pool rental, instructor fees, recruitment and promotion costs. By a measurement method involving a bench-mark of $50000 per quality-adjusted-life year, using the community-weighted Quality of Well-being Scores and patient-specific Current Health Desirability Rating for the calculation of quality-adjusted-life-years, Patrick (2000) concluded “this randomized,

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community-based study of aquatics based exercise program for persons with osteoarthritis did not demonstrate reduced costs and improved health outcomes compared with usual care.” They postulate on the limitations and insensitivity of their measurement methods in their discussion. Comparative effects between alternative interventions, variable levels of intervention, group or individual service delivery modes, and types of professionals delivering aquatic therapy are of interest. However, conclusions from these questions are presently limited. Several researchers undertook intention-to-treat analysis and investigated the difference in outcomes for participants who adhered sufficiently with the prescribed program against those whose attendance was considered less than sufficient – the non-adherers (Hinman, Belza, Patrick.) The poorer compliance was generally explained in all trials for reasons unrelated to the intervention itself. Effect-sizes were smaller for non-adherers. Foley (2003), Wyatt (2003) and Suomi (2003) compared aquatic exercise for osteoarthritis against land-based exercise finding improvement in both groups. Walking distance was improved more by hydrotherapy than land-based exercise, but the result was reversed for walking speed (Foley 2003). Aquatic exercise yielded comparatively better against land-based PACE exercise (People With Arthritis Can Exercise) except in balance and agility and right hip abduction strength (Suomi 2003). Pain was less for water exercises than land exercisers (Wyatt 2003). Electro-acupuncture was compared against hydrotherapy, both resulting better than patient education alone, among osteoarthritic patients as reduced pain, increased function, and increased quality of life (Sterner-Victorin 2004). RHEUMATOID ARTHRITIS What evidence? Five papers reporting on aquatic therapy for individuals with rheumatoid arthritis were retrieved to include in this review. Randomised controlled trials were conducted by Sandford-Smith (1998, n=24), Bilberg (2005, n= 46), and Eversden (2007, n=115). Lineker (2000, n=31) investigated the sensitivity of several outcome measures by focus group. Bender (2005) presents a literature review contrasting “hydrotherapy”, “balneotherapy” and “spa therapy” with 61 references. Balneotherapy for rheumatoid arthritis has been reviewed by Verhagen in 2000 and 2007, but is outside the scope for this review. What treatment? Sandford-Smith (1998) randomized 24 subjects to 10 weeks , thrice weekly aquaerobics or a land-based range-of-movement control group. Exercise instruction was delivered by physiotherapists. “Each session consisted of one hour of exercises performed in a hydrotherapy pool heated at 36oC. A 15 minute warm-up of slow stretches for the spine and extremities was followed by 20-25 minutes of aerobic exercises working up to a target heart rate of 70% of maximum heart rate. Maximum heart rate was determined from the treadmill stress test and patients were taught how to measure their radial pulse in order to monitor activity. Aerobic activity consisted of

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combinations of upper and lower extremity movements (e.g. bilateral arm swings, jogging on the spot, jogging through the water, “jumping-jacks”) performed in water up to the mid-sternum utilizing the properties of water (e.g. buoyancy and turbulence). The aerobic component was progressed over the 10 week period in accordance with each individual’s capability. To close the class, a 15 minute cool-down was used which involved gentle stretching and relaxation. Throughout the entire class music was played, the tempo of which was consistent with the intensity of exercises being performed.” The subjects of Bilberg (2005) exercised in a temperate pool twice a week for 12 weeks in groups of 8-9. The program was briefly described: “Each session was 45 min long and of moderate aerobic intensity. It comprised exercises for aerobic capacity, dynamic (eccentric and concentric) and static muscle strength, and muscle endurance in the upper and lower extremities, flexibility, coordination and relaxation. The pace of the exercises was guided by music… The aerobic exercise part of the training programme had been designed to achieve and maintain a target heart rate of 70% of the maximum heart rate, which is considered to improve aerobic capacity. We measured the heart rate at two training sessions to ensure the exercise intensity.” Eversden (2007) designed a hydrotherapy program of significantly less frequency of weekly 30 minute sessions over 6 weeks and controlled with a land-based program. Participants were supervised by a physiotherapist and exercised in groups of 1-4, limited by size of pool. “The exercise content in each group was similar and exercises were tailored to each individual’s ability. Participants warmed-up by mobilizing and stretching. The core exercises, repeated each week, focused on joint mobility, muscle strength and functional activities. The degree of difficulty was reviewed weekly to ensure each participant made progress at their individual pace. A cool down phase concluded each session. Functional limitations of participants were considered at all times.” The focus group investigation by Lineker (2000) provided detail of their intervention simply as “adults who registered for a course in group hydrotherapy in several therapist and lay-run settings…. Program content was based on Arthritis Foundation Guidelines.” The intervention period was 10 weeks with post-intervention measures taken after 3 months. What effect? Function, ambulation, pain, strength and muscle endurance, range of movement, health status and disease activity were improved in subject with rheumatoid arthritis undertaking aquatic therapy. Global measures of health status and function was gainfully measured by Short Form 36 (Bilberg 2005, Lineker 2000 and Eversden 2007), Arthritis Impact Measurement Scale -2 (Bilberg 2005 and Lineker 2000) and the Health Assessment Questionnaire (HAQ) (Eversden 2007). Eversden (2007) also measured self-reported health-related

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quality of life and health status evaluation with the EuroQol-5D. The Standford Health Assessment Questionnaire used by Sandford-Smith (1998) evaluated function as dressing and grooming, rising from a chair, eating, walking, hygiene, reaching, gripping and general activity, and produced results in opposition to their hypothesis where the control group faired significantly better in walking and total score, while only a trend for improved HAQ total score was achieved in the aquaerobics group. Of note however, was the alternative intervention unintentionally applied to the control group of land-based range-of-movement exercises. Ambulatory function in subjects with rheumatoid arthritis did not appear to be a targeted outcome as it was measured by very few investigators compared with other arthritic studies. Ten meter walk speed improved and the improvement was maintained for 3 months post-intervention in the trial by Eversden (2007). Pain was measured most sensitively by the SF 36 bodily pain and Numerical Pain Rating Scale by Lineker (2000) who compared several pain and self-rated outcome tools. Improved pain status was maintained 3 months post-intervention with 64% of the study cohort having joined a community fitness or support program following their evaluation. Fifty percent had continued or joined another hydrotherapy program. Eversden (2007) yielded conflicting effects on pain between measures where VAS pain improved but HAQ pain did not. Range of movement of the shoulder was measured goniometrically by Bilberg (2005) and increased significantly in the training group compared with the control group. Grip strength improved. Bilberg (2005) used the Grippit method, while Sandford-Smith (1998) used a Martin Vigorimeter. Two tests of muscle endurance, the chair test and the shoulder endurance test, yielded greater improvement in the hydrotherapy training group (Bilberg 2005). The Index of Muscle Function (IMF), comprising 11 tests for the lower extremities, including tests of muscle strength, balance, coordination and endurance, was positively influenced (Bilberg 2005). Aerobic capacity, estimated using a submaximal ergometer cycle, did not change in either the aquatic group and control group (Bilberg 2005). Disease activity, as measured by Active Joint Count, and Erythrocyte Sedimentation Rate improved with both exercise interventions of Sandford-Smith (1998). Comparing aquatic therapy programs against land-based exercise programs produced variable results. Of Self-rated Overall Effect of treatment, Eversden (2007) reported “significantly more patients treated with hydrotherapy felt much better or very much better than the patients treated with land exercise.” The range-of-movement exercise group of Sandford-Smith (1998) performed as well or better than the aquaerobics group.

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OSTEOARTHRITIS & RHEUMATOID ARTHRITIS What evidence? Four papers combined subjects with osteoarthritis and rheumatoid arthritis in their study cohorts undertaking aquatic therapy. Randomized controlled trials was undertaken by Suomi (1997, n=27) with 13 subjects with rheumatoid arthritis (RA) and 14 subjects with osteoarthritis (OA), Suomi (2000, n= 24), 11 subjects with RA and 13 with OA, and Suomi (2003, n= 30) with 8 RA subjects and 22 with OA. A prospective trial with pretest – post test measures was reported by Gyurcsik (2003, n=216) in which “the most common forms of arthritis were osteoarthritis (n=114), rheumatoid arthritis (n=31) and fibromyalgia (n=15)”, leaving 56 subjects of unspecified arthritis type. This is an interesting and different study investigating predictors of compliance with 8 weeks of aquatic exercise by goal-setting and self-efficacy. What treatment? “Participants were recruited from 14 Arthritis Foundation Aquatics Program sites in a mid-western state. The sites offered the program, which involved range of motion, strengthening, and endurance exercises for 1 hour…”Gyurcsik (2003). The studies of Suomi (1999, 2002 and 2003) also investigated participation in the Arthritis Foundation Aquatic Program, both authors in the US, presumably utilizing the same program, described in more detail by Suomi as “this program consists of 68 aquatic exercises designed to promote strength, range of motion, and mobility for persons with arthritis. … Providing additional physical resistance in moving a body part is not allowed, and the use of resistive devices such as fins, plastic hand paddles, or webbed gloves to increase the workload is not permitted. Instructors leading these classes are to encourage participants to exercise at their own rate, to use good form, and to maintain correct posture when performing the aquatic exercises.” What effect? Strength, range of movement and balance were positively affected by aquatic exercise. Measurement of isometric strength by Nicholas dynamometry yielded significant and insignificant results in the studies by Suomi (1997 and 2003) with improvements in hip abduction but not shoulder abduction, and improvements in left hip abduction but not right. A repeated biceps curl test was part of a Functional Fitness Assessment which also included a sit-and-reach-test and ‘soda pop’ hand-eye co-ordination test, and yield to change (Suomi 2003). Goniometric hip abduction improved (Suomi 2003), but shoulder abduction did not (Suomi 1997). Balance results were also bivalent. Improvement was recorded in lateral sway, with and without vision, total sway, with and without vision, and sagittal sway, without vision but not with vision (Suomi 2000). The agility and dynamic balance test of rising from a chair, walking around a cone placed 3.3m diagonally to the right of the chair,

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return to full seated position and repeat to the left, was insensitive to change (Suomi 2003). Similarly, the 880 yard test was unchanged. “Only a limited number of individuals with arthritis are active at sufficient levels over time to achieve (exercise-related) benefits” and “of those individuals with arthritis who begin an exercise program, 45-60% will not maintain the behaviour” (Gyurcsik 2003). In their investigation of theory-based correlates of adherence, Gyurcsik (2003) found that goal-difficulty, goal-specificity and task self-efficacy were independent predictors of attendance. The postulation is that influencing patient goal-setting and self-efficacy will improve outcomes for patients from exercise-based programs. ARTHROPLASTY What evidence? Nine articles published between 1997 and 2007 pertaining to hydrotherapy and water exercise for patients undergoing lower limb joint arthroplasty were identified and included in this evidence-based guide. Ackerman (2004) undertook a systematic review of pre-operative physiotherapy. A randomized controlled trial was undertaken by Gilbey (2004, n= 57). Pre-test post-test experimental studies were reported by (Weigenfeld-Lahav 2007, n= 16) and Winter (2000, n=8). A case study of bilateral total knee replacement is presented by Kenkowitz (2003, n=1). Giaquinto (2004) presents a technical article detailing pool design for water-walking analysis of this patient population. Giaquinto (2007 (b, n= 60), (c, n= 18) and (d, n= 16)) further investigated the use and method of water walking making comparisons of gait between healthy patients and patients following knee and hip arthroplasty. Table 3 indicates studies of prosthetic hip recipients, knee, or hip and knee, and those reporting pre-operative aquatic protocols versus post-operative.

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Table 3. Trials Investigating Pre or Post Operative, Hip or Knee Replacement

Reference Level of Evidence Subjects Hip / knee Pre / Post op

Ackerman (2004) Systematic Review 5 trials Hip & knee

Pre-op

Giaquinto (2004) Technical article n/a Hip & knee

n/a

Giaquinto (2007)(b)

Case-matched comparative study

60 Hip & knee

Post-op

Giaquinto (2007)(c)

Cohort prospective study

18 Knee <2 weeks post-op

Giaquinto (2007)(d)

Cohort prospective study

16 Hip < 2 weeks post-op

Gilbey (2004) RCT 57 hip Pre and post op

Kenkowitz (2003) Case study 1 Bilateral TKR

Post-op

Weigenfeld-Lahav (2007)

Cohort, pre-test post test, experimental study

16 hip < 3 months post op

Winter (2000) Cohort, pre-test post test, experimental study

8 knee Pre op

What treatment? Pre-operative aquatic exercise programs were described by Gilbey (2003) and Winter (2004). Gilbey (2003) combined land-based and home exercise protocols with their hydrotherapy format of 30 minutes twice weekly over 8 weeks prior to surgery. The protocols were individualized, based on authoritative exercise prescription practice, and was described in excellent detail, tolerant of repeatability by subsequent researchers and clinicians. The pre-surgery hydrotherapy program “began with a warm up of subjects walking 3 sets of 10 widths (7m) of the pool (forwards, backwards, side-stepping)….subjects were reminded to concentrate on good technique, with a high knee lift, and transfer of weight from heel to toe with the foot in antero-posterior alignment to reduce the degree of external rotation. A series of stretching exercises were then performed to improve flexibility of the hamstring, quadriceps, thigh adductor, thigh flexor, and calf muscle groups as well as musculature of the trunk and shoulders…. Muscle strengthening exercises were also performed including: seated body raise, partial squat and hip hike… The hydrotherapy program concluded with 5 minutes of water cycling / running.” Winter (2000) also selected an 8 week pre-operative phase, choosing a frequency of 3 times per week of sessions lasting 30 to 40 minutes. The program is sufficiently tabulated in an appendix. The program is described: “The water exercise protocol

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consisted of a warm-up, a workout set of exercises, and a stretch/relax set of exercises. The warm-up lasted five to ten minutes and consisted of water walking or slow suspended bicycling if the walking was too painful. The workout sections varied to keep interest level high and depended on the participant’s level of pain and movement ability. Suspended exercises, including bicycling, jogging, cross-country skiing, and jumping jacks, were performed for 30 to 40 minutes. Participants alternated these activities as they chose. Water-walking was also included in this part of the protocol if pain allowed. Water-walking with leg extensions and water-walking with leg curls were added for variety and for quadriceps and hamstrings strengthening. The last five to ten minutes consisted of the stretch and relax period. Patients performed shoulder rolls, side-to-side arm drag, side reaches, standing or seated hamstrings stretches, ankle rotations, calf stretches, low back stretches, and quadriceps stretches, as tolerated. Each stretch was performed statically and held from 20-30 seconds.” Post-operative hydrotherapy was reported to have been initiated within the first 2 weeks by Giaquinto (2007 a, b &c), after 21 days in the case of Kenkowitz (2003), describing bilateral knee arthroplasty, and Gilbey (2004) of hip arthroplasty, and within the first 3 months by Weigenfeld-Lahav (2007). Water-walking was the only exercise construct investigated by Giaquinto (2004, 2007 a, b & c), however in worthy detail considering it ubiquitous application by almost all practitioners. Patients undertook drills over six days per week for 15 to 18 sessions. Post-surgery hydrotherapy was similar to the pre-surgical protocol of Gilbey (2004) over 20 weeks, for 30 minutes, twice weekly, with additional land and home-based components: “Step-up activities were included to improve ROM of the operated hip and increase confidence in stair climbing in a controlled environment. Patients graduated from a low to a high stool placed on the bottom of the pool and performed the exercise leading with both the non-operated and operated limb. Balance activities with eyes open and eyes closed, were included to improve proprioception and to help guard against falls. Ankle weights were introduced where appropriate to increase the resistance when water cycling while the patient was supported in a flotation device. Water running with the water level approximating the xiphoid process and the use of flippers were also introduced into the program for some of the younger patients. The seated body raise (specifically included to improve pre-surgery arm and shoulder strength) was omitted from the post-surgery program.” Kenkowitz (2003) instituted a thrice weekly schedule of 50 to 60 minutes duration over 5 weeks for the single case of bilateral knee arthroplasty. The prescription comprised home exercises, a land component, ice pack applications and aquatic therapeutic exercises: “ankle pumps / circles were initiated to help circulation in her legs. Hip flexion and extension, along with hip abduction and adduction, allowed her to utilize the muscles around her hip with decreased strain on her knees. Hamstring, knee flexion, and dorsiflexion stretches targeted knee musculature…. Hamstring curls / pulls were utilized to increase the activity of the knees. Bicycle and scissor kicks enabled the controlled use of all her lower limb joints in a coordinated fashion. Calf raises and flamingos pre-empted the initiation of gait training by allowing closed-

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chain exercises and single-leg stance, respectively. Walking (forward, backward, and side-side) was initiated unsupported before she would have been able to ambulate on land. Squats and can-can allowed coordination and control during closed chain exercise.” Weigenfeld-Lahav (2007) measured exercise over 6 weeks applied twice weekly. “The intervention program included activity stimulation at the ankle, knee and hip joints performed in buoyant prone, supine and underwater positions, as well as in the vertically supported positions, at waist to chest depth. Exercises were modified, and the number of repetitions in each joint was increased gradually from lesson to lesson. Emphasis was placed on all the joints, although not in every lesson. Exercises included the use of the swimming pool wall as a base of support for moving the trunk or body parts against water resistance. Other exercises were performed while walking or standing in the water using flotation belts to increase buoyancy, and kick boards to increase resistance. Every session began with walking in different directions at various depths and patterns: forward backward, sideways: on heels and toes; and with knee lifted (reaching 90o flexion). Exercises were then performed at different stations: (a) lowering a kickboard to the bottom of the pool and continuing movement with the object on the floor (b) walking across the pool width with ankle weights, (c) walking up and down the pool stairs (d) sitting on the kickboard and performing bicycling movements in the water to the other end of the pool, and (e) walking on a cylinder in water. The session concluded with a cool down of stretching and breathing activities.” What effect? (Pre-surgery) The systematic review of Ackerman (2004) included five papers of suitable merit describing pre-operative physiotherapy for lower limb joint replacement and was not limited to the exercise medium of land or water. Three of these papers included hydrotherapy. Considered together, improvements could not be ascribed to the pre-operative programs alone because the studies included additional intensive post-operative physiotherapy programs. However, the papers which included hydrotherapy programs, two included here and Wang 2002), received favourable comment and comparison against others in description of intervention, statistical effect, and sample size (Gilbey 2003). Pain, range of movement, strength and ambulatory function were improved pre-operatively in programs including hydrotherapy. “Participation in the pre-surgery exercise program had a positive effect on reducing pain levels in exercise subjects prior to total hip arthroplasty. More than 63% of exercise subjects compared to only 10% of control subjects rated their level of pain as either “some what better” or “much better” compared to that experienced at baseline” (Gilbey 2003). However, in patients awaiting knee arthroplasty, improvement in the Numerical Pain Rating Scale did not reach statistical significance, and the pain level indicated by a descriptive word scale did not change (Winter 2000).

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Goniometric knee flexion improved by around 17o, while improvement in knee extension was not significant (Winter 2000). This was explained by the authors as reflective of a bias in exercise prescription for knee flexion activities such as bicycling suspended. Strength was improved pre-operatively in patients awaiting total hip (Gilbey 2003) and knee (Winter 2000) arthroplasty. Formerly, a composite hip strength score was calculated using bilateral thigh flexion, thigh extension, and thigh abduction strength. Ackerman (2004) noted this measure to have utilized isokinetic strength, however, in their research report, Gilbey (2003) does not specify isokinetic or isometric measurement nor angular velocity. Of knee arthroplasty (Winter 2000), muscle strength of quadriceps and hamstrings was investigated using a one-repetition maximum test and a Nautilus prone flexion machine, recording insignificant change. Ambulatory function was measured with the Timed Up and Go Test, yielding statistically significant effect (Winter 2000). “Pre-surgery exercise patients exhibited improved scores from baseline for each of the variables assessed” by Gilbey (2003), which included 25 meter walk and Six Minute Walk Test, however statistical significance is not reported. WOMAC total score and the domains of stiffness and physical function also improved (Gilbey 2003). What effect? (Post-surgery) Ambulatory function, lower limb strength, pain and range of movement were assisted by aquatic exercise following arthroplasty. Global improvement in hip status was measured by the WOMAC tool and Hip Harris Score (Gilbey 2003). Health related quality of life, as indicated by the Short-Form 36, was improved in sub-acute hip arthroplasty (Weigenfeld-Lahav 2007). Recovery of knee function was indicated with the Lyshom Knee Rating Scale (Lenkowitz 2003). Gait parameters such as speed, stance and swing time, stance-swing ratio, stance and swing ratios between operated and non-operated sides, and stride length were investigated from the second to fourth weeks post-surgery in patients with knee arthroplasty (Giaquinto 2007c) and hip arthroplasty (Giaquinto 2007d) and comparisons made between hip and knee arthroplasty (Giaquinto 2007b). Generally, increases in gait speed occurred over the study period and readily approached the measures of the healthy, un-operated controls. However, the study designs appeared deficient in determining if a rigorous water-walking program could hasten recovery of gait quality as they did not compare no-treatment to the water-walking intervention. Six Minute Walk Test was recorded by Gilbey (2003) at 3 weeks, 12 weeks and 24 weeks post-surgery with superior distances achieved by the exercise participants compared to the untreated controls. Similarly, 25 meter walk, yielded faster and shorter recovery times of walking speed. This inclination was supported by

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Weigenfeld-Lahav (2007) measuring Timed-Up-and-Go and recovery of balance via the Berg Balance Scale in later stages of rehabilitation from 3 months post-surgery. This study was uncontrolled but measured no change from baseline to the commencement of intervention six weeks later (pre-test) and improvement in all measures after six weeks (post-test) of hydrotherapy twice weekly. Gilbey (2003) acknowledged return of ambulatory function in her single case study of bilateral knee arthroplasty as independence from reliance on assistive devices for ambulating distances less than 1000ft after 6 weeks of aquatic therapy. Isokinetic hip strength, as measured by a composite hip score of bilateral thigh flexion, thigh extension, and thigh abduction strength, improved more readily in the exercise participants (Gilbey 2003). “The greatest gains occurred during the first 12 weeks with a continued but less marked improvement to post+24. Exercise group however, experienced accelerated improvement in strength and function compared to controls.” Manual muscle testing of hip and knee flexion, and knee extension was clinically measured and improved in the case study of bilateral knee arthroplasty (Lenkowitz 2003). Hip range of movement was positively influenced by hydrotherapy to the magnitude of 6o of flexion and 8o of abduction, measured by digital inclinometry, following the 6 week program of Weigenfeld-Lahav (2007) around 3 months post-surgery. Gilbey (2003) also recorded improved ROM hip, and Lenkowitz (2003) of goniometric knee ROM. Swelling of the thigh and calf was tracked over throughout recovery from bilateral knee arthroplasty by girth measurements, and improved (Lenkowitz 2003). ANKYLOSING SPONDYLITIS What evidence? Three papers reported on aquatic therapy for ankylosing spondylitis between 1997 and 2007. Van der Linden (2004) and Dagfinrud (2007) composed systematic reviews of aquatic and non-aquatic physical therapy with 4 and 6 trials, respectively, meeting the inclusion criteria. The trial of van Tubergen (2001, n=120), a randomized controlled trial, was the only trial of aquatic therapy post 1997 and was included in both the systematic reviews. What treatment? “Spa-exercise therapy” was investigated by van Tubergen (2001), which included multiple exercise modalities, and multiple hydrotherapy modalities of spa therapy (immersion in warm water and resting in hot, humid, radon-rich air as ‘sauna’), balneotherapy (immersion in warm water, with or without minerals) and, presumably, hydrokinesiotherapy (exercise in warm water). The primary intervention period was 3 weeks, with the intervention group undertaking a 5 days per week in-patient protocol,

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while the control group undertook a once weekly protocol. After 3 weeks, both groups continued the control group protocol for a further 37 weeks. The intervention group undertook a standardized program supervised by physiotherapists consisting of one hour of physical exercises, followed by 30 minutes of walking, and posture correction therapy by lying supine on a bed (initially 14 minutes, but increasing daily by two minutes to a final period of 30 minutes a day). Every second afternoon, patients visited the Gasteiner Heilstollen in Austria (high temperature, high humidity area with radioactive radon) or a similar thermal (sauna) treatment in Arcen in The Netherlands, where they rested for 1 hour. On the other afternoons, patients undertook 30 minutes on intensive hydrotherapy and 30 minutes bathing in thermal water, followed by 1 hour of sports. The control group undertook a program without the sauna component, consisting of weekly group physical therapy of 1 hour of physical exercises, 1 hour of sports, and 1 hour of hydrotherapy. No further detail is provided on the content of the “intensive hydrotherapy” component. From a methodological standpoint, many variables are under question in this study design, including particularly, the sauna-type treatment and frequency of 5x versus once per week intervention. It is impossible to determine the effectiveness of the water-based exercise component in this format. What effect? Function, pain, global well-being, disease activity, general health, quality of life and medication use were affected by “spa-exercise” with varying significance and trends (Van Tubergen 2001). Stiffness did not change. Trends of improvement peaked after 4 weeks, the main phase of the intervention, but were sustained above baseline levels for 28-40 weeks. All outcome measures were elicited by self-assessment questionnaires. Functional ability was measured with the Bath Ankylosing Spondylitis Functional Index (BASFI), visual analogue scales were used to measure, patient’s global well-being, pain intensity and night pain. Morning stiffness was measured in minutes. Disease activity was measured by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) (fatigue, back pain, swelling of the peripheral joints, localized tenderness, duration and severity of morning stiffness). General health and function was measured by the Health Assessment Questionnaire for Spondyloarthropathies (HAQ-S). Quality of life was measured by the Ankylosing Spondylitis Quality of Life Questionnaire. The intake of non-steroidal anti-inflammatory drugs was recorded. (van Tubergen 2001). Dagfinrud (2004) concludes that “Home exercise therapy is better than no intervention, supervised group physiotherapy is better than home exercises, and that combined inpatient spa-exercise therapy followed by supervised outpatient weekly group physiotherapy is better than weekly group physiotherapy alone.”

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FIBROMYALGIA What evidence? Nine articles were found that investigated aquatic therapy for patients with fibromyalgia. A systematic review of eight pool-exercise studies is presented by Gowans (2007). Randomized controlled trials have been undertaken by Assis (2006, n=60), Gusi (2006, n= 34), Jentoft (2001, n=34), Mannerkorpi (2000, n=58) and de Melo Vitorino (2006, n=50). Patients were followed-up 6 and 24 months after intervention in a prospective study by Mannerkorpi (2002, n=26). Mannerkorpi (2003, n=19) also provided a qualitative study of how patients experienced group physiotherapy treatment of pool exercise and education. Other articles captured under the search word of “hydrotherapy” for fibromyalgia include the randomized controlled trial of Eskioglu (2007, n=50) which investigated electro-hydrotherapy as “Stanger Bath”, and Faull (2005, n=13) which investigated hydrotherapy as Watsu and Aix Massage in a pre-test post-test design. These complementary and alternative medicine (CAM) therapies fall outside the scope of this review and practice guide. What treatment? Assis (2006) randomized 60 subjects with fibromyalgia to deep water running (DWR) or land-based exercise (LBE) training for 60 minutes, 3 times per week for 15 weeks at anaerobic threshold. “For both groups, each session was composed of a 10 minute stretching warm-up, followed by aerobic training, according to the desired intensity, for 40 minutes, and after that, a 10 minute relaxation period. The exercise prescription was based on the heart rate at the anaerobic threshold determined at the initial assessment (graded treadmill exercise test with spirometric analyses). Heart rate was re-adjusted after week 8 based on the second test. The HR variation in immersion is influenced by water temperature and exercise intensity: therefore the DWR group trained at 9 beats/min lower than the LBE group.” Sessions were supervised by 2 physiotherapists, and intensity was monitored by HR wrist watches.” The LBE group walked to the desired HR or jogged or ran in the training area. DWR consisted of simulated running in the deep-end of the pool aided by a flotation device that maintained the head above water. Patients were instructed in the following technique: 1) an upright posture with spine maintained in a neutral position; 2) running in place, held in one location by a tether cord; 3) water line kept at shoulder level; 4) upper limbs alternating shoulder flexion-extension movements, with elbows at right angle, moving hands at waist level to 5cm below the water surface; 5) hands held tightly clenched; 6) lower limbs in a bicycling action; 7) end f hip flexion at 70o with lower leg being perpendicular to the horizontal and 8) through out the cycle, ankle dorsiflexion and eversion occurring during the lower leg flexion and plantar flexion and inversion during the extension.”

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Gowans (1999a) program of education and exercise was conducted over 6 weeks, with 2 exercise classes and 2 multidisciplinary education sessions per week. Exercise classes were 30 minutes long. “Each class consisted of 20 minutes of walking / jogging / sidestepping / arm exercises against water resistance and 5 minutes of stretching at the beginning and end of each class.” Gusi (2006) investigated exercise in waist-deep water at 33oC, 3 times per week for 12 weeks. “Each 1 hour session included 10 minutes of warming up, with slow walks and mobility exercises, 10 minutes of aerobic exercises at 65%-75% of maximal heart rate (HRmax), 20 minutes of overall mobility and lower limb strength exercises (4 sets of 10 repetitions of unilateral flexion and extension of the knee at slow pace with the body in a vertical position using water as resistance) another set of 10 minutes of aerobics at 65-75% HRmax, and 10 minutes of cooling down with lower intensity exercises. Heart rate was monitored using a pulse meter.” Jentoft (2001) compared pool exercise (PE) against land-based exercise (LE). “A standard exercise program based on the Norwegian Aerobic Fitness Model was used. The aim of the program was to improved cardiovascular capacity with minimal risk of injury. Each exercise session lasted 60 minutes and consisted of body awareness, training, ergonomics, warm-up exercises, aerobic dance, cooling down exercises, muscle stretching exercises, strengthening exercises, and relaxation training. The exercises followed a certain pattern and each part lasted a predetermined time. The exercises consisted of dynamic muscles work, and they were accompanied by music. The Norwegian Aerobic Fitness Model was used in its original form for the LE group. A modified version of the model, adapted to the restriction s imposed by the water, was used for the PE group. The training intensity and muscles activated were as similar as possible in the 2 groups. In at least 40-50% of the 60 minute exercise sessions the training intensity was kept within 60-80% of the maximum heart rate for the age of each patient. A pulse watch recorder monitored the heart rate at least twice during the whole exercise period”. Mannerkorpi (2000, 2002, 2003) appeared to have used the same aquatic therapy intervention for 3 published reports. Patients with fibromyalgia participated in physiotherapist supervised group exercises once a week for 6 months. “Each session lasted 35 minutes and comprised exercises for endurance, flexibility, co-ordination, and relaxation. The aims of the program were to enable the patient (a) to perform the movements, described below (1-7), with awareness and to find her own rhythm and harmony when exercising, to learn the limits and possibilities of her body; (b) to enable her to apply this new knowledge in other physical activities; (c) to increase her motivation for physical activity; and (d) to improve function. At the start and when new patients entered the group, the leader demonstrated all the movements at a slow speed and smooth pace, emphasizing that every one should adjust the exercise individually with respect to their threshold of pain and fatigue. When the participants had learnt the exercises, and performed them correctly, the pace was increased for those who accepted it. Individual instructions were given whenever needed.

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1. Walking forward and backward, or jogging forward, in the water. Either paddling with arms to select the pace and resistance, or smoothly stroking the arms in the water.

2. Arm movements and knee bending when standing. The patients were instructed to select the pace and resistance (by positioning hands during the movement) with respect to their current threshold of pain.

3. Jogging or walking on the spot combined with arm movements. 4. Relaxation and breathing exercises. 5. Jogging on the spot, alternatively jumping with one leg forward and the other

back ward. The exercise was alternated with bicycling in a supine position. 6. Stretching of the hamstrings, the quadriceps and iliopsoas muscles, out ward

rotators and abductors of the hip, the gastrocnemius muscles, the trapezius muscle, and the levator scapulae muscle. Individual instruction of stretching of other painful or shortened muscles when appropriate.

7. Relaxation, performed either standing and leaning against the wall or lying supine. Air-filled tires and neck collars were provided.

De Melo Vitorino (2006) sleep among fibromyalgia patients in response to 3 weeks of hydrotherapy (HT) against conventional physiotherapy (CT). “Patients underwent 60 minutes of individualized HT or CP according to their assignment… Each patient of the HT group was subjected to the following: (1) warm up (5 min), (2) stretching (6 min in the beginning and in the end) , (3) aerobic exercises (30 min), and (4) relaxation (13 min). Warm-up included exercises such as walking forward, walking backward, and walking sideways, always in association with movements of the upper limbs. Muscle groups stretched were sural, ischiotibial, quadriceps, hip flexors, upper limbs and spine muscles. The aerobic exercises included steady little jump and walking sideways, feet sliding on the pool floor, with dissociation of the pelvic and scapular waists, knee bend jump, flexion and extension using boards in the hands. During relaxation the patient was kept in dorsal decubitus by means of floaters while the therapist performed dorsal massage and pumping massage.” What effect? Pain, function, mood, quality of life, fitness and sleep were improved in patients with fibromyalgia undertaking aquatic therapy. Pain in patients with fibromyalgia was measured by visual analogue scale and improved (Assis 2006, Gusi 2006). Pain after performing a walk-test improved in Mannerkorpi’s study (2002). The Fibromyalgia Impact Questionnaire was used by several researchers to measure improved perceptions of physical function, well-being, pain, fatigue, stiffness, anxiety and depression (Assis 2006, Gowans 1999a, and Mannerkorpi 2002). Ambulatory function was enhanced as indicated by Six Minute Walk Test (Gowans 1999a, Mannerkorpi 2002) and walking time over 100m (Jentoft 2001).

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Well-being, depression, and self-efficacy were gainfully measured by the Beck Depression Inventory (Assis 2006), and Arthritis Self-efficacy Scale for controlling pain and other symptoms and function (Gowans 1999a). The emotional health domain of the Short Form 36 Health Survey was sensitive to change (Assis 2006). Del Melo Vitorino (2006) concluded better quality of life from SF-36 measurement and Mannerkorpi (2002) recorded changes across several SF-36 domains. Health-related quality of life was assessed using the EQ-5D questionnaire and improved with aquatic therapy (Gusi 2006). Sleep, recorded by sleep diary, changed over the course of aquatic therapy, with total sleep time (TST) increasing by 1 hour and total nap time (TNT) decreasing (Del Melo Vitorino 2006). The qualitative study of Mannerkorpi (2003) on patient perceptions of group exercise and education concluded; “Positive experiences of body were intertwined with a new relationship to self and objects in the world. Interactions between co-participants promoted the process of new patterns of thinking and acting in the social world.” Strength improvements were more difficult to yield with only knee concentric extensors changing of all the strength measures undertaken by Gusi (2006): “maximal isokinetic strength for knee flexors and extensors in concentric and eccentric actions at 60o/second and 210o/second, and in the shoulder abductors and adductors in concentric contractions.” Grip strength was measured by Jentoft (2001), finding greater improvement in their land-exercisers compared to the pool-exercisers. Mannerkorpi (2002) measured positive gains in grip strength over 10 seconds using the Grippit Method. Over time, Gowans (1999a) showed that enhanced walking distance, well-being and self-efficacy were maintained 3 and 6 months post aquatic intervention, while their recording of subject’s perception of fatigue and knowledge of fibromyalgia were lost. Six month follow-up by Jentoft (2001) similarly showed sustained improvements including cardiovascular capacity with cycle ergometry. Symptom severity, physical function, and quality of life measures (all SF-36) still showed improvement 6 months post intervention, and 2 years post-intervention gain was still noticeable for pain, fatigue, walking ability (6 minute walking test) and social function (Mannerkorpi 2002). Compared with land-based exercises, deep-water-running yielded faster change in Fibromyalgic Impact and higher recordings by patients of “global response to therapy” (Assis 2006). Similarly, pool-exercisers in the trial of Jentoft (2001) showed greater improvement in “number of days feeling good”, self-reported physical impairment, pain, anxiety and depression. Improvements in sleep were less dramatic among patients treated with conventional physiotherapy than those in the hydrotherapy group of Del Melo Vitorino (2006). LOW BACK What evidence?

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Fourteen papers were found to investigate and report on the effect of aquatic therapy on low back pain. Four systematic reviews (Pengel 2002, Liddle 2004, Guzmán 2005, and Hettinga 2007) were captured under the hydrotherapy search phrases of this present review that implied some form of hydrotherapy was included among some of the trials or some of the interventions. Thirteen randomized controlled trials (RCTs) met the inclusion criteria of Pengel (2002) investigating sub-acute low back pain of between 6 and 12 weeks duration, with one trial including hydrotherapy published in 1994. Sixteen RCTs of chronic low back pain, pain longer than 3 months, were reported by Liddle (2004). Guzmán (2005) investigated multidisciplinary rehabilitation for patients with chronic low back pain, including 10 RCTs of 1964 patients, with one trial including hydrotherapy published in German in 1990. Similarly, Hettinga (2007) captured one hydrotherapy trial among their 31 RCTs of higher quality evidence of the effectiveness of exercise interventions for non-specific low back pain greater than six weeks. The same hydrotherapy trial by McIlveen (1998) is reported by Liddle (2004) and Hettinga(2007). Three randomized controlled trials (RCTs) published less than 10 years prior to 2007 were found to investigate aquatic therapy for patients with low back pain, including Sjogren (1997, n=60) comparing a hydrotherapy program and land-based exercise in chronic low back pain, McIlveen (1998, n= 109) also investigating chronic low back pain with a highly cited trial of high quality, and Schrepfer (2000, n=49) who investigated acute low back pain of less than 3 months comparing a single session of alternative aquatic therapy approaches. Two experimental studies were reported by Barker (2003, n=26) with subjects experiencing chronic low back pain for more than 12 months, and Winter (2002, n=6) whose subjects were described with non-specific chronic low back pain. Two case studies are described by Vargas (1998, n=1) of an 87 year old man with chronic low back pain detailing a combination of aquatic therapy approaches, and Lorenzetti (1999, n=1) of a 49 year old man with low back pain subsequent to a fall at work. Four opinions on aquatic therapy for low back pain were published from Shepherd (1998) describing the application of manual physiotherapy technique in passive lumbar mobilization, Griffiths (2004) a physician recommending hydrotherapy in acute low back pain less than one week once screening for serious pathology was considered, and Konilan (1999) who presented a rationale for aquatic therapy with an exercise selection supported by references to previous publications. What treatment? McIlveen (1998) deservedly wins high appraise in the systematic reviews of hydrotherapy for chronic low back pain with an uncommonly thorough description of the exercise program with probable tolerance to clinical reproduction. Participants

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undertook group hydrotherapy for 60 minutes, twice weekly for 4 weeks. “Each hydrotherapy session was led by experienced pool volunteers, with additional training in delivering the prescribed 20 spinal exercises. Ten repetitions of each prescribed exercise were included during each session.” Briefly, the program included directional walking, marching, squats, side lunges, leg swings standing at the rail of hip flexion-extension and abduction-adduction, kneeling with pelvic rocking, hanging from the rail with trunk side flexion, standing a distance from the rail flexing and arching the trunk toward and away from the wall, water cycling, floating supine scissoring the legs in hip abduction-adduction, alternately extending the hips while supine, swinging the trunk into lateral flexion whilst supine, standing and rotating the trunk with the arms abducted, pushing and pulling a kickboard in front and raising it up and down, swinging the arms at the sides with hand paddles and across the water surface. Sjogren (1997) compared a twice weekly hydrotherapy program with a land-based exercise program over 6 weeks. “Both exercise group regimens lasted approximately 50 minutes, and were structured with similar components, including warm-up and cool-down components lasting between 5 and 10 minutes. The majority of time in each exercises regime was spent on exercises that were aimed at increasing truncal range of movement as well as improving general strength and endurance.” Similarity of exercise intensity between the groups was determined in a pilot study where subjects responded to the Borg Perceived Rating of Exertion scale. Schrepfer (2000) compared the effect on pain of a single 20 minute session of deep water walking versus deep water hanging in somewhat cool water of 84oF (29oC). “Deep water walk subjects were instructed to walk the length of the pool for 20 minutes at a brisk pace using a cycling motion with the lower extremities… Verbal cues were provided to adjust the deep water pace to maintain 60-80% of maximal heart rate. Deep water hang subjects were instructed to place the two buoyancy dumbbells under the axilla and to minimize active movement of the trunk and lower extremities for 20 minutes.” Barker (2003) investigated exercise intensity and the perception of exercise intensity in hydrotherapy. Sessions were 60 minutes long, and measurements were taken over four sessions. “They were instructed to exercise at a level high enough to become out of breath, but not to provoke their pain…. The session included 4 minutes warm-up, a 16 minute exercise period, and a 4 minute cool-down. General exercises included walking forward, backward and sideways, and jogging in the water. Other exercises were aimed at improving trunk range of movement and improving the strength, mobility, and endurance of the lower limbs and trunk. The exercises were progressed gradually and selected on the basis of the likelihood of improving symptoms without aggravating the patient’s pain.” Winter (2002) described a 12 week intervention of twice weekly aquatic lumbar stabilization and strengthening exercises over 40 minutes. The detail of exercise selection is described over a page. “Seven categories of exercise were established: water walking series, shallow upper extremity series, lower extremity series, seated

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vertical suspended series, deep water series, supine modified swim, and prone modified swim. Each category was further subdivided into three levels.” The case study by Lorenzetti (1999) of a 49 year old man who incurred low back pain following a fall at work, commenced hydrotherapy after 4 weeks and continued 3 times per for 16 weeks. Adjunctive therapy included chiropractic spinal manipulation and interferential therapy. “The patient performed the following exercises in 3 sets of 10 repetitions each in a variable depth pool with a treadmill floor. Resistance was provided by 3 water jets located at the front of the pool, each capable of pumping up to 400 gallons per minute. A stabilization bar is locked into the floor in order for the patient to fixate himself into a position while exercising against the force of the water jets and to stabilize himself against the buoyancy effect of the water, especially at higher depths. The patient began with a warm-up by walking the treadmill in waist deep water at 2-3 mph for 5 minutes. Water temperature was 89oF. Lumbodorsal spine range of motion exercises in each plane in the pain free range in a still pool was followed by warm-up exercises. The depth of water was adjusted to the patient’s range of motion for each plane so that the water was as deep as possible, but the patient could keep his head above water at the end range. This was done to maximize the decompression effect of the water. …. Next he began lower extremity exercises that included knee flexion and extension and hip flexion, extension, abduction and adduction all done in a still pool. Emphasis was placed on the pain free range of motion with the patient performing smooth continuous movements concentrically and eccentrically. This was done three times per week for 4 weeks, after which time resistance was added to the routine by water jets starting at 20% maximal pumping (80 gallons/min). The patient perceived this to be very low to low resistance. Water pressure was directed at the patient’s torso for spinal exercises and at the lower legs for lower extremity exercises.. After 4 more weeks, upper extremity exercises were added. Webbed gloves were used during treadmill walking as the patient moved his arms through the water for resistance. Forward and reverse flys were done with elastic cords with arms in the water to further work arm, shoulder, and chest muscles. After an additional 4 weeks, the patient was jogging on the treadmill at approximately 5-6 miles/hour with forced water jet resistance at 25% maximal pumping (100 gallons/min).” The case study by Vargas (1998) of an 87year old male with chronic low back pain describes 6 weeks of aquatic physical therapy undertaken 3 times per week and included applications of Halliwick, Watsu, Bad Ragaz, manual interventions (myofascial release, spinal distractions and deep friction massage for muscle spasm) and dynamic aquatic activities. The latter comprised directional gait training, “closed kinematic chain activities including stair climbing and wall sliding, bicycling, deep water reciprocal walking, deep water double knee lifts, active pelvic tilts, active knee to chest exercises, and resistive exercises for bilateral ankle dorsiflexors, evertors and invertors. Vertical suspension was incorporated into the treatment, as it provided the patient a position of comfort after completion of dynamic deep water activities.” The Halliwick, Watsu and Bad Ragaz components are supported in their description with 14 photos.

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What effect? Pain, disability and return-to-work were improved by hydrotherapy in patients with sub-acute and chronic low back pain as concluded by authors of the systematic reviews (Pengel 2002, Liddle 2004, Guzmán 2005, and Hettinga 2007). However, claims about the efficacy of hydrotherapy from systematic reviews are to be taken with caution due to the small numbers of hydrotherapy trials included among those of other interventions, and the older publication dates of the trials included within these reviews. Pengel (2002) concluded that “Evidence from high quality trials supports manipulation for reducing pain and disability, co-ordination of primary health care and wearing a corset reduces disability, and that transcutaneous electrical nerve stimulation (TENS) in combination with rehabilitation improves the return to work rate”. The hydrotherapy-relevant part of this statement is derived from the citation to Herman (1994, n=26) who investigated work-injured patients with sub-acute low back pain of less than 26 weeks duration. The intervention included 15 minutes of TENS, 15 minutes of acupuncture, and “rehabilitation” of hydrotherapy, mobility and strengthening exercises and cardiovascular training, versus placebo TENS and rehabilitation. Hydrotherapy was included in both the intervention group and the control group, the intended primary variable in this research design being TENS, and not hydrotherapy. The systematic review of Guzmán (2005) presents a similarly nebulous opinion of hydrotherapy. Multidisciplinary rehabilitation, appearing as multimodal rehabilitation, was under investigation in patients with chronic low back pain of longer than three months duration. The RCT of Jükel (1990, n=71) is the only citation inclusive of hydrotherapy. Inpatients received a 4-6 week program of hydrotherapy, physical modalities such as heat or cold applications and TENS, exercise and massage, which satisfied Guzmán et al to classify this intervention as “intensive therapy of greater than 100 hours per week”. From the critique of all 10 RCTs, Guzmán et al concluded: “(1) there is strong evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration improves function when compared with inpatient or outpatient non-multidisciplinary rehabilitation (2) there is moderate evidence that intensive multidisciplinary biopsychosocial rehabilitation reduces pain when compared with non-multidisciplinary rehabilitation or usual care (3) there is contradictory evidence regarding vocational outcomes of that intensive multidisciplinary biopsychosocial rehabilitation (4) regarding less intensive multidisciplinary biopsychosocial rehabilitation five trials (not Jükel 1990) could not show improvements in pain, function or vocational outcomes when compared with non-multidisciplinary outpatient rehabilitation or usual care”. Liddle (2004) and Hettinga (2007) whose systematic reviews conclude efficacy of hydrotherapy in chronic low back pain from the same RCT (McIlveen and Robertson 1998) do not specify an outcome domain that is positively influenced by hydrotherapy, but allude to strength gains. “Higher quality evidence particularly supports the use of strengthening exercises, (organized) aerobic exercises, general

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exercises, hydrotherapy and McKenzie exercises for back pain of at least 6 weeks duration” (Hettinga 2007) Function and disability in patients with chronic low back pain was measured by the Oswestry Disability Index in several trials. Improvement by hydrotherapy was recorded by McIlveen (1998), Barker (2003) and Sjogren (1997). The Bennett Valley Therapy Inc Low Back Functional Outcome Questionnaire, an analogue scale based on the Oswestry, was selected by Winter (2002) whose aquatic therapy subjects changed from severe disability to moderate disability. The Oswestry was also used to track changes in the case study by Lorenzetti (1999) showing a change from 44% disability rating initially down to 38% by the third, and presumably, final measure. Lorenzetti (1999) stated “the Oswestry Questionnaire outcomes were not encouraging and did not coincide with measured levels of progress.” Lorenzetti (1999) also used a computerized physical capacity test of ten isometric lifting tasks with gainful result post-treatment. Ambulatory function was an outcome selected by only a few investigators. The experimental trial of Sjogren (1997) found that 100m walk time was improved in both intervention groups following hydrotherapy and land-based exercise regimes. Improved gait characteristics and decreased reliance on a wheelchair were qualitative outcomes posed by Vargas (1998) from his single subject case report. Pain reduction was measured by several authors using the McGill Pain Questionnaire (McIlveen 1998, and Vargas 1998) and visual analogue scale (Sjogren 1997, and Lorenzetti 1999). Winter (2002) measured improved pain by the New Category Pain Scale by Borg. Barker (2003) investigated pain as it compared to perceived rate of exertion and intensity of hydrotherapy exercise finding that pain was not provoked by hydrotherapy, but pain perceptions limited exertion. Strength in patients with chronic low back pain was not widely investigated. Lorenzetti (1999), as mentioned above, recorded improved isometric lifting capacity in a single subject. Vargas (1998) reported improved lower limb strength by manual muscle testing of ankle dorsiflexors and evertors in a single subject. The higher quality and larger study by McIlveen (1998) failed to significantly affect lower limb strength by measure of manual muscle testing. Range of spinal movement was measured by the Schöber method by Sjogren (1998), McIlveen (1998), and Winter (2002) using a tape measure between surface land-marks during lumbar flexion, extension and lateral flexion. The measure was insensitive to significant change in all three trials. McIlveen (1998) also evaluated straight leg raise by hydrogoniometric measure, finding it similarly resistant to change by hydrotherapy.

Other measures not changed over the course of the hydrotherapy interventions included lower limb reflex status and light touch sensation (McIlveen 1998). Sjogren

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(1997) monitored changes in medication with 13 of 56 subjects changing to a smaller dose or a less potent type of analgesic. The subject in the case study of Lorenzetti (1999) achieved return-to-work nine months after injury. On comparability between Borg Rating of Perceived Exertion (RPE) and percentage heart rate of age-predicted maximum, Barker (2003) reported; “at workloads sufficient to induce an aerobic training response (55-85%), and yet be safe for patients with chronic back pain, RPE was an accurate predictor of exercise intensity. At lower intensities (<55%), back and leg pain may exert a mediating influence.” Comparing alternative interventions applied to patients with chronic low back pain, Sjogren (1997) found no difference between hydrotherapy group participants and land-based exercisers in pain reduction and improvement in function. In a single 20 minute session of deep water walking or deep water hanging, the mean change in pain for the deep water hangers was more than twice that of the deep water walkers (Schrepfer 2000). UPPER LIMBS What evidence? Ten papers were found to report on aquatic therapy for musculoskeletal conditions of the upper-limb. Two systematic reviews were identified. Watts (2007) provides a low quality systematic review of 7 papers including one randomized controlled trial. Hodgson (2006) reviewed rehabilitation of humeral fractures extracting evidence from eight studies, one of which includes water exercise. Kelly (2000, n=6) published an experimental study of shoulder muscle activation in healthy subjects. Palmer (1998, n=1) describes a case study of aquatic therapy for supraspinatus tear. Clinical opinions are posed by Schrepfer (1998) on manual techniques, Thein (2000) on aquatic therapy techniques for rehabilitation in athletes, Binkley (2002) on aquatic exercise prescription, Hirasawa (2002) on cubital tunnel syndrome of the elbow, Liotard (2003) on rehabilitation following rotator cuff repair and shoulder arthroplasty, and Gangaway (2005) on clavicle resection. Of significant note is the paucity of clinical trials investigating aquatic physiotherapy for upper limb conditions, with published report appearing to cover just 7 subjects and only one symptomatic subject. No randomized controlled trials of symptomatic patients appear to have been published in the 1997 to 2007 date range. Considering anecdotal popularity of aquatic physiotherapy for upper limb musculoskeletal conditions, clinical research is of urgent need. What treatment?

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Palmer (1998) describes a 14 week daily home aquatic exercise program for a 78 year old female with a supraspinatus tear. The patient was seen at the clinic for 10 sessions for monitoring and exercise progression. “A T-bar served as the foundation exercise tool for range of motion training underwater…The following motions were performed with the T-bar as the PT provided manual and verbal cues: shoulder extension, forward flexion, horizontal abduction, external rotation, shrug and scaption. Bilateral hand placement was a necessity in the early stages of rehabilitation. The patient performed shoulder shrugs independently as she held the T-bar bilaterally and anteriorly. Gentle muscle strengthening was accomplished with isometric holds in various joint positions. Isometrics were strongly emphasized by encouraging the patient to count aloud for 5-10 seconds (duration depended upon patient fatigue and comfort level). Exercise dosage was initiated at 5-10 repetitions and progressed to 3 sets without onset of pain. Phase 2 commenced at the 8th week and consisted of 3 levels of progression: 1) phase one exercises performed with light resistance theraband; 2) arm circles, biceps curls and internal/external rotation performed with webbed gloves; and 3) advancement to a functional strengthening program which included some work simulations such as sweeping.” Kelly (2000) compared muscle activation of rotator cuff and shoulder synergists during rehabilitation exercises performed in water or on land with electromyography. The motions were shoulder elevation (0-90o) in the scapular plane with neutral rotation at three different speeds (30 o/s, 45 o/s, and 90 o/s). As the papers of clinical opinion do not offer measurement of outcomes, their aquatic therapy treatment postulations are not further detailed in this guide (Schrepfer 1998, Thein 2000, Binkley 2002, Hirasawa 2002, Liotard 2003, and Gangaway 2005). Aquatic physiotherapists cannot consider these treatments to be supported by evidence until the proposed aquatic interventions are tested by clinical trial. What effect? Function, range of movement and strength in patients with upper limb conditions are influenced by aquatic exercise as supported by low quality evidence. Hodgson (2006) states of rehabilitation of proximal humeral fracture that “Electrotherapy or hydrotherapy does not enhance recovery and joint mobilisation has limited evidence of its efficacy”. This opinion is formulated from the result of one 1992 trial by Revay, Daelstrom and Dalen titled “Water exercises versus instruction for self training for shoulder fracture”. The authors fortunately concede “… more research is needed to test the efficacy of hydrotherapy”. Palmer (1998) measured functional limitations including personal care, performing household duties, driving, recreation and socialization utilizing a recording method of a computerized documentation system, “Therapy Report Programmes (Ventura California)”. Goniometric measurement was recorded of shoulder range of movement. Strength of rotator cuff muscles were measured by a “microfet” hand-held

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dynamometer, and grip strength measured by Jamar dynamometer. Pre and post measures were tabulated but not statistically analysed. Palmer (1998) summarizes outcome effects: “Upon discharge from physical therapy, the patient had regained her functional mobility and strength of the right shoulder complex such that she was no longer limited as noted during the initial evaluation…. Her final check-up with the orthopaedic surgeon confirmed her successful recovery without the need for surgical intervention… At the 2 year follow-up, the patient was able to demonstrate the overhand crawl for two continuous lengths of a 40-foot indoor pool.” Rotator cuff muscle activation as measured by waterproof intramuscular indwelling wire electrodes (supraspinatus, infraspinatus and subscapularis), waterproof surface adhesive electrodes (anterior, middle and posterior deltoids) and electromyography was investigated by Kelly (2000). Subjects were submerged up to their necks and elevated their shoulder from 0 to 90o in the scapular plane. Muscle activation during 30o/s and 45o/s test speed was significantly less when performed in water versus performed on land. The authors interpret; “ a raid rate of movement (i.e. 90o/s) appeared to be the point where buoyancy of water was overcome by the resistive effects of water.” They further postulate from their study of unsymptomatic subjects; “ for very painful and guarded shoulders, exercise and active motion in water may be an effective method for introduction of shoulder rehabilitation.” LOWER LIMBS What evidence? Four papers report on hydrotherapy for musculoskeletal non-arthritic lower limb conditions. Two papers investigated symptomatic subjects (Geigle 2001, and Katrak 2003,) the other two reporting on muscle performance factors in healthy subjects (Fuller 1999, and Petrick 2001). The number of symptomatic subjects investigated is astoundingly low considering the anecdotally regarded merit of hydrotherapy as a graduated weight-bearing medium in rehabilitation of lower limb conditions. Geigle (2001, n=2) reported on a comparative case study of two female athletes with lateral ankle sprain, one undertaking a rehabilitation program including land-based and aquatic therapy, the other undertaking only land-based therapy. Katrak (2003, n=2) reported on case studies of a 78 year old male and 53 year old female with chondrosarcoma and metastatic breast cancer respectively, who each underwent total femur replacement. Fuller (1999, n=51) evaluated the use of aquatic biofeedback on a specific closed chain exercise on land and in the water in healthy subjects in an experimental study. Petrick (2001, n=53) conducted a pseudo-randomized controlled trial of asymptomatic subjects who participated in progressive resistance quadriceps muscle training on land or in water. What treatment?

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Following acute inversion sprain ‘subject 1’ of Geigle (2001) undertook 60 minutes of land-based rehabilitation 4-5 times per week for 11 sessions, while ‘subject 2’ undertook 30 minutes of land-based therapy and 30 minutes of aquatic physical therapy 4-5 times per week for 15 sessions. The number of sessions was determined by a sport-specific functional assessment to determine return-to-sport. The aquatic physical therapy sessions included a 5 minute warm-up “to increase blood flow, and increase ankle range of motion comprising:

• laps with kickboard emphasizing ankle movement with varying lower extremity swim stroke patterns,

• walk in the shallow end (waist high) forward, backward, on toes, on heels, • progress to jog in waist high water.”

The subject then undertook “a 20 minute work-out divided into 5 minutes of open chain, and 15 minutes of closed chain activities:

• to increase ROM: ankle circles/ ankle alphabet, wall calf stretch (gastrocnemius and soleus), inversion and eversion stretch,

• to increase strength: bilateral calf raises, progressing to unilateral calf-raises (on ladder or block), step-ups, forward/reverse lunges with toe raise on involved side at mid stance (progressing to single limb propulsion at mid stance), single limb wall squat, lateral bounding, wall propulsion, jumping jacks with deep knee bend, and scissor jumps,

• to increase balance: single limb stance on involved leg with contralateral ankle alphabet (eyes open/eyes closed), single limb stance on involved leg with contralateral leg movement (flexion, abduction, adduction, extension), heel toe gait, Karaoke, side step, jump turn landing on bilateral lower extremities in squat position (progress to unilateral landing on involved side).”

The session was completed with “a 5 minute cool-down of: • jog to walk, • lower extremity stretch.”

The first subject of the case study by Katrak (2003) was a 78 year old retired farmer with grade I chondrosarcoma. “He underwent an en-bloc resection of the tumour together with excision of the entire femur, extra articular acetabular resection (including sections of gluteus medius and piriformis), and replacement of the femur, hip and knee joints.” The orthopaedic surgeon recommended “ no active straight leg raising or active hip abduction for 6 weeks and touch weight bearing for 12 weeks post operation to allow the allograft to become well incorporate”. The patient was transferred to rehabilitation unit two weeks post surgery. He commenced gym and hydrotherapy, starting at 30 minutes a day (for each activity), increasing over 4 weeks to 90 minutes. He remained an inpatient for two months while radiotherapy continued, and was not to receive outpatient rehabilitation because he lived a long distance away. “A hydrotherapy program was undertaken daily using the deep end of the pool and a hoist to transfer in and out. The exercises in water included walking forward and backward initially then sideways when active abduction was permitted at 6 weeks post surgery. Other pool exercises included mini squats, hip and knee flexion, and hip extension exercises. The patient was able to progress from 10 repetitions of each exercise to 30 and 40 repetitions within a 2 to 3 week period.”

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The second subject of the case study of Katrak (2003) was a 53 year old woman who developed metastatic disease seven years after mastectomy for breast cancer. She had “hot spots” on bone imaging and pathological fractures throughout the hip, femur and tibial plateau. She underwent resection of the entire femur, knee joint and 12 cm of the tibia and fibula with significant muscular and bone reconstruction. The patient was transferred to a rehabilitation hospital after 4 weeks. The orthopaedic surgeon advised “no active flexion of the knee, to wear a Zimmer splint (a knee orthosis with posterior, medial and lateral malleable bars and anterior Velcro straps to hold the knee in full extension) at all times including hydrotherapy, no active abduction of the hip or straight leg raise”. Hydrotherapy was delayed by two weeks due to methicillan-resistant Staphylococcus aureus. “After this period, exercises in the pool were performed with the Zimmer splint around the knee. They included, left hip extension, toe raises, and ankle range of motion exercises, walking forward, walking backward and general fitness work for the right lower limb and the upper limbs.” The experimental study of Fuller (1999) investigated electromyographic analysis of vastus medialis oblique during partial single leg squats on land and in waist deep water and chest deep water. The progressive resistance quadriceps muscle training in the study of Petrick (2001) involved training five times per week for 8 weeks with comparative land and water based programs following a modified DeLorme Protocol. “Exercises were done at 60 degrees per second (60o/s), this being the speed at which isotonic exercises are normally performed. To ensure that both groups exercised at this speed, the exercises were done to a tape recording of the beat of a metronome set at 40 beats per minute. Subjects would extend the knee on one beat, and flex on the next, extend again on the next and so on. In this way, with the knee travelling through 90o in one beat, the exercise would approximate 60o/s.” A baseline Ten Repetition Maximum (10 RM) was established as being the maximum weight the health young women could correctly lift ten times. “ At each exercise session, two sets of ten repetitions were done at each weight, starting at 50% of the ‘assigned 10 RM’ increasing to 75% of the ‘assigned 10 RM’ and ending with 100% of the ‘assigned 10 RM’. A rest of five counts was allowed between the two sets and 10 counts between changing weights…. The magnitude of the resistance offered by the exercises was the same in both groups. The land exercise group used sandbags while the water exercise group used plastic bottles filled with varying amounts of water, tied to their legs.” Further description and commentary is provided by the authors postulating the hydrodynamic forces that tend to effect knee flexion and knee extension. The exercise position in water is diagrammatically represented as prone over the pool edge with the hip flexed to 90o and knee flexion performed with the lower leg arcing from vertical to horizontal. “A warm up, consisting of jogging on the spot for two minutes and stretching the hamstrings and quadriceps muscles was done by all subjects.” What effect?

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Balance, ambulation and pain were outcomes reported to be effected by hydrotherapy. Geigle (2001) tracked the return of balance post ankle-sprain by measuring timed single limb stance with video analysis with eyes open and eyes closed. Each test was terminated when the uninvolved foot touched ground or postural sway was measured greater than 12o in the coronal plane or 16o in the sagittal plane. “The assessment of the aquatic intervention data indicates that there is a positive relationship between the use of a supplemental aquatic physical therapy program and performance on unilateral tests of balance following an inversion ankle sprain injury.” Swelling was measured as ankle girth using a “figure-of-eight method”, and while swelling decreased over time, the difference was not statistically significant. In the case studies of Katrak (2003) on rehabilitation following femur replacement, manual muscle testing and goniometric hip and knee range of motion was recorded prior to and on completion of hydrotherapy. Qualitative clinical observations of ambulatory function were noted. The 78 year old male subject demonstrated grade 2/5 strength of hip abduction, quadriceps and hamstrings, 35o of hip flexion, 65o of passive knee flexion and 40o of active knee flexion post-surgery prior to commencing hydrotherapy and inpatient rehabilitation. At 2 ½ year follow up, he was pain-free; “one crutch is still used in the right hand to aid mobility, but he can walk more than 2 km at a time. Hip range of movement is almost full and knee flexion is 85o.” The 53 year old woman was discharged home after 5 weeks, “could walk independently on elbow crutches and could manage stairs with supervision. The patient continued her rehabilitation on a day-only basis for another 12 weeks”. On discharge, she was walking with 1 cane and had achieved active hip flexion to 90o, 30 o of abduction, 20 o of adduction, 15 o of internal rotation, 30 o of external rotation, and active knee flexion to 85 o. After 2 years she was able to walk 800m with either 1 or 2 crutches. Study of muscle performance factors in healthy subjects included electromyographic (EMG) analysis of vastus medialis oblique (VMO) during squat in water (Fuller 1999). Recordings from the MyoTracII revealed EMG activity of “a mean of 128.5 microvolts on land, 63.6 microvolts in waist deep water, and 30.9 microvolts in chest deep water. Therefore the results showed that the muscular activity generated by the VMO in waist deep water is 50% of that on land and 25% in chest deep water.” Petrick (2001) measured isokinetic muscle strength of knee flexors and extensors at 60o/s and 270o/s finding no change following the 8 week land or water-based training. However, on isotonic testing using the Ten Repetition Maximum measure, significant strengthening occurred in both exercise groups. “The 10RM of the water group increased by 5.63kg and that of the land group by 5.34kg”. Exercise induced pain was also measured using a visual analogue scale. “Significantly more subjects in the land than the water group complained of pain while exercising.”

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3 Aquatic Physiotherapy in Neurology Previous systematic review of hydrotherapy found investigation of hydrotherapy applications in neurology to be scant (Geytenbeek, 2002). Investigation in neurology subjects is problematic in the difficult trial methodology, finding homogenous subject groups, and complex physiotherapeutic interventions inappropriate for generic group application. For the purpose of this evidence-based guide in the present era and status of evidence-based research in neurology, it was decided to positively discriminate toward any and all published papers reporting on aquatic-based therapy, irrespective of the level of evidence of each paper. Neurology diagnoses included papers reporting on stroke (3), acquired brain injury (3), adult cerebral palsy (4), multiple sclerosis (2), spinal cord injury (4), Guillian Barré syndrome (1), and post-polio syndrome (2). Aquatic therapy applied by physiotherapists or supervised physiotherapy students. Mostly individualized prescriptions. STROKE What evidence? Three papers reported on stroke including a randomized controlled trial (Chu 2004, n=12), a case study (Johnson 2002, n=1), and a single subject experimental study (Marklund 2006, n=5). What treatment? The aquatic-based interventions in these three trials were diverse and distinctly different. Chu (2004) instigated a therapeutic program with an aerobic intent, working to targeted heart rates progressing in three steps over 8 weeks. Johnson (2002) detailed a program of “wand” and “ball” exercises specifically aimed at the restoration of upper-limb function post stroke. Marklund (2006) describe a two week intervention titled “constraint induced mass practice” of which, in a 6 hour day of various therapeutic techniques, “pool training” was a component. Chu (2004) and Johnson (2002) selected 60 minute sessions, 3 times weekly, for 8 and 12 weeks respectively. What effect? Fitness, ambulation and function have been shown to be effected by aquatic therapy. Chu (2004) recorded effectiveness in improved cardiovascular fitness (VO2max) as measured by a symptom limited graded cycle ergometer test. Their subjects also improved in isokinetic dynamometric muscles strength in the paretic and non-paretic hip and knee. Both Chu (2004) and Marklund (2006) recorded improvement in gait parameters including speed over 8 meters (Chu 2004) and 10 meters (Marklund 2006), the six minute walk test (Marklund 2006) and Timed Up and Go test (Marklund 2006). Functional improvement was recorded in two of the trials including the

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Franchay Activities Index (Johnson 1998) and Fugl-Meyer functional diagnostic test (Marklund 2006). Johnson (1998) qualitatively observed of upper limb function improved exercise performance including pattern tracking, range of motion, assistance with the affected arm, stable balance, hand grasp, transfer from hand to hand in front- and behind- the body, reciprocal movement. Balance was investigated in two trials with Marklund (2006) recording an improved standing weight distribution, but subjects failed to achieve a significant change in the Step Test. Statistical significance was not achieved with the Berg Balance score (Chu 2004). ACQUIRED BRAIN INJURY AND INTELLECTUAL DISABILITY What evidence? Three papers reported on acquired brain injury and one paper reported specifically on severe and profound intellectual disability in a pre-experimental pre-post design (Jones 2005, n= 22). An alternating treatment single subject study was reported by (Driver 2003, n=3), a randomized controlled trial (Driver 2004, n=16), and a single case study by Keren (2001, n=1). Driver (2003 and 2004) investigated outpatients with acquired brain injury who were above level six (confused – appropriate) on the Ranchos Los Amigos Scale of Cognitive Functioning or who had experienced their brain injury for more than one year. The course of rehabilitation from acute to 3 years post accident was detailed by Keren (2001). What treatment? Driver (2003 and 2004) selected a therapy schedule of 60 minute sessions, three times per week, taking measurements over an eight week period. The intervention was individualized following three in-pool sessions trialling activities enjoyed by each subject and selecting activities specifically targeting the bodily areas most affected by the brain injury. These included areas where spasticity was greatest. Sessions were divided into 3 activity categories: (a) aerobic (b) resistance, and (c) a mixture of aerobic and resistance activities. During exercise sessions all participants used Polar Heart Rate Monitors and heart rate was kept between 50-70% maximum heart rate. Keren (2001) detailed a multitude of interventions used over the three year course of rehabilitation including casting, the use of orthoses, biofeedback, hippotherapy, medication and nerve blocks for reducing spasticity. Hydrotherapy was instituted from 22 months post injury in a day care setting. Jones (2005) investigated a 16 week physiotherapist-devised programme. “It provided access to a needs-led high frequency (three to five additional periods of exercise per week), low impact exercise program involving moderate to low levels of activity. The senior physiotherapist and nursing staff used findings from a physical function assessment to design an exercise regime for each individual service user that was appropriate to their needs and included progression where appropriate…. The exercise program was based largely on a rebound therapy programme but also included the most appropriate activities from such as active exercises, passive

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exercises, swimming, hydrotherapy and team games, body awareness, and specialist activities for single service user.” What effect? Strength, flexibility, range of movement, fitness, affect and esteem, and goal attainment were measured to be effected by aquatic therapy. The Physical Activity Affect Scale (Driver 2003) measured improved chronic and acute feeling states of increased positive affect, decreased negative affect, decreased fatigue, improved tranquillity, lessened stress and reduced aggression. The Physical Self-Description Scale (Driver 2003) measured improved self-esteem and physical self-concept in strength (increased), body fat (moderate effect), endurance (increased), coordination (increased), flexibility (increased), and self-esteem (increased). Sub-maximal cycle ergometry to 75% of theoretical maximum was used to record improved fitness (Driver 2004). Body composition by skin-fold thickness improved, as did dynamometric grip strength, flexibility by the sit and reach test and goniometric range of movement of elbow flexion, hip flexion and extension and knee flexion (Driver 2004). Shoulder flexion and extension, elbow and knee extension remained unchanged, and no improvement in muscular endurance by the Modified Curl-up was recorded (Driver 2004). Jones (2005) investigated effectiveness by Goal-Attainment Scaling, or “monitoring of (subjects’) progress towards individualized goals.” Individualized patient goals were set in areas in which the programme was designed to have an effect including behaviour, inclusive access to community-based experiences, health and physical-competence targets. Statements operationalising five levels of attainment were set for each goal. Examples of this outcome measure unfamiliar to physiotherapist clinicians were tabulated. The authors concluded “changes in goal attainment were concurrent with global clinical impression scores” and improvement in the Aberrant Behaviour Checklist (58 items: irritability and agitation, lethargy and withdrawal, stereotypic behaviour, hyperactivity and non-compliance, inappropriate speech). Health Indicators were unchanged by the intervention, including resting pulse, blood pressure, oxygen saturation, weight, height, body mass index, or seizure frequency. ADULT CEREBRAL PALSY What evidence? Four papers reported on adult cerebral palsy, including a longitudinal study (Jensen 2004, n=50), a literature search (Maynard 2004), a retrospective case report (Thorpe 2000, n=1) and a case series (Voglte 1998, n=6). What treatment? Chronic pain among adults with cerebral palsy was investigated by Jensen (2004) over a two year period. Subjects were surveyed on their use of a wide variety of treatments (17) intended for pain relief, among which was aquatic therapy. The report

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by Maynard (2004) tracked a logical attempt to guide aquatic based treatment for an individual with cerebral palsy from the published evidence. A water-walking program was hence-forth developed comprising sessions of 30 to 45 minutes duration. Thorpe (2000) selected aquatic therapy three times weekly, for 45 minutes sessions over ten weeks for an individual patient whose case details were presented in the report. “Each session began with 15 minutes of stretching exercises performed in the water addressing the heel-cords, calves, trunk and pelvis, hip flexors, quadriceps and hamstrings. The next 20 minutes were spent performing lower extremity resistive exercises for hip flexors and extensors, knee flexors and extensors, hip abductors, and dorsiflexors in waist to chest deep water while holding onto a side rail in the pool. Each exercise was performed for 10-15 repetitions bilaterally and progressed as tolerated. A program trainer assisted with stabilization for the stretching and resistive exercises. The last 10-15 minutes of each session was spent water-walking. When an increase in resistance was indicated, Hydro-Tone Boots were used to perform all exercises and for water-walking.” Voglte (1998) selected a combination of individual and group delivery, twice weekly, recording patient response to treatment over seven weeks. “The same WATSU sequence (15 minutes) was used with all subjects (tabulated). Many of the specific manoeuvres were modified to accommodate each client’s range of motion restrictions. Other modifications to the techniques included the use of floats (i.e. the use of small flotation cuffs placed distal to the knees, and short water noodles to support the legs). After approximately 45 minutes of WATSU a 15-20 minute Halliwick method group session was conducted. Activities used were designed to improve head, trunk and extremity control. Although all clients participated in the same activities, the difficulty of activity was modified to the client’s capabilities by adjusting the amount of manual guidance provided by each student therapist”. What effect? Pain, function, ambulation, self-perception, strength and range of motion proved amenable to improvement by investigators of aquatic therapy for adults with cerebral palsy. Aquatic therapy rated as providing at least moderate relief (as defined by a rating of ≥5 on the 0-10 relief rating scale) 6 months and 18 months into the trial period by Jensen (2004). However, the Numerical Pain Rating Scale was insensitive to change (Jenson 2004). Voglte (1998) used facial expression to determine pain status with a positive effect measured. Ambulatory status, use of aids, distance, endurance and speed improved with aquatic therapy in the case example of Thorpe (2000) as measured by unaided stance time, Timed Up and Go, Energy Expenditure Index (in a 3 minute walk test), and Functional Reach Test. Improvement in function was indicated by Gross Motor Function Measure (dimensions D and E) (Thorpe 2000) but “ease of care” (lift, dress, bathe) did not change according to a rating scale used by the carers of subjects in the study of Voglte (1998). The Adult Self-Perception Profile proved sensitive to change (Thorpe 2000) while the Social Interaction Status – Adaptive Behavioural Scale: Residential and Community Edition, did not change (Voglte 1998). Passive range of motion improved (Voglte 1998) as did dynamometric isometric lower extremity strength (Thorpe 2000). Physiological parameters noted by Voglte (1998) during the aquatic therapy sessions included a

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measured decrease in heart rate and systolic blood pressure while diastolic pressure was unaffected by the immersion and exercise. MULTIPLE SCLEROSIS What evidence? Two papers reported on multiple sclerosis including a case report (Coco 2006, n=1), and a pre-test / post-test quasi-experimental study (Roehrs 2004, n=19). What treatment? Sixty minute aquatic therapy sessions were selected by both Coco (2006) and Roehrs (2004) each using individualized programs delivered by physiotherapists. The intervention was applied three times weekly by Coco (2006) and twice weekly by Roehrs (2004), with measurement periods of 15 and 12 weeks respectively. Both researchers selected cooler than thermo-neutral water at 28oC as recommended in previous literature for patients with multiple sclerosis and affirmed by Coco (2006) who, in their single case study, found the initial warmer temperature of 32oC fatiguing and intolerable. Coco (2006) briefly described their intervention: “the rehabilitative program included 4 types of exercises (passive mobilization, leg muscle potentiation, abdominal muscle potentiation, and postural and walking re-education”, tabulating progressions in minutes for each exercise category over time. Roehrs (2004) provided a list of exercises of the class in an appendix. What effect? Strength, function, fatigue and quality of life were parameters assessed for benefit by aquatic therapy. Coco (2006) tracked improvements in lower-limb strength by Manual Muscle Testing of the hip flexors, extensors, abductors and adductors, knee flexors and extensors, ankle dorsiflexors and plantar flexors. Functional benefit was measured by the Functional Independence Measure (Coco 2006) which perhaps contrasted with an unchanged score on their Kurzke Expanded Disability Status Scale: physical impairments. Both researchers measured improved fatigue, with Coco (2006) selecting the Fatigue Severity Scale, and Roehrs (2004) using the Multiple Sclerosis Quality of Life Inventory. This scale also suggested a perception of improved social support which was paralleled in the results of the Short Form 36 where the subscale of social function increased. SPINAL CORD INJURY What evidence? Four papers reported on spinal cord injury including a cross-over experimental study (Gass 2002, n=4), a single case study (Stowell 2001, n=1), a controlled experimental study (Thomaz 2005, n=23), and a control case-matched study (n=20) (Kesiktas 2004, n=20).

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Gass (2002) and Thomaz (2005) studied physiological parameters of immersion for consideration in selecting aquatic exercise programs for tetraplegic patients. On 60 minutes of seated immersion to the depth of the nipple line at 39oC, Gass (2002) measured relative changes in plasma volume and haemodilution. Both rectal temperature and heart rate increased (Gass 2002). Thomas (2005) also studied seated immersion, however to shoulder depth, in isothermic water (33.5 – 34.5 oC), measuring respiratory parameters after 5 and 15 minutes. Specifically, FVC (Forced Vital Capacity) and FEV1 (Forced Expiratory Volume in 1 second) improved. FEV1 / FVC ratio decreased. Slow Vital Capacity (SVC) increased by 25%, the mean IC (Inspiratory Capacity) increased, while there was no change in ERV (Expiratory Reserve Volume). Thomaz (2005) drew the conclusion that while vital capacity reduces during the immersion of normal patients, in tetraplegic patients, breathing mechanics are improved by immersion. Stowell (2001) described a combined land-based and aquatic therapy program for a patient with an incomplete C6 spinal cord lesion, selecting twice weekly, 50 minute sessions over 16 weeks. “Land-based treatment sessions consisted of sit-stand transfers training and FWB (full weight bearing) gait training with a rolling walker and appropriate lower extremity bracing. Each aquatic session consisted of closed-kinetic chain lower extremity exercises, supine facilitation exercises, reciprocal gait training in deep water and ambulation with assistance in waist deep water.” Kesiktas (2004) focused their study on the management of spasticity with multiple modalities including passive range of motion exercises twice a day, oral baclofen and 20 mins water exercises at 81oF (27oC) over ten weeks. “Patients were placed into the pool either with or without a flotation device to assist them. Floats (such as rings for the trunk and extremities) paddle boards, slippers, parallel bars, and weighted stools or chairs were used during hydrotherapy.” What effect? Spasticity, function, ambulation and lower limb strength was improved. Kesiktas (2004) measured improved spasticity using the Ashworth Score and noting decreased oral baclofen intake. The Functional Independence Measure indicated improved ambulation. Stowell (2001) measured improved ambulation by the maximal distance ambulated and amount of assistance required (Stowell 2001). Improved muscle performance was indicated by the American Spinal Cord Injury Association lower extremity scores and muscle activation by surface electromyography of key muscles. GUILLAIN BARRÉ SYNDROME What evidence? One single case study (n=1) (Taylor 2002) reported on aquatic physiotherapy for a ventilated patient with Guillain Barré syndrome.

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What treatment? Six months following the onset of paralysis by Guillain Barré syndrome, hydrotherapy was instituted for the inpatient with 30 minutes sessions, three times weekly over 28 weeks. The report details the practical effort and precautions taken with the ventilated patient in the pool, and particularly notes the assistance and number of health personnel required to successfully treat the patient with hydrotherapy. Of the aquatic physiotherapy program, “a flotation pillow was removed from one limb at a time and a combination of neutral and buoyancy resistant exercises were performed.” Initially this included: hip extension (against buoyancy), hip abduction and adduction (neutral buoyancy), arm abduction with external rotation (neutral buoyancy), arm adduction (neutral buoyancy), and familiarization with the pool environment and floating sensation. Later, independent sitting on step with trunk movements from side to side, forward and backwards were included. Later again, assisted standing and walking across the pool was achieved. POST-POLIO SYNDROME What evidence? Two papers reported on post-polio syndrome including an evidence-based clinical opinion (Jubelt 2004) and a controlled trial (Willen 2001, n=28). Jubelt (2004) provides a contemporary over-view of post-polio syndrome, clinical features and interventions, stating “cardiopulmonary conditioning can be improved without muscle over-use in patients with post-polio syndrome with cycling and dynamic aquatic exercise”. Jubelt’s reference to research evidence for aquatic exercise is of the study by Willen (2001) who studied physiotherapist-led group-delivered aquatic exercise in 40 minutes sessions, twice weekly over 20 weeks. The program, “accompanied by music… was designed to train general physical fitness including resistance and endurance activities, balance, stretching and relaxation. The participants were told to pace the exercises at an intensity level where muscle fatigue was not present during or after the training session including the night after.” Willen (2001) provides a table of 12 exercises included in the program in adequate detail. What effect? Pain and fitness were improved by the aquatic intervention. The Nottingham Health Profile (pain dimension) was used to indicate improvement in pain. Willen (2001) measured a reduction in heart rate for the same watt level in a cycle ergometry test and improved anaerobic threshold. However, peak load, peak VO2 and peak heart rate did not change.

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4 Paediatric Aquatic Therapy Reviews of evidence for paediatric aquatic therapy have been previously published. Dumas (2001) reports: “In 1983, an annotated bibliography titled Aquatics for Disabled Persons was published in a special edition of Physical and Occupational Therapy in Pediatrics. The bibliography included summaries of books pamphlets and journal articles published between 1965 and 1981 that described aquatic therapy for children with cerebral palsy, mental retardation, muscular dystrophy, spina bifida and blindness….. Our review focuses on articles in the rehabilitation literature that relate to the use of aquatic therapy for children and adolescents with neuromuscular and musculoskeletal diagnoses…. We reviewed research reports, case reports, and clinical practice articles published between 1979 and 1999.” Dumas (2001) presented 17 articles including three experimental designs, five case reports, and seven clinical practice articles. Two of these reports (Hutzler 1998, and Figuers 1999) satisfy the 10 year date-range and definitional criteria of “hydrotherapy” for this aquatic physiotherapy evidence based practice guide. Diagnoses included in the report by Dumas (2001) include cerebral palsy (Hutzler 1998 (n=46) and Penganhoff 1984 (n=1)), spinal muscular atrophy (Cuhna 1996 (n=50), and Figuers 1999 (n=1)), high risk neonatal infants (Sweeney 1983, n=3), Waarenburg’s syndrome (Duvall 1999, n=1), mild neurological dysfunction (Attermeier 1983, n=1), and deaf-blind (Harris 1983, n=1). Getz (2006) undertook a systematic review of evidence supporting aquatic interventions for children with neuromotor and neuromuscular impairments. Eleven articles of 173 returned from searches of electronic databases met the inclusion criteria and covered articles published between 1974 and 2003. Five of the 11 articles were published between 1997 and 2007. These include two similar controlled trials by Hutzler (1998a, n=46, and 1998b, n=46) who investigated cerebral palsy. A case-study of an 8 year old child with spastic diplegia was reported by Mac Kinnon (1997, n=1) but was unretrievable for review for this guide. A case study of an 11 year old child with Rett Syndrome was reported by Bumin (2003, n=1), and a 1 year old infant with spinal muscular atrophy by Figuers (1999, n=1). The search for evidence for paediatric aquatic physiotherapy for this evidence-based guide of 1997 to 2007 returned papers including diagnoses of autism, cerebral palsy, complex regional pain, intellectual disability, juvenile idiopathic arthritis, neuromotor impairment, Rett syndrome, and spinal muscular atrophy. AUTISIM What evidence? Hulls (2004) recognized anecdotal evidence of the benefit of aquatic therapy for children with autism and an absence of research studies. “One of the first steps in establishing a new line of research is to identify the key dependant variables. This poses a problem in a condition such as autism where the wide ranging nature of

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associated impairments results in a large number of potential outcomes… Some outcomes of interest are difficult to operationally define and measure (e.g. increased eye-contact). In order to maximize research efforts in this area, it would be helpful to identify the outcome measures most likely to change as a result of aquatic therapy prior to conducting intervention studies.” Hulls (2004) developed a survey to identify occupational therapists’ perceptions of benefits of aquatic therapy for children from 4 to 10 years old with autism. What treatment? Survey respondents indicated a median length of aquatic therapy sessions to be 45 minutes, ranging from 30-60 minutes. The frequency of sessions was 4 per month (median, range from 1–8). The duration of treatment varied greatly depending on the child, with the shortest noted to be 3 months and the longest 2 years. What effect? From 18 surveys “ The majority of therapists indicated a substantial increase in skill performance in seven of these (23) outcomes: performing swim skills (72%), concentrating or paying attention (61%), muscle strength (61%), maintaining balance (61%), tolerating touch (61%), initiating and maintaining eye contact (56%), and demonstrating water safety (56%). …. 83% of therapists felt that children performed less self-stimulating behaviours as a result of aquatic therapy. Eighty nine percent of families reported that they participated in more water activities since the beginning of aquatic therapy sessions... Open-ended sections of the survey identified the following as showing a substantial increase in performance as a result of aquatic therapy: toleration of supine position, reciprocal upper extremity movement, bilateral motor co-ordination, gravitational security, motor modulation, lip closure, blowing air out of lips, body awareness, sensory modulation, seeking appropriate input, motivation, making transitions, impulse control, risk taking, expanding out of comfort area, participation in extra-curricular activities, self-initiated play, and nutritional intake…. and activities of daily living.” CEREBRAL PALSY What evidence? Four papers report on aquatic therapy for children with cerebral palsy. The literature review by Dumas (2001) includes two reports, with one case study of a 14 year old girl undertaking a swimming program (Penganhoff 1984). Controlled trials are reported by Hutzler (1998, n=46) and Getz (2007, n=22), and a clinical opinion is offered by Kelly (2005). What treatment?

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Investigating respiratory function and water orientation skills in 5-7 year old children with cerebral palsy, Hutzler (1998) conducted a six month study of a twice weekly movement and swimming program. “Physical therapy programs have emphasized treatment intended to stabiles muscle tone, conserve range of motion, and increase motor development. Less attention has been directed at secondary disorders such as (1) increased adiposity, (2) low muscle force, (3) subnormal aerobic and anaerobic power, (4) decreased mechanical efficiency, and (5) considerably decreased respiratory function.” Subjects included 19 children with spastic diplegia and 17 with hemiplegia. Twenty one were independent walkers and 16 used walking aids. The control group received two 30 minute sessions of Bobath therapy per week. The intervention group received the additional aquatic therapy program. “The program consisted of two sessions per week of individual aquatic exercise consisting of water orientation skills and one session per week of group movement exercise (composed mainly of locomotion and ball-handling exercise). Each aquatic and gymnasium session lasted 30 minutes and a ratio of 66 to 33% of aquatic to gymnastic exercise was provided.” Getz (2007) investigated perceived physical competence and social acceptance in 3 to 6 year old children with spastic diplegia, comparing four month, twice weekly 30 minute session of aquatic intervention against land-based intervention. The aquatic intervention was described as: “The 10 point plan of the Halliwick Method, which includes water adjustment skills, longitudinal rotations, sagittal rotations, and swimming skills was used. Flotation devices were not used. Sessions were constructed of three parts: (1) the first 5 minutes of each session were devoted to a structured group activity with six children and their instructors; this part encouraged mental adaptation to their aquatic environment and was accompanied by rhythmic children’s songs that were repeated throughout the program, (2) the second part consisted of a 20 minute period during which the children practiced individually or in pairs according to treatment goals; and (3) the last 5 minutes of each session was devoted to group activities and children’s songs , and were aimed at ending the session and disengaging the children from the aquatic environment”. The land-based exercise intervention included physiotherapy once per week and an adapted activity program including fundamental motor skills such as walking, stepping over obstacles, climbing, throwing and catching objects. The literature review and clinical opinion reported by Kelly (2005) comments on land-based and aquatic exercise for children with cerebral palsy. Kelly (2005) makes a distinction between exercise and activity, and exercise and therapy. ‘Aquatic therapy’ is noted to comprise of “interventions in the water that are not intended to produce a fitness effect.” The emphasis is then made toward exercise: “Aquatic exercise is a unique form of exercise that may be particularly useful for improving fitness levels of children with cerebral palsy. However several factors need to be considered when implementing aquatic exercise in children with cerebral palsy. These include the following: (1) ensuring adequate intensity, duration and frequency to promote a fitness effect; (2) determining when a group environment may be more beneficial than individual interventions; and (3) making sure that the pool environment is

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suitable and safe for intervention.” Of intensity, Kelly recommends aquatic exercise that is 30-60 minutes long, on most or all days of the week, at 60-70% maximum oxygen uptake or 70-80% maximal heart rate. She suggests monitoring of intensity by waterproof telemetry or a scale of perceived exertion such as the Children’s OMNI Scale of Perceived Exertion. “A variety of exercises may be used to target aerobic fitness in the water for children with cerebral palsy, including length swimming, shallow water tuck jumps, stride jumps, jumping jacks (star jumps), on-the-spot and propulsive running, and wall and sit-kicking (i.e. holding onto the ledge and kicking). Participation in aquatic exercise may be facilitated by support from the wall, a foam ‘pool noodle’ (a long flexible buoyancy aid), a floating kickboard, a floating barbell, a life or neck jacket, or another person (skilled in working in the water with individuals with physical disabilities).” Kelly (2005) suggests using velocity and drag to target muscle strengthening, and that group work provides motivation, peer modelling and social stimulation by the use of games, races, and co-operative activities. What effect? Respiratory function and water skills have been measured to improve in children with cerebral palsy by their participation in water exercise (Hutzler 1998). “Aquatic intervention appears to have a positive effect on perceived social acceptance and social function as reported by care givers” (Getz 2007). Using a calibrated 9 litre turbine spirometer, vital capacity was measured and compared against child norms with arm span used in the prediction equation rather than height. An adapted version of the Water Orientation Checklist was used to record the degree of adjustment to water and swimming skills. With 23 items and Lickert scaling “completing the full set of criteria would mean independent skilled swimming of at least one lap (25m) in the rough form of any stroke (breaststroke, backstroke and crawl).” “A marked reduction of respiratory function in children with cerebral palsy compared with normal children, adjusted for age, weight and arm span (23 – 35% predicted values at base line) was observed at baseline (Hutzler 1998). Vital capacity increased in both groups but was much higher in the treatment group. “The movement and swimming program seems to be beneficial in improving respiratory muscle function and modifying learned postural responses that prevent efficient breathing in children with disabilities.” Comparing types of neuron-motor impairment, “baseline results indicated significantly lower raw vital capacity values for children with spastic quadriplegia than children with either spastic hemiplegia or ataxia / athetosis. These children should receive particular attention when developing future programs and treatment designs.” Hutzler (1998) successfully measured significant change in the water orientation skills score with the aquatic intervention, and found a significant relationship between vital capacity and water skills orientation.

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Getz 2007 measured social function using the Paediatric Evaluation of Disability Inventory (PEDI) social function domain, finding no difference between land-based and aquatic interventions and no difference in pre-post measures. However, there was a significant difference measured in the caregiver’s social domain in the aquatic group not recorded in the land-based group. The Pictorial Scale of Perceived Competence and Social Acceptance was used to measure physical and social competence finding no difference between the groups that both recorded improvement over the 4 month interventions. The effect size indicated that the aquatic group yielded better gain in social acceptance. The Aquatics Independence Measure was used to assess the children’s level of skill acquisition in the aquatic environment finding significant difference between pre and post test scores. COMPLEX REGIONAL PAIN What evidence? One paper reported on the inclusion of hydrotherapy in an intensive exercise therapy program for the treatment of childhood complex regional pain syndrome (CRPS). This was a prospective study of 103 children (median age 12.7 years, range 7.7-21.1), with 49 followed for more than 2 years Sherry (1999). What treatment? The intensive exercise program was delivered to a majority of patients treated in the 1980s as inpatients (60). Due to insurance changes over the years, the majority of those treated in the 1990s were outpatients (31). “The duration of exercise therapy was 5-6 hours daily for most. Four hours were divided by occupational and physical therapy and 1-2 hours consisted of hydrotherapy in a heated (34oC) swimming pool. All patients also had evening and weekend home exercises programs that would take from 45 minutes to 3 hours to perform… The mean duration of exercise therapy was 14 days (range 1-90), but over the past 2 years had decreased to 6 days (range 1-25).’ “Our program stressed function almost exclusively through aerobic exercise training rather than progressive resisted exercises…Therapeutic activities for the lower extremity included jumping activities, running up and down stairs, various bilateral co-ordination movements (such as mini-trampoline, skiing, jumps, and jumping jacks), and relevant age-appropriate physical education simulated activities and sport drills. Upper extremity exercises concentrated on weight bearing, functional activities (such as wall washing and hand writing), and co-ordination drills. Hydrotherapy was administered in a pool and focused on specific limb exercises and general aqua aerobic training.” What effect?

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Pain and function comprised the outcome measures of interest. Psychological evaluation was also undertaken and the authors comment on this with respect to predictors of recurrent symptoms and poorer outcomes. Pain was measured by visual analogue scale, and dysfunction was measured by self-report and observation – participation in physical education, dressing one’s self, endurance walking or ability to open a car door “Complete resolution of pain and full function were observed in 92% of patients.” Long-term follow up (> 2 years) revealed “88% with no symptoms of CRPS, and 15% had had recurrent episodes of disproportional pain (with or without symptoms of autonomic dysfunction) that resolved with reinstitution of an exercise program. One child was still dysfunctional with CRPS, and 10% had mild pain but were fully functional.” Out patient treatment was less effective than inpatient treatment. JUVENILE IDIOPATHIC ARTHRITIS What evidence? Two papers were found to report on the effectiveness of aquatic physiotherapy for children with juvenile idiopathic arthritis. Takken (2001, n=10) presented a pilot study of a pretest – post-test experimental design of 5 to 12 year old females, and Epps (2005, n=78) a substantial randomized controlled trial of 4 to 19 year old males and females with a significant economic analysis of cost-effectiveness and reporting over 76 pages with 99 references. What treatment? Takken (2001) selected a 15 week program devised by a paediatric physical therapist and exercise physiologist with children working in groups of 2-4 for weekly sessions each 60 minutes long. “The aim of the study was to investigate whether an aerobic aquatic training programme could improve not only the endurance of JIA patients but also the functional ability and health related quality of life… The training took place in a heated swimming pool (32oC)… The training started with a warm-up followed by a conditioning part. The training ended with a cooling down. The warm up, rest and cooling down periods consisted of low intensity swimming, aquaerobics, play, flexibility exercises, or ball games. The conditioning parts consisted mainly of high intensity swimming, diving, walking through the water, aquajogging or splashing with the legs. The duration and intensity of both conditioning parts increased stepwise during the program. During the training sessions the heart rates of children were measured using a portable heart rate monitor to get an impression of training intensity and overreaching.” Epps (2005) randomized subjects to either a land-based exercise group or a combined intervention group of land-based exercise and hydrotherapy. Both groups exercised for 2 hours, the combined group exercising for 60 minutes of land-based exercise followed by 60 minutes of hydrotherapy. Sixteen treatments were delivered

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over two weeks, followed by weekly or fortnightly land Physio and “usual activity”. Swimming was allowed as “usual activity” in both groups, but the land-based group was not to undertake any hydrotherapy in the post-intensive therapy phase. Seven highly experienced physiotherapists conferred to determine an optimal treatment protocol and tested the treatment protocol on a number of patients before the trial. This level of scrutiny and consensus to formulate an exercise–based intervention appears unique among the aquatic therapy literature and stands as an attempt to standardize the application of physiotherapy craft. “Exercise were designed to increase range of motion, muscle strength, function, independence and fitness. They included passive stretches and hold-relax techniques, which were performed in each restricted anatomical direction of movement at any of the child’s joints affected by the disease process. A muscle strengthening program incorporated the use of repetitive movements… hydrotherapy exercises incorporated hydro-static and hydrodynamic principles, hold-relax techniques, passive stretches and simulated function and aerobic activity. The position of the patient when performing the activity was varied so that buoyancy could be used to assist or resist the movement. The muscle force needed to generate movement was also varied by the use of flexing or extending the limb (leverage), altering the speed of movement performed (creating water turbulence), altering the streamlining of the limb (using flippers or bats) and using partially or fully inflated floats.” The exercise programs were described in detail in two of five appendices over seven pages each, with a high chance of influencing trial and clinical reproduction. What effect? Function, ambulation, strength, fitness, health-related quality of life, disease activity and cost effectiveness were measured with variable results. Takken (2001) measured functional ability with the Childhood Health Assessment Questionnaire showing a trend to improvement that was not statistically significant and returned to baseline within the study period. A Juvenile Arthritis Quality of Life Questionnaire measured domains of physical function, psychosocial function, general symptoms, and pain. Scores improved insignificantly, however, there was a trend to relapse three months following the intervention which achieved statistical significance. Endurance was measured problematically with the Six Minute Walk Test. A proportion of subjects were unable to attempt the test at various stages of the study due to disease activity, pain or fatigue. Statistical significance was not achieved. The secondary outcome measures selected by Epps (2005) of cardiovascular fitness, isometric muscle strength, and patient satisfaction were improved by the exercise therapy. Physical fitness was measured by cycle ergometry with a protocol adapted for joint stiffness. Peak isometric muscle strength of the knee extensors and hip abductors were affected by the exercise therapy as measured by hand-held dynamometer and maintained at 6 months in the combined therapy group. Shoulder

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abduction strength was not affected. Knee extension strength, fitness and endurance improvements were greater in the combined therapy group. Change in pain was negligible in both groups. Patient satisfaction was determined by a physiotherapist assistant independent of the trial asking “If you could choose either gym exercises or exercises in the pool, which would you like better and why?” Eighty-nine percent of patients in both groups preferred hydrotherapy exercise for reasons of: “adherence with exercise, easier and less painful to exercise and fun and enjoyment” (Epps 2005). Disease improvement was determined as a decrease of greater than 30% in any three of six core set variables without there being a 30% increase in more than one of any of the remaining three variables. All core measures improved in both groups including number of active joints, number of stiff joints, Childhood Health Assessment Questionnaire (measuring function in 8 areas: dressing and grooming, arising, eating, walking, hygiene, reaching, grip and activities), visual analogue scale of physician assessment of global improvement, visual analogue scale of parent’s assessment of child’s global wellbeing, and erythrocyte sedimentation rate (Epps 2005). However, on cost-effectiveness, Epps (2005) concludes “There appears to be no evidence to justify the cost of building pools or initiating new services specifically for use in this disease.” This summary was determined by measures of Health Service Resource Use including inpatient-outpatient care, GP visits, drugs, interventions and investigations, and Productivity Costs including parents time away from paid work. Economic analysis was undertaken using the Health Related Quality of Life measures, EQ-5D and Quality-Adjusted Life-Years. “The gains in disease improvement during intervention were insufficient to affect HRQoL meaningfully and have QALYs gained in either group, and although more patients improved in the land than the combined group, the difference was neither clinically nor statistically significant.” RETT SYNDROME What evidence? Two papers were identified to report on aquatic therapy for Rett Syndrome. Lotan (2004) espouses the potential benefits from the treatment modality but does not provide evidence of effectiveness with measurement in a clinical opinion, and Bumin (2003, n=1) describes a short case report of an 11 year old girl. The systematic review of Getz (2006) also captured the paper by Bumin (2003). What treatment?

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Bumin (2003) described twice weekly aquatic physiotherapy applying the Halliwick method for eight weeks with three measurement points; before therapy, five minutes after a single session, and following the eighth week. What effect? Observational measurement by video analysis indicated a reduction in the number of stereotypical movements (Bumin 2003). Hand-to-mouth, and hand squeezing movements disappeared, although hand wringing appeared. “Feeding skills, and hand skills in transferring objects and holding them for 10 seconds improved.” Gait apraxia, trunk ataxia and imbalance found initially gave way to improved walking balance, increased interaction with the environment and decreased hyperactivity and anxiety. SPINAL MUSCULAR ATROPHY What evidence? The systematic reviews of Dumas (2001) and Getz (2006) include the case report of Figuers (1999, n=1) which was reprinted in the Journal of Aquatic Physical Therapy 2005. Aquatic therapy for a 1 year old boy was described. What treatment? The frequency and duration of aquatic therapy was not reported but implied to have continued “during the summer months”. Sessions involved the therapist, patient and one parent. Active range of movement was encouraged by flutter kicking and hip abduction-adduction. Stretches were implied. Reaching was encouraged with toys. Therapist support for trunk stability and head control facilitated extremity movement. Vestibular stimulation was provided by supporting the child in a hugging position and the therapist walking in different directions or “bouncing”. Respiratory activity was also suggested. What effect? A significant increase in active movement of the lower extremities was not observed. However, Figuers (1999) suggest continued weight gain without a decrease in strength or active movement were indicative of merit. Ease of handling by the parent, social interaction, spontaneous active movements while bathing, smiling and laughter, and reduced fear and anxiety were observed and implied to be effected by the aquatic therapy intervention.

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5 Aquatic Therapy in Women’s Health PREGNANCY-RELATED WELLBEING What evidence? Four papers were retrieved that reported on pregnancy-related well-being. Parker (2007) presented a systematic review investigating pregnancy, psychological stress and exercise capturing 25 research papers of which one detailed aquatic exercise (Lox 2000, n=41), and then presented findings from the authors own pilot study (n=15). A randomized controlled trial was undertaken by Poleman (2007, n=66) investigating the effect of a single bout of exercise on the mood of pregnant women participating in an aqua- or studio based exercise class compared to a parent-craft or a control group. An uncontrolled experimental trial was conducted by Smith (2006, n=40) looking at the effect of aquatic exercise on perception of body image, participation in health-promoting behaviours, barriers to health promotion participation, level of physical discomfort, and mobility in subjects who, pre-pregnant, were obese. Blood pressure changes in pregnant women during aquatic exercise participation was investigated by Ward (2005, n=33) in an experimental, same subject repeated measures trial. Kent (1999, n=18) compared water aerobics and static immersion for effect on pregnancy-related oedema in an experimental study. Katz (2003) summarized recent research on water exercise in pregnancy in a literature review with 58 references under headings of immersion effects on maternal physiology, effects of immersion on pregnancy, interactions of exercise in the water with pregnancy. A full report of the controlled trial by Liquori (2003, n=13) proved difficult to source, however, the abstract suggests its purpose was “to evaluate an established prenatal water aerobics program for its impact on the physiological function and well-being of women with low risk pregnancies in the 2nd and early 3rd trimesters.” What treatment? Most trials comprised of aquatic exercises classes designed for pregnant women in their 2nd and 3rd trimesters, the exceptions being Smith (2006) who recruited women of more than 19 weeks gestation, and Parker (2007) who did not state a stage of pregnancy. Smith (2006) described an aquatic exercise intervention: “The first 10 minutes of the class involved warm up exercises and stretches. Next, the continual movement phase lasted 25-30 minutes. During this portion of the class, exercises targeted large muscles of the body, such as legs and buttocks. Participants were instructed to self-monitor their level of exercise intensity using the Perceived Level of Exertion Scale. The PLES is a visual analogue scale ranging from 6 to 20 with the safe intensity range for pregnant women between 12 and 16. The last phase of the class (10-15 minutes) was designed to strengthen the abdominal muscles, stretch the muscles of

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the lower portion of the back, and promote flexibility. After this, a warm-down, stretch-out, and a relaxation session concluded the class.” The pilot study of Parker (2007) involved patient self-selection to either an aquatic aerobics group or a non-exercising group for six weeks. Frequency and content were not described. Of similarly brevity impairing useful clinical guidance, the single session study of Poleman (2007) describes “Aqua-classes of 45-50 minutes duration involving “rhythmic exercise with music” and “mainly aerobic and muscular endurance exercise” of low to moderate intensity. The blood pressure study by Ward (2005) operated around a non-aerobic aquatic exercise class: “The class consisted of 5 minute warm up and 30 minutes of strengthening exercises interspersed with 15 minutes of stretching exercises. The four body areas emphasized by the exercises were the abdominals, spine, upper limbs, and lower limbs. This was followed by 10 minutes of relaxation at the end of the class.” The oedema study by Kent (1999) included a water aerobic comparison; “The water aerobic session included a 5 minute of warm up of water walking (at axilla depth). This was followed by 10 minutes of water jogging and upper extremity workout with hand buoys. There were then 10 minutes of deep water work out using a foam cylinder between the legs to float and 5 minutes of toning and cool-down (at axilla depth). Exercise intensity was evaluated using the Borg perceived exertion scale at 13 minutes into the session and again at 23 minutes. Any subject who seemed short of breath or reported a perceived exertion of greater or equal to 15 was instructed to reduce the intensity of her workout to a more comfortable level.” What effect? Pregnancy-related wellbeing was measured to be positively effected by aquatic exercise with improved stress management, enhanced mood, decreased depression, positive body image, improved mobility, and reduced physical discomfort. From the systematic review by Parker (2003); “The published studies that were located provide evidence of the following: (1) stress reactivity increases physiologically during pregnancy, (2) pregnant women may experience additional stressors that are not usually experienced in a non-pregnant state, (3) psychological stress in pregnancy is associated with adverse foetal outcome, (4) exercise can be a method of stress reduction, (5) exercise in pregnancy is not associated with adverse foetal outcome, and (6) exercise in pregnancy may provide benefit to the foetus.” Participation in aquatic aerobic exercise classes were deemed to provide psychological stress management as measured by the Health Promotion Lifestyle Profile. This scale reportedly included a stress-management subscale that addresses the degree of stress and the use of stress-relief methods. Parker (2003) concluded from their pilot study; “The subjects who participated in the aquatic

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aerobics intervention reported a higher level of participation in health promoting stress management activities.” Smith (2006) used the Pender’s Health Promotion Lifestyles Profile to measure self actualization, health responsibility, physical activity, nutrition, interpersonal relationships, and stress management. Psychological individual characteristics of body image were measured with the Pregnancy Body Shape Questionnaire, mobility was measured with the Timed Up and Go Test, and physical discomfort was measured using the Smiths Pregnancy Discomfort Intensity Index. “Women who participated in the aquatic exercise program reported significantly less physical discomfort, increased participation in health promoting behaviours, improved mobility, and positive body image.” Measuring mood by the Profile of Mood States over a single bout of aqua- or studio exercise found an increase in overall mood and an increase in the vigour subscale (Poleman 2007). A decrease in the depression subscale was only recorded in the aqua-exercise group, while no changes in mood were recorded for the parent craft or control groups. Systolic, diastolic and mean arterial blood pressure all decreased significantly within 2-5 minutes of entering the water for an aquatic exercise class (Ward 2005). “The women’s blood pressure remained low, even decreasing slightly further following the non-aerobic exercise.” Blood pressure remained low post-exercise while still immersed, and returned to pre-immersion levels following immersion. Ward (2005) concluded that aquatic exercise was safe for non-hypertensive pregnant women in their third trimester. Measuring urine volume, urine specific gravity, and leg volume, Kent (1999) concluded; “Water aerobics had diuretic and oedema relieving effects similar to static immersion.” Katz (1999) qualify their results suggesting “immersion is not a treatment for pathologic oedema or for elevated blood pressure.” However, their results suggest that “the haemodiluting effects of immersion may counter the haemoconcentrating effects of exercise.” PREGNANCY-RELATED BACK PAIN What evidence? Two papers were retrieved that reported on the management of pregnancy-related back pain. Pennick (2007) conducted a systematic review that examined the effects of various pregnancy-specific exercises, physiotherapy programs, acupuncture and using special pillows compared to usual care or other treatment. Eight randomized controlled trials were included, with one, Kihlstrand (1999, n=258) reporting specifically on the effect of water exercise. What treatment?

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Limited exercise details were provided by Kihlstrand (1999). The program comprised once weekly water exercise for 60 minutes, for approximately 20 sessions, from 18 weeks gestation to late pregnancy. The program included 30 minutes physical exercise and 30 minutes relaxation, all in water and to music adjusted the different exercises and relaxation. “The exercises were recommended by the Swedish Swimming Society and were tested by physiotherapists. Two different exercise programs were used; one with exercises suitable for earlier pregnancy, to be used for the first ten training sessions, and one with exercises suitable for later pregnancy for the last ten sessions.” What outcome? By systematic review, Pennick (2007) found “that specifically tailored strengthening exercise, sitting pelvic tilt exercise programs and water gymnastics all reported beneficial effects.” Acupuncture seemed more effective than physiotherapy. Water exercise reduced pain and absenteeism from work. Kihlstrand (1999) measured pain reduction by visual analogue scale and absenteeism by a questionnaire on sick-leave finding less-sick leave in the water exercise group (932 days, n=124) than in the act-as-usual control group (1484 days, n=120). LABOR-RELATED PAIN What evidence? Database search for “hydrotherapy” revealed hydrotherapy during labour of the nature of immersion in warm water, not requiring specialized aquatic physiotherapy knowledge or skill. Three papers were retrieved reporting on labour-related pain. Nikodem (2002) reports a systematic review of immersion in water in pregnancy, labour and birth, including analysis of eight randomized controlled trials. Benfield (2001, n=18) documents a randomized controlled trial into the psychophysiological effects of hydrotherapy in labour, and Florence (2003) offered a clinical opinion of pharmacological and non-pharmacological interventions for pain management in labour including hydrotherapy supported by 8 bibliographic references. What treatment? Benfield (2001) placed subjects in a tub at 37oC for one hour during early labour. Florence (2003) cites temperature ranges from 35.6 to 41oC but recommends a range from 36 to 38oC. What effect? “There is evidence that water immersion during the first stage of labour reduces the use of analgesia and reported maternal pain, without adverse outcomes on labour

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duration, operative delivery or neonatal outcomes. The effects of water immersion during pregnancy or in the third stage are unclear” (Nikodem 2003). Labour-related pain and anxiety was measured to be positively effected by warm water immersion by visual analogue scale after 15 and 60 minutes (Benfield 2001). Bathers used the same amount of total pain medication as non-bathers. Seven non-bathers requested epidural medication compared with three bathers (n=18). Measurement of urine catecholamines was undertaken as an indicator of sympathetic nervous system arousal from maternal anxiety in labour, however no significant difference was found between bathers and non-bathers. Measurements of haemoglobin and haemotocrit were used to calculate plasma volume shift as an indirect measure of uteroplacental perfusion, with significant increase in plasma volume recorded for bathers. Benfield (2001) concludes “that bathing in labour may promote short term relaxation by decreasing anxiety and pain and that it is associated with a positive plasma volume shift. These effects may help correct uterine dyskinesia while decreasing the total length of labour and the need for analgesics, epidural anaesthesia, and pitocin augmentation…The study supports the therapeutic effects of water immersion as an alternative or supplemental intervention for clients who need fast, short-acting anxiety and pain relief” POST-MENOPAUSAL WELLBEING What evidence? Three papers were retrieved reporting on aquatic exercise for post-menopausal wellbeing. Devereaux (2005, n= 50) and Tsourlou (2006, n=22) conducted randomized controlled trials, the former of women with osteopenia and osteoporosis, the later of healthy women. Devereaux (2005) investigated the effect of aquatic exercise on balance, fear of falling and quality of life. Tsourlou (2006) instituted a particularly intense aquatic training program which included both aerobic and resistance components over 24 weeks, to determine the effect on muscle strength (isometric and dynamic), flexibility, and functional mobility. Alberton (2007, n=8) conducted an experimental study of healthy women investigating the comparison between oxygen uptake (VO2) and heart rate in different water exercises. What treatment? Devereaux (2005) and Tsourlou (2006) described their aquatic exercise intentions in details, selecting twice weekly 60 minute sessions for 10 weeks, and three times weekly 60 minute sessions for 24 weeks respectively. Devereaux (2005) reported: “The class comprised warm-up, stretches, aerobic, Tai Chi, strength, posture, gait, vestibular, proprioception and balance activities (50 minutes in total), and education (10 minutes) . The aims of the activities undertaken in the classes were to increase dorsiflexion, knee flexion, hip extension and stride

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length, improve ankle proprioception and trunk stability, contralateral co-ordination, and stimulate righting reactions and the vestibular system. Balance and vestibular systems were performed in functional positions in water and practiced in meaningful ways with decreased risk of injury compared to land. Exercises for the lower limbs, particularly for the hip flexors, quadriceps, and ankles were emphasized as they may be clinically important in improving toe clearance during the swing phase of the gait cycle. Land-based Tai Chi movements were transferred to the water environment to enable subjects to perform activities they may not be able to achieve on land.” Tsourlou (2006) suggested that previous studies of aquatic exercise in this population were not specific enough to yield the desired effect: “an understanding of the effects of targeted exercise interventions (with higher intensity and specialized equipment) in elderly is lacking. ” Thus, a particularly intense program was designed and studied. “The aerobic activity incorporated large muscle mass and consisted of lateral travelling, long lever pendulum-like movements of the extremities, forward and backward jogging with arms pushing, pulling, and pressing, leaps, kicks, leg crossovers and hopping movements focusing on travelling in multiple directions, and bounding off the bottom of the pool. Heart rate was monitored throughout the exercise sessions… Exercise intensity progressively increased from 65% HRmax (first 4 weeks) to 80%HRmax (last 12 weeks) … Music tempos of 100-140bpmwere used during the aerobic workouts. The resistance exercises were performed using DE-HAG water resistance products. Noodles and cuff devices were used for upper- and lower- body exercises respectively. Each training session included 4 exercises for the upper body: plunge jacks, rocking-horse press, and plunge front, plunge behind and squeeze behind. In addition 4 exercises were performed for the lower body, while the subject was holding the pool side: knee extension-flexion, hip extension-flexion with extended knee, double knee lifts, and side-press kicks. The exercises were performed keeping time with music pace. During the first two weeks 2 sets of 12-15 repetitions were performed without any external resistance in order to familiarize the subject with the movements at the cadence of 60 bpm and represented 15 complete repetitions per minute of the 4 count exercise. From this point on, the actual strength training in water was conducted using specialized resistance equipment in order to increase the resistance offered by the water. The progression of the training program was ensured by varying the amounts of repetitions per set, sets and the velocity of the movement.” Alberton (2007) compared individual aerobic aquatic exercises for their effect on oxygen uptake (VO2) and heart rate. Descriptions were supported with photo images. Each exercise was performed at 60 beats/ min for 4 minutes. The participants were immersed to the xiphoid-process level, with their arms submerged approximately from elbow to the hand, in thermoneutral water. The exercises were:

Stationary running with arms pushing alternately to the front (SR-AP) Stationary running with horizontal shoulder flexion and extension (SR-FE) Frontal kick to 90o with arms pushing alternately to the front (FK-AP) Frontal kick to 90o with horizontal shoulder flexion and extension (FK-FE) Cross country skiing with arms pushing alternately to the front (CCS-AP)

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Cross country skiing with horizontal shoulder flexion and extension (CCS-FE) Jumping jacks with arms pushing alternately to the front (JJ-AP) Jumping jacks with horizontal shoulder flexion and extension (JJ-FE)

What effect? Balance, quality of life, strength, ambulatory mobility, flexibility and body composition were measured to be improved by aquatic exercise in post-menopausal women. Devereaux (2005) measured balance using the Step Test, placing one off on and off a 7.5cm high step repeatedly in 15 seconds without hand support, recording significant change following the 10 week program. However, the measure of fear of falling, the Modified Falls Efficacy Scale did not yield significant change. Four of 8 domains of quality of life (physical function, vitality, social function, mental health) of the Short Form 36 indicated improvement in quality of life. Strength was measured over multiple measures by Tsourlou (2006) including maximal isometric torque of knee extensors and flexors (Cybex), grip strength (Jamar dynamometer), the 3 repetition maximum (3RM) test of chest press, knee extension, lat pull-down and leg press, with all but lat pull-down yielding significant gain. Explosive power improved as measured by the Squat Jump. The Timed Up and Go test recorded enhanced ambulatory function. The Sit and Reach Test measured trunk flexion and revealed increase. Measurement of body composition via a bioelectrical impedance test showed increased lean body mass but essentially unchanged body mass. Alberton (2007) concluded that “water exercise classes should be prescribed based on percentages of maximal heart rate or VO2, not on a fixed cadence (or musical rhythm rates) because different exercises correspond to different percentages of maximal effort.” The highest oxygen uptake (VO2) and heart rate results were found during “frontal kick to 90o with horizontal shoulder flexion and extension” (FK-FE) and lowest for “jumping jacks with arms pushing alternately to the front” (JJ-AP). Heart rate results were 135bpm (FK-FE) and 97bpm (JJ-AP). BREAST CANCER RELATED LYMPHODEMA What evidence? One case report described the application of “aquatic lymphatic therapy” for 3 women post-mastectomy with axillary node dissection (Tidhar 2004, n=3). What treatment? Aquatic lymphatic therapy was applied once or twice weekly for 14 months and was based on a particular series of slow rhythmic movements postulated to utilise hydrostatic pressure for lymph evacuation. Vertical limb placement was emphasised.

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Self-massage and breathing exercises were included. Proximal limb exercise preceded distal to proximal exercise. Standing neck deep in water, distal movements included elbow, wrist and hand, opening and closing the hand repeatedly. A “frog exercise” was described, involving underwater prone positioning on hands and feet. Additional exercise variants were described for each of the three patients whose presentations of lymphodema and co-morbid back pain and knee osteoarthritis were respected. What outcomes? Circumferential limb measurements were measured at six points along the affected limb to calculate limb volume with improvements of 249, 326 and 116mls recorded for the three patients. Subjective improvements for arm strength, overall endurance and general wellbeing were recorded for each patient. OSTEOPORPOSIS What evidence? Three trials were identified to have investigated the effect of aquatic exercise on osteoporosis between 1997 and 2007. Controlled trials were conducted by Ay (2003, n= 41) and Ay (2005, n=62), and a pretest-post-test study was undertaken by Bravo (1997, n=77). In 2003, Ay investigated whether moderate increased physical activity as aquatic exercise has anabolic effects on bone and evaluated this in terms of quantitative ultrasound and hormonal variables. In 2005, Ay compared the effects of weight bearing and aquatic exercise on calcaneal ultrasonic scores. Ay (2003) cited two previous studies on aquatic exercise and bone assessment techniques of 1994 (Tsukahara) and 2000 (Malliopoulos, congress abstract). Ay (2003 and 2005) included sedentary subjects who undertook less than 1.5km of walking per day or less than 4 hours standing per day. What treatment? Bravo (1997) selected “exercise in a pool with waist-high water for 60 minutes, 3 days a week, over a 12-month period. Forty minutes of each session were devoted to successive jumps and muscular exercises designed to promote bone accretion, strength, and endurance.” Both the 2003 and 2005 studies of Ay utilized the same aquatic exercise regime at a frequency of three times per week for 6 months; “The first-week aquatic exercisers did 5 mins of warm-up exercises (walking slowly and breathing), 10 mins of aerobic exercise (walking fast, jumping, and swaying in the water), 5 mins of cool down exercises (walking slowly and breathing), and 5 mins of stretching of the iliopsoas, hamstrings, quadriceps, gastrocnemius, pectoral muscles, and dorsal extensors

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(outside the pool). In the second week, aerobic exercise was extended to 15 mins. The duration of aerobic exercise was gradually prolonged to 25 mins until the fourth week. In the fourth and following weeks, the total duration of the exercise in one session was 40 mins.” The intensity of exercise was adjusted to a submaximal level between 10 and 13 according to Borg’s scale. This represents exercise that is “moderate” to “quite hard”. Radial pulses of the subjects during the exercise were adjusted to 120 +/- 5 bpm in the 2003 study and 110 +/- 10 bpm in the 2005 study. What outcomes? The studies of Ay (2003 and 2005) found aquatic exercise to be efficacious in the osteoporotic population while the earlier study of Bravo (1997) was unable to achieve statistically significant change in the measures of bone quality chosen. Ay (2003) selected measures of Broadband Ultrasound Attenuation (BUA) and Speed of Sound (SOS) T scores which were reported to be associated with the quantity and quality of the bone. Growth hormone (GH), insulin-like growth factor-1 (IGF-1), calcitonin and parathormone (PTH) levels were chosen as markers of bone quality. “GH, IGF-1, and PTH are correlated with osteoblastic proliferation, differentiation, and matrix mineralization. These hormones are affected by mechanical stimulus, serum calcium levels, and interacting hormones such as sex steroids.” Following the 6 month aquatic exercise intervention, exercisers faired significantly better than controls over these measures. Serum levels of insulin-like growth factor-1 increased by 36%, growth hormone increased by 75% ( but decrease by 61% in the control group). Calcitonin levels increase by 54%, and parathormone decreased by 31% decrease in parathormone. T scores of BUA increased by 19%, and SOS increased by 63%. Thus, Ay (2003) could conclude; “Aquatic exercise was determined to be effective to make an anabolic effect on the bone of the post-menopausal sedentary subjects.” Ay (2003) endorses aquatic exercise in osteoporosis; “Sometimes, weight bearing exercises may cause unpleasantly excessive physical stress, which yields pain and discomfort. Excessive physical stress must be avoided for osteoporotic subjects with fragile vertebrae. Inactivity must be avoided too, so at this point, a moderate type of physical activity like walking and swaying in the water may be suggested as an alternative exercise modality. It combines the stimuli of minimal mechanical impact on the spine with intermittent contractions of the back muscles.” Ay (2005) compared Calcaneal BUA scores in aquatic exercisers, weight-bearing exercisers and control subjects. “It was determined that a moderate increase in regular physical activity, either as aquatic or weight bearing exercise, is effective to increase calcaneal BUA by 3.1% and 4,2 % respectively in sedentary post-menopausal women.” Following the 6 month intervention period, the BUA score decreased by 1.3% in the control group. Ay (2005) concluded; “Although weight bearing physical activity is known to be superior to non-weight bearing activity to increase the bone mass, our present evidence shows that aquatic and weight bearing exercises can both increase calcaneal BUA.”

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Bravo (1997) measured functional fitness (flexibility, coordination, agility, strength/endurance, and cardiorespiratory endurance) with the American Alliance for Health, Physical Education, Recreation and Dance battery, and psychological states evaluated with Dupuy's General Well-Being Schedule. Spinal and femoral bone mineral density (BMD) was measured by dual-energy X-ray absorptiometry. Spinal BMD decreased significantly, whereas there was no change in femoral neck BMD. Flexibility, agility, strength/endurance, and cardiorespiratory endurance, and psychological wellbeing were affected positively by the exercise program. OBESITY What evidence? Two randomized controlled trials were found to report on the effects of non-swimming aquatic exercise in the management of obesity in women. Gappmaier (2006, n=38) investigated women with 25-47% body fat. Nagle (2007, n=44) investigated women with a body mass index of 34.9+/-3.8kg/m2. Both investigators intended to compare land-based weight-bearing exercise with aquatic exercise in the presupposition that non-weight-bearing exercise was frequently cited as ineffective in weight loss. Gappmaier (2006) suggested, “Obesity is frequently linked to musculoskeletal disorders due to excessive joint stresses. Existing joint conditions may be exacerbated by weight bearing exercise resulting in discontinuation of an exercise program due to over use injury. Experts therefore recommend non-weight bearing activities for obese individuals. The decreased joint loading environment of the water due to buoyancy renders aquatic exercise an ideal activity for obese individuals and those suffering from orthopaedic conditions.” What treatment? Gappmaier (2006) selected a 13 week exercise-diet program involving supervised sessions of 40 minutes, 4 times per week at 70% of age-predicted maximum heart rate. Three exercise conditions were compared including walking on land, swimming in 27oC alternating breast- side- back-stroke without face immersion, and walking in shallow water below navel level in 29oC (Gappmaier 2006). “The initial exercise duration of 10 minutes was increased by 5 minutes every other session until 40 minutes of continuous exercise was reached in 3 weeks.” Guidance in diet was also programmed. “Participants received a food composition table, which rated the fat and refined carbohydrate content of most food in units. One fat unit (FU) represented 6g of fat while one refined carbohydrate unit (RCU) represented 6g of sugar. No more than 3FUs and 3RCUs were allowed per day. Subjects had to complete daily diet records listing type and amount of all foods and beverages consumed with respective FUs and RCUs. Weekly consultation meetings were held during which experiences with and questions about the diet were discussed.”

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Nagle (2007) investigated a 5 days per week, 16 week behavioural treatment program including two exercise conditions of combined aquatic and walking exercise, and walking alone. In addition to two supervised exercise sessions, both groups were required to complete three sessions of home-based walking per week. “The total time spent during each session was gradually increased each week … in accordance with recommended 200 / 300 minutes per week for weight loss and maintenance of weight loss. The aerobic-conditioning portion of exercise sessions increased from 20 to 40 minutes of exercise per day by the ninth week of the study. For both groups, exercise intensity was prescribed at a moderate level, that is, 60-70% of age-predicted maximum heart rate. All sessions included a 5- to 10- minute warm up and 5- to 10- minute cool down composed of flexibility and range of movement exercises. The aquatic exercise sessions were performed in shallow and deep water and included rhythmic movements involving whole body muscle groups with a focus on both cardiorespiratory and muscular endurance (i.e. water aerobics, callisthenics and circuit training). Behavioural sessions were conducted weekly and addressed behavioural principles related to weight management (e.g.. stimulus control, motivation, principles of reinforcement, tools for overcoming barriers etc.). All participants followed daily dietary caloric requirements indexed to pre-treatment body mass (i.e. 1200 kilocalories for <90kg, 1500 kilocalories for >90kg). An individualized fat-gram-reduction goal of approximately 20% of daily caloric intake was also prescribed.” What outcome? Body weight was effectively reduced in the exercise programs including aquatic exercise. Gappmaier (2006) recorded reduced body weight, reduce percentage body fat and reduced skinfold thickness in all three exercise conditions. Body density was measured using an under water weighing technique, and converted to percentage body fat, and lean body weight was calculated from the percentage body fat and body weight. Triceps and subscapular skinfolds were measured with callipers, and circumference of abdomen, hips and thighs was measured by tape. Gappmaier (2006) concluded that aerobic activities in water were as effective as aerobic exercise on land on body composition components as long as similar intensity, duration and frequency were used. “In the aquatic exercise group, total body weight, cardiorespiratory fitness, flexibility, strength, and health-related quality of life significantly improved over time similarly to the water group. Slightly greater non-significant losses in body weight, improvements in flexibility, greater attendance rates, and significantly greater enjoyment scores also occurred in the aquatic exercise group” Nagle (2007).

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6 Cardiorespiratory Aquatic Therapy Search of electronic databases on aquatic therapies and cardiorespiratory practice returned clinical trials falling largely into two categories: chronic heart failure and chronic obstructive pulmonary disease. This evidence is detailed below. Other “hits” included a critique of hydrotherapy for respiratory patients, challenging its effect on patients with particularly low lung volumes (Anstey 2000). Clinically, this article should be read alongside that of Thomaz (2005) which measured spirometric parameters of tetraplegic patients. Compared with normal subjects immersed in shoulder depth water, vital capacity was increased in tetraplegic patients. Practical insight to the management of a ventilated patient with Guillain Barré syndrome was described by Taylor (2003). Hydrotherapy for patients with laryngectomy was discussed and measured by Crevanna (2003) including fatigue, expectoration, mobility, elasticity / flexibility, postural control / co-ordination, general well-being and quality of life. Barben (2005) considered the prevalence of pseudomonas aeruginosa in swimming pools and the risk to patients with cystic fibrosis. Asthma, outside of inclusion of some patients in trials of hydrotherapy for chronic obstructive pulmonary disease, did not feature exclusively among titles of clinical trials for aquatic therapy. Asthma, does however, feature in literature on swimming, for example (Matsumoto 1999), and pilot study (Kosonen 2006, n=20) of cardiorespiratory responses to basic aquatic exercises: walking in place, running in place, bilateral hip and arm abduction-adduction, cross-country skiing, walking forward and running forward. HEART DISEASE AND FAILURE What evidence? Seven papers were associated with aquatic therapy and chronic heart failure between 1997 and 2007. A randomized controlled trial of combined resistance and aerobic training where aerobic components were undertaken on land or in the water was undertaken by Volakis (2007, n=34). Cider (2003, n=25) randomized subjects to a hydrotherapy or control group. An experimental study undertaken by Bermingham (2004, n=10) reported on the effect of arm ergometry whilst immersed to the nipple line. Municino (2006, n=18) conducted a pilot study of “cardio-hydrokinesitherapy”. A clinical opinion was authored by Meyer (2006) cautioning practitioners in the use of aqua therapy and swimming for patients with left ventricular dysfunction and chronic heart failure with citations to ten references, five of which predate 1980. Cider and colleagues authored a further two studies in 2005 and 2006 investigating cardiorespiratory parameters of patients with chronic heart failure whilst immersed in warm water in order to understand the additional effect of exercising in warm water. What treatment?

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A four month training program of 4 sessions per week was compared on land and in water by the subjects of Volakis (2007). “The Water Exercise program consisted of 2 aerobic sessions (at 50%-70% of maximal heart rate achieved during symptom limited grade exercise test) and 2 sessions of resistance training (60%-80% of the maximal number of repetitions performed of each exercise at baseline). All sessions lasted 60 minutes and included a warm up period (10 minutes), the main program (30-40 minutes), and a cool down period (10 minutes). The aerobic regimen included exercises such as water walking, jogging, walking and jogging in combination with various arm movements, side stepping, water cycling, and adapted water games (volley and basket). During resistance training, the following 8 exercise were performed: chest / upper back guide, chest back press, behind the back press, pivoted shoulder press (upper body), and calf lifts, supported squats, outer / inner thigh scissor, and forward and backward leg glide (lower body). Each movement during resistance training was conducted using specialized equipment to increase the water resistance and the stimulus offered by the water. The progression of the training program was ensured by increasing the amount of sets, the number of repetitions, and the speed of the exercises.” A thorough exercise description was reported by Cider (2003) in an appendix, introduced in the body-text: “The training program comprised of 45 minutes sessions in a heated pool (33-34oC), three times a week over an eight week period. The patients trained as a group following a low to moderate exercise level (i.e. 40-70% of maximal heart rate reserve). The basic posture was standing with water just below neck level. The exercise regime was designed to include muscle utilized in activities of daily living such as walking, dressing and household activities. The program focused on peripheral muscle training but central circulatory exercises were also included. The purpose was to improve aerobic capacity, peripheral muscle strength and endurance. The physiotherapist used music to facilitate the correct pace of exercise. A heart rate recorder was used to monitor the intensity.” Perhaps intended to expand the understanding of immersion on cardiac function, supplemented with above-water exercise, Bermingham (2004) describes; “The work consisted of interval arm ergometer work, with three endurance phases of sufficient stimulus to produce a heart rate of between 70% and 85% of attained heart rate. The ergometer was at shoulder height, with the patient standing with the arm extended. For the water exercise, the ergometer was placed on the edge of an indoor hydrotherapy pool, with the subject in the pool to nipple line. The water temperature was 28oC, which was similar to the air temperature.” Described in the abstract, Municino (2006) coined “cardio-hydrokinesitherapy” or “cardio-HKT” as “a novel rehabilitation program that includes training sessions in warm water (31oC) integrated by educational and psycho-behavioural sessions to promote healthy life style modifications. Cardio-HKT consisted of a three week daily in-water training, combined with educational and psycho-behavioural sessions.” What effect?

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Respiratory function, blood lipids, body composition, muscular strength, ambulatory function and quality of life in patients with chronic heart failure were measured to be effected by aquatic exercise. Using continuous gas analysis, Cider (2005) measured the effect of seated immersion at rest and seated exercise in patients with chronic heart failure and healthy subjects. “Four minutes of standardized sub-maximal leg-exercise which consisted of reciprocal unilateral knee extension (range of motion 0-120o), without external weights applied, with a cadence of 60 extensions per minute using a metronome.” No difference was found between land and water for carbon dioxide production, total ventilation, respiratory frequency, respiratory exchange ratio, heart rate and blood pressure. Oxygen uptake was greater in healthy subjects than cardiac subjects, at rest, on land and in water. Oxygen kinetics increased in both groups with the exercise. “Hydrotherapy was well tolerated and the vast majority of the cardiorespiratory responses during warm water immersion in a clinical setting are similar in patients with CHF compared with healthy subjects” (Cider 2005) Comparing echocardiography in cardiac patients and health subjects on land and in water, Cider (2006) found “A general increase in early diastolic filling was accompanied by a decrease in heart rate, leading to an increase in stroke volume and ejection fraction in most patients with CHF during warm water immersion. These beneficial haemodynamic effects might be the reason for the previously observed good tolerability of this exercise regime.” From a single exercise session of arm ergometry, Bermingham (2004) found that high-density lipoprotein cholesterol (HDL-C) was improved more whilst performed on land than when standing in water, and that the in-water condition failed to change HDL-C in patients with a low baseline of HDL-C. However, following the 4 month land or water exercise regimes of Volkaris (2007), total cholesterol and triglycerides were positively affected. Both groups improved in body weight and skin-fold measurements, and exercise time on a symptom-limited treadmill exercise test with electrocardiographic monitoring. Using one-repetition maximum testing on bench press, pull down, seated row, pec-deck, leg extension and hamstrings curl, muscular strength was deemed to have improved following both land-based and water-based exercise interventions. No changes were recorded for any measure among the untreated control group. Municino (2006) measured fitness as ambulatory function with the Six Minute Walking Test finding greater distance covered by subjects following 3 weeks of Cardio HKT. Quality of life was markedly improved per the Minnesota Living with Heart Failure Questionnaire. Respiratory parameters as peak VO2 and VE/ CO2 were positively influenced.

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CHRONIC OBSTRUCTIVE PULMONARY DISEASE What evidence? Six articles were retrieved reporting on the use of aquatic exercise in the management of chronic obstructive pulmonary disease (COPD). Premised on the recommendation “in the Nederlands, patients with COPD are advised by their GPs to improve their physical condition; for example by walking, cycling or swimming,” Chavannes (2006) undertook a systematic review to investigate the effect of “physical activity in patients with mild to moderate COPD on exercise tolerance, dyspnoea, and quality of life…the number of hospitalization days and exacerbations expressed as oral prednisolone courses.” Returning five original articles that met the set criteria from 4968 broadly selected articles, no trial was found to have been undertaken to answer the research question with regard to swimming or aquatic exercise. Otherwise, “a positive influence of physical activity on exercise tolerance in mild to moderate COPD was reported in four out of five studies. There was no clear effect on dyspnoea or quality of life.” O’Brien (2003, n=12) and Wadell (2004, n=43) undertook similar studies comparing the effects of land-based and water exercise on patients with COPD. However, the randomized crossover study of O’Brien (2003) was abstracted in conference proceedings, the original article being unavailable for this review. Pseudo-randomization to land, water and control groups was based on travelling distance to the exercise venue by Waddell (2004). Kurabayashi reported three similar studies in 1998 (n=24), 1998 (n=12) and 2000 (n=17) investigating the effect of a breathing exercise involving immersion to shoulder depth and exhalation into hot spring water at 38oC, pH of 2, and mineral content mainly of sulfates. Tending to better satisfy the definition of balneotherapy than hydrokinesiotherapy, the trials are documented here for consideration of application by aquatic physiotherapists as the physical properties of water were hypothesized to provide relevant physical pressure to aid respiration. What treatment? Intensity and frequency of a breathing protocol were variables of interest in the studies by Kurabayashi (1998). A twenty minutes per week protocol (10 minutes per day, 2 times per week) was compared against two protocols of 120 minutes per week. Twenty minutes, twice daily for 3 sessions per week (protocol B) was compared with twenty minutes per day for 6 days per week (protocol C). “After a 5 minute warm-up period, patients entered a pool filled with 38oC hot spring water to the level of their shoulders. Then, they breathed in deeply in a standing position, and breathed out slowly through their mouth into hot spring water after sinking their nose 3 to 5 cm below the water level by bending their knees. They repeated this breathing exercise for 10 minutes. In protocol B and C, another 10 minutes exercise was followed by a five minute rest after coming out of the water.” Kurabayashi suggested

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“our protocols were designed to use hydraulic pressure during breathing exercise. The subdiaphragmatic peritoneal pressure elevated by hydraulic pressure could work as a load to diaphragm constriction during inspiration, resulting in diaphragm exercise, and could help the diaphragm to elevate and evacuate air during expiration resulting in a decrease in dead space. Furthermore, expiration into water may increase respiratory tract pressure to prevent collapse of the small airway. In addition, hydraulic pressure was reported to increase cardiac output leading to an improvement in blood gas exchange in the pulmonary capillaries.” Kurabayashi further investigated the breathing protocol in 2000 comparing exhalation into water with exhalation into air. “During diaphragmatic breathing by head-out immersion patients did not sink their nose into the water but remained standing and breathed out slowly through their mouths into the air, not into the water. The breathing exercises were repeated for 30 minutes a day, 5 days a week. After exercise, patients dressed and rested on a chair in a comfortable room (25oC) for 30 minutes. In a cross-over design, O’Brien (2003) selected a 6 week intervention including water-based exercise, followed by 6 weeks of land-based exercise, with measurements taken at baseline, between interventions and post intervention. Wadell (2004) described; “The training program for both intervention groups consisted of outpatient aerobic group training for 45 minutes (including warm-up and cool-down) three times per week for 12 weeks. Physiotherapists led the training. The programs in water and on land were designed to have the same intensity profile. The sessions started with warm up and flexibility exercises for 9 minutes. The session was ten performed in the following order: 4 minutes endurance exercises, 3 minutes strength exercises for the legs, 4 minutes endurance exercises, 3 minutes strength exercises for the arms, 4 minutes endurance exercises, 3 minutes strength exercises for the torso, 3 minutes flexibility exercises and finally cool-down and stretching exercises for 12 minutes. The intensity increased for each successive endurance portion. The endurance parts of the sessions consisted of varied repetitive large muscle exercises intending to increase the load on the cardiovascular system and increase heart rate. The complete program was supported by music, which guided the intensity of the performance during the session.” The intensity target was to achieve a mean heart rate on 80-100% of peak heart rate according to maximal test on cycle ergometer and the patients were encouraged to reach Borg Scale 5 for dyspnoea and 15 for rated perceived exertion.” What effect? Ambulation, fitness, activity, health-related quality of life, respiratory and cardiac function were measured to have improved following aquatic therapy interventions for patients with COPD.

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Ambulatory function was measured to improve over distance and speed with the Incremental Shuttle Walk test and Endurance Shuttle Walk test in COPD patients undergoing either land-base or water-based group exercise (Wadell 2004). During the incremental symptom-limited cycle ergometer test both the water and the land training groups significantly increased the time cycled. VO2 peak was increased, as was peak heart rate in the water group. Peak ventilation and peak lactate were unchanged. O’Brien (2003) found no difference between land-based and water-based exercise on the Six Minute Walk Test. O’Brien (2003) measured FEV1 and FVC, but failed to indicate effect on these parameters in their abstract. Health Related Quality of Life was measured with the St Georges Respiratory Questionnaire, with the control group measuring a decline over the 12 weeks, and only the water training group recording a slight increase in overall score, and significant improvement in activity score (Wadell 2004). O’Brien’s land-based exercise yielded a significant change in quality of life as measured by the St Georges Respiratory Questionnaire. The Short Form 36 questionnaire revealed significant improvement in the water training group on the physical component score, better than either the control or land-based group (Wadell 2004). No group achieved significant change in the mental health component. Spirography, blood gas analysis and echocardiography were used in the studies by Kurabayashi (1998 a & b, 2000). Respiratory function as peak flow and FEV1/FVC was measured to be improved by 120 minutes breathing exercise per week. Oxygen and carbon dioxide concentrations were enhanced, and ejection fraction increased. “These results suggest that the breathing exercise by immersion is useful not only treating emphysema but also in improving cardiac function” (Kurabayashi 1998a). On comparing exhalation into water or air, Kurabayashi (2000) returned better spirographic, echocardiographic and blood gas analysis results for the water exhalation method; “These results suggest that the breathing out into water exercise enhances the effects of a breathing exercise during immersion and is in rehabilitation for chronic pulmonary emphysema.”

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7 Aquatic Therapy in Sports and Training DEEP WATER RUNNING The search terms of “aquatic”, “water” and “exercise” readily return articles reporting on deep water running. A specifically directed search of “deep water running” as not done, and thus the completed representation of this topic among the literature may in fact be larger than that represented here. However, the impression is gleaned that the technique stands as one available for aquatic physiotherapists to apply to patients requiring higher levels of fitness training or injured athletes unable to train for a time in their usual weight-stressing environment. What evidence? Twelve articles were reviewed reporting on deep water running in both healthy non-athletic and athletic subjects, and injured athletes. Chu (2001) provided a thorough literature review supported by 29 references with a pooled tabulation of four trials investigating various training schedules of deep water running, thus closely approximating the definitional requirements of a systematic review without, however, describing the review to have been undertaken with systematic methodology. The review by Reilly (2004) is of similar methodology citing 73 references and tabulating the results of 17 experimental studies published between 1987 and 1997. A randomized controlled trial with a crossover analysis was undertaken by Davidson (2001, n=10) comparing deep water running and road running as training techniques capable of yielding comparative oxygen uptake. Uncontrolled experimental studies were the most common investigative method, usually studying physiological parameters of deep water running, typically heart rate and oxygen uptake, in various subject combinations and conditions. Brown (1997, n=24) investigated running cadence and gender differences. Hamer (1997, n=12) compared heart rate and ratings of perceived exertion in both deep water running and treadmill running. Robertson (2001, n=42) contrasted deep water running with shallow water running. Gehring (1997, n=14) compared recreational and competitive runners’ abilities to replicate characteristics of land training intensity in deep water running. Bushman (1997, n=11) measured on-land running performance before and after a four week deep water running training program instead of continued on-land training. Sherman (1997, n=42) developed a field test and formula for estimating VO2 max using deep water running. Clinical opinions were presented by Bushman (1999), Nelson (2004) and Lauder (2001). Nelson (2004) suggested that deep water running is a cross-training technique allowing the athlete to remain at a high level of fitness while recovering from an injury, or a way of reducing the chances of sustaining an injury, or a means of expediting the rehabilitation process. “A good knowledge base regarding the physical properties of water and the physiological responses to water immersion

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makes it easier to design and implement a deep water running program.” Lauder (2001) described “the physiological characteristics of deep water running, specifics of deep water running program design, deep water running mechanics, and the advantages of deep water running over other aerobic forms of exercise to maintain land running performance in military personnel on temporary non-weight-bearing profiles.” Lauder (2001) drew on experience with “181 active duty Army soldiers, placed on temporary profiles for injuries that precluded them from their regular weight-bearing physical fitness activities, who participated in a deep water running program. Injuries to the back, knee, and ankle were the most common reasons for referral to the program.” Pohl (2003, n=6) investigated the physiological response to running and walking in different depths of water in an experimental design. The test conditions include thigh-deep and waist-deep treadmill run or walk, as opposed to deep water running. What treatment? Deep water running is generally investigated in and undertaken in cool pool water (22-25oC). Suppositions on heart rate and exertion in warmer water should be made cautiously. Chu (2001) describes deep water running; “In is simplest terms, deep water running is simulated running in the deep end of the swimming pool. Deep water runners typically wear a buoyancy vest to help keep them afloat during the exercise. Workload increments can be increased through one of two ways: (i) increasing the cadence using a metronome to maintain stride frequency; or (ii) being attached to a tethered apparatus. Although running styles may vary the general technique that should be used for deep water running follows these criteria: (i) the trunk should be slightly forward of an upright position; (i) the arms and legs should follow a somewhat unilateral forward motion, thereby avoiding the motions of treading water (i.e. circular leg and arm motions); (iii) in the swing phase, the swing phase leg should be brought to the horizontal position; (iv) the elbows should be at a 90o angle; and (v) the hands should remain completely open in the sagittal plane or in a closed fist, to avoid ‘dog paddling’ in the water.” Brown (1997) suggested “proper form” involved alternatively flexing each hip 45o and hyperextending to 10o. “Shallow Water Running,” as investigated by Robertson (2001), simply involved running in water at a depth to the xiphoid process, with a tethering cord, to prevent forward movement, and protective “aqua socks”. Robertson (2001) suggested that shallow water running has “several advantages over deep water running. Shallow water is more available than deep water and is less threatening to those with a fear of drowning. In addition, the shallow water running technique requires no flotation device, is easily learned, and better simulates the on- land running style.”

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Frequency of training in deep water running programs ranged from 3 to 6 days per week, for 20 to 60 minutes, at steady intensities or intervals. Intensity was described in various ways; from 60-100% VO2max, a rating of perceived exertion (RPE) from moderate to high intensity, 80% heart rate reserve minus 10 beats per minute, and 80% of mode-specific peak heart rate (Reilly 2004). Bushman (1997) devised “standardised workouts consisting of long and short intervals (2 days per week each) as well as long duration (1 or 2 days per week) sessions were used.” The schedule was tabulated and, using rating of perceived exertion for intensity, varied the intensity and length of sessions from 25 to 45 minutes, some sets between 45 seconds and 8 minutes, and included a 45 minute long “run” per week. What effect? Deep water running is hard. The perceived level of exertion of deep water running is higher for a given heart rate compared with treadmill running. “While the slope of the heart rate to rating of perceived exertion regression equations remained similar, the mean heart rate was 17 beats per minute lower in the deep-water running condition than during the treadmill run” (Hamer 1997). Deep water running can be undertaken effectively to yield fitness results comparable to treadmill running and road running. Measuring fitness via VO2, Davidson (2000) found; “Both deep water running training and road-running training improved cardiovascular fitness of young sedentary women.” Gehring (1997) parallels; “Competitive runners were able to achieve training intensities similar to land training for water running with or without a flotation vest.” And Bushman (1997), found no deterioration in running performance; “Four weeks of deep water running training apparently provided a sufficient stimulus to maintain on-land running performance in a group of well trained distance runners.” Performance measures included 5km race on treadmill, running economy determined by submaximal run at the same absolute workload, a lactate threshold test, maximal oxygen consumption, and global mood state (Profile of Mood States). “When deep water running is performed across different running cadences, the metabolic response is linear for both genders but lower in women than men” (Brown 1997). A reason postulated for the gender difference is that of buoyancy, tending to be greater in females, effecting lower effort. The finding of linearity is significant in that deep water running is comparable to other exercises of high aerobic intensity, like treadmill running, and arm or leg cycling, and, running at a certain speed is fairly predictive of VO2. This result of Brown (1997) was well supported by that of Sherman (1997) who proposed an equation to predict VO2. “Cadence, rating of perceived exertion (RPE), body weight, and gender were used to develop the following regression model: VO2 max (L x min-1) = 0.425 + (Cad x 0.0291 + (RPE x -0.169) + (Wt x 0.013) + (Gender(0,1) x 1.2). The model accurately estimated VO2 max. Based on these results, a self-selected, submaximal deep-water running bout can be used to estimate VO2 max in young, healthy adults.”

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Robertson (2001) found shallow water running to be harder than deep water running; “The results revealed a significant difference of 10 beats x min-1 between the mean heart rate during shallow water running (155.8 beats x min-1) and deep water running (145.8 beats x min-1).”

PLYOMETRIC TRAINING Miller (2001) introduces; “Plyometric activity activates a muscle’s stretch-shortening cycle, which is created by a rapid eccentric stretch of a muscle followed immediately by a rapid concentric contraction, producing forceful, explosive movement. When used in conjunction with periodised strength training, Plyometric may be beneficial for athletes or physically active individuals. Research has shown improvements in vertical jump performance, leg strength, power, and increased joint awareness and proprioception. Four articles published between 1997 and 2007 were retrieved reporting on plyometric training in an aquatic environment including three randomized controlled trials and a clinical opinion. Robinson (2004, n=32) described a randomized controlled trial comparing identical plyometric training programs performed on land or in an aquatic setting with physically active women. The randomized controlled trial of Martel (2005, n=19) compared an aquatic plyometric program with a flexibility exercise program in young volleyball players. Miller (2002, n=40) compared ‘sedentary to recreationally active subjects’ assigned to either a land-based program, a water-based program or an untrained control group. Miller (2001) provided an informative clinical opinion detailing the prescription of an aquatic plyometric program. What treatment? Thrice weekly for eight weeks, “the training activities lasted 50 minutes and consisted of 3-5 sets of 10-20 repetitions of ten drills involving a series of bounds, hops, and jumps that were specifically designed for the development of explosive power and force production of the knee extensors, knee flexors, rectus femoris and biceps femoris. The aquatic training sessions were performed in a pool at a depth of 4 to 4 ½ feet of water. The temperature of the pool water was kept at a consistent 25-26oC. The ratio of water depth to subject height was 48in.:66in. (≈0.73)” (Robinson 2004). Martel (2004) described a graduated program: “The Aquatic Plyometric Program (APT) program was conducted twice a week for 6 weeks in a swimming pool with a depth of 122cm and a temperature of 28oC. All APT sessions were begun within 30 minutes after cessation of preseason volleyball training sessions. Each APT session lasted approximately 45 minutes and consisted of a warm-up, APT, and cool down, all performed in the water. The warm-up consisted of approximately 5 minutes of light jogging in the water. The APT exercises included power skips, spike approaches,

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single-and double-leg bounding, continuous jumping for height, squat jumps with blocking form, and depth jumps. The subjects were encouraged to perform all exercises in an explosive manner, and to apply their maximal effort on all manoeuvres. The power skips and spike approaches, single- and double-leg bounding and squat jumps were all performed with maximal effort along the width of the pool (12.2m) two times per session during the first week. These exercises were then performed along the width of the pool three times per session during the second week, four times per session during the third and fourth weeks, and five times during the fifth and sixth weeks. Bouts of continuous maximal squat jumps were performed three times (10s of continuous jumps per bout, separated by 30sec recovery periods) per session during the first week, four times per session during the second week, four times per session during the third and fourth weeks (increased from 10 to 20s for each bout separated by 30 second recovery periods), and four times per session during weeks five and six (increased from 20 to 30s for each bout). A series of depth jumps were performed involving three submerged boxes (61cm in height) two times per session in week 1, three times per session in week 2, four times per session for weeks 3 and 4, and 5 times for weeks 5 and 6. The subjects began the depth jump circuit by squat jumping from the pool floor without hesitation as high as possible, and landing on the floor between the first and second box, at which point they immediately squat jumped as high as possible, landing on the second box. The subjects continued this pattern over the third and final box, and recovered while walking back to the beginning of the circuit. After recovering for approximately 30 seconds, the subjects began the next interval. The cool-down period consisted of approximately 5 minutes of walking in the water followed by static stretching of the major muscles groups of the legs.” The plyometric exercises of Miller (2002) were tabulated and described; “An 8 week plyometric training program was developed using two training sessions per week. The training program was based on recommendations of intensity and volume from Piper and Erdman, using identical drills, sets, repetitions and volume for both the land and aquatic training groups. Training volume ranged from a minimum of 80 foot contacts to 120 foot contacts per session while the intensity of the exercises increased through out the course of the training program. The subjects were instructed to perform each exercise to their maximal ability. The aquatic training was held in approximately waist deep water.” From the tabulated exercise list, drills included, at nominated intensities; “\side-side ankle hops, standing jump and reach, front cone hops, double leg hops, lateral cone hops, tuck jump with knees up, lateral jump over barrier, lateral jumps single leg, and single leg hop.” What effect? Aquatic plyometric programs achieved gains in power and strength, with less muscles soreness. Robinson (2004) concluded, “Aquatic plyometrics provided the same performance enhancement benefits as land plyometrics with significantly less muscle soreness.”

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Measurement included an ordinal scale of muscle soreness. Pain sensitivity over rectus femoris, biceps femoris and gastrocnemius was gauged using and algometer with a palpation pressure rated of ‘extreme pain’ determined with low pressure of 2kg, and ‘no pain” with a high pressure of 20kg. Performance indicators included Sargent vertical jumps, isokinetic strength testing and 40m sprint. The vigorous aquatic plyometric program of Martel (2004) achieved similar results measuring vertical jump and isokinetic knee extension and flexion at 60 and 180o/sec; “The combination of APT and volleyball training resulted in larger improvements in vertical jump than in the control group. Thus, given the likely reduction in muscle soreness with APT versus land-based plyometrics, APT appears to be a promising training option.” Improvement continued in the APT group after week 4 whereas, in the control group it at plateaued. With similar measures including a visual analogue scale of muscle soreness, isokinetic knee flexion and extension, isokinetic ankle plantar flexion and dorsiflexion, goniometric knee and ankle range of movement, and power determined by running a flight of steps with electronic switch mats, Miller (2002) concluded; “Results indicate that aquatic plyometric training can be an alternative approach to enhancing performance.”

SPORT-SPECIFIC TRAINING AND REHABILITATION What evidence? Four papers were retrieved that reported on sport-specific training and rehabilitation. The sports included volley-ball, football, and athletes in general. A randomized controlled trial was reported by Martel (2005, n=19) investigating the effect of an aquatic plyometric program on volleyball players. This study is described under ‘Plyometric Training’ above. Geigle (2001, n=2) and Irvin (n=2) reported case studies of NCAA athletes and US footballers respectively. Athletes with lateral ankle sprain were investigated by Geigle (2001). The trial of Geigle (2001) is also described in the “Musculoskeletal Aquatic Physiotherapy - Lower Limb” chapter above. Prins (1999) provided a detailed clinical opinion on aquatic therapy in the rehabilitation of athletic injuries, proposing benefits in range of motion, cardiorespiratory fitness and joint mobility. Exercise suggestions are given for shoulder, cervical, lumbar and knee rehabilitation in tabulations. The clinical opinion is supported by 41 references. What treatment? Martel (2005) selected twice weekly aquatic plyometrics for 6 weeks with hour long sessions. Exercises included light jogging, power skips, spike approaches, single-and double-leg bounding, continuous jumping for height, squat jumps with blocking form and depth jumps (For further detail, see ‘Plyometric Training above).

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Irvin (2000) also selected twice weekly training for six weeks. “The program was set up in a circuit style manner with a total of six stations. Each athlete would complete 30 seconds of maximal exercise with 2 minutes rest between each station. The full circuit would take approximately 18 minutes to complete and be repeated twice with a five minute rest break between circuits. The stations of exercises included the following; swim fin straight leg raise, high knees, bell squats, tray squats with a plus, Speedo step plyometrics, and standing long jumps.” Following acute inversion sprain ‘subject 1’ of Geigle (2001) undertook 60 minutes of land-based rehabilitation 4-5 times per week for 11 sessions, while ‘subject 2’ undertook 30 minutes of land-based therapy and 30 minutes of aquatic physical therapy 4-5 times per week for 15 sessions. The number of sessions was determined by a sport-specific functional assessment to determine return-to-sport. The aquatic physical therapy sessions included a 5 minute warm-up “to increase blood flow, and increase ankle range of motion comprising:

• laps with kickboard emphasizing ankle movement with varying lower extremity swim stroke patterns,

• walk in the shallow end (waist high) forward, backward, on toes, on heels, • progress to jog in waist high water.”

The subject then undertook “a 20 minute work-out divided into 5 minutes of open chain, and 15 minutes of closed chain activities:

• to increase ROM: ankle circles/ ankle alphabet, wall calf stretch (gastrocnemius and soleus), inversion and eversion stretch,

• to increase strength: bilateral calf raises, progressing to unilateral calf-raises (on ladder or block), step-ups, forward/reverse lunges with toe raise on involved side at mid stance (progressing to single limb propulsion at mid stance), single limb wall squat, lateral bounding, wall propulsion, jumping jacks with deep knee bend, and scissor jumps,

• to increase balance: single limb stance on involved leg with contralateral ankle alphabet (eyes open/eyes closed), single limb stance on involved leg with contralateral leg movement (flexion, abduction, adduction, extension), heel toe gait, Karaoke, side step, jump turn landing on bilateral lower extremities in squat position (progress to unilateral landing on involved side).”

The session was completed with “a 5 minute cool-down of: • jog to walk, • lower extremity stretch.”

What effect?

Martel (2005) measured improved vertical jump in volley ball players following an aquatic plyometric program. Irvin (98) recorded improved yard dash on grass, vertical jump, t-shuttle run (on asphalt), bench plyometric jumps and standing long jump, with the subjects of the case studies being promoted in their football squads. Using video analysis of single limb stance as measurements of postural sway, Geigle (2001) found “a positive relationship between the use of a supplemental aquatic physical therapy program and performance of unilateral

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balance tests with eyes open. Aquatic physical therapy is a useful tool for balance retraining following ankle sprain.”

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