CLINICAL ISSUES

Comparing the efficacy of aquatic exercises and land-based exercises for

patients with knee osteoarthritis
Tsae-Jyy Wang, Shu-Chiung Lee, Shu-Yuan Liang, Heng-Hsin Tung, Shu-Fang V Wu and Yu-Ping Lin

Aims. The study aims to compare changes over time among three study groups on the primary outcome, pain, as well as on the
secondary outcomes, other symptoms, activities of daily living function, sport and recreation function, knee-related quality of
life, knee range of motions and the six-minute walk test and to investigate whether aquatic exercises would be superior
compared with land exercise on pain reduction.
Background. Osteoarthritis is a prevalent musculoskeletal disorder. Appropriate exercise may prevent osteoarthritis-associated
disabilities and increase life quality. To date, research that compares the effects of different types of exercise for knee osteo-
arthritis has been limited.
Design. The study is a randomised trial.
Methods. Eighty-four participants with knee osteoarthritis were recruited from local community centres. Participants were
randomly assigned to the control, aquatic or land-based exercise group. Exercise in both groups ran for 60 minutes, three times
a week for 12 weeks. Data were collected at baseline, week 6 and week 12 during 2006–2007. The instruments included the
Knee Injury and Osteoarthritis Outcome Score, a standard plastic goniometer and the six-minute walk test. Generalised
estimation equations were used to compare changes over time among groups for key outcomes.
Results. Results showed statistically significant group-by-time interactions in pain, symptoms, sport/recreation and knee-related
quality of life dimensions of Knee Injury and Osteoarthritis Outcome Score, knee range of motions and the six-minute walk test.
However, the aquatic group did not show any significant difference from the land group at both weeks 12 and 6.
Conclusions. Both aquatic and land-based exercise programmes are effective in reducing pain, improving knee range of
motions, six-minute walk test and knee-related quality of life in people with knee osteoarthritis. The aquatic exercise is not
superior to land-based exercise in pain reduction.
Relevance to clinical practice. Similar outcomes could be possible with the two programmes. Health care professionals
may consider suggesting well-designed aquatic or land-based exercise classes for patients with osteoarthritis, based on their
preferences and convenience.

Key words: clinical research, exercise, knee osteoarthritis, nurses, nursing, rehabilitation

Accepted for publication: 24 November 2010

Authors: Tsae-Jyy Wang, PhD, RN, Associate Professor, Department National Taipei College of Nursing; Yu-Ping Lin, PhD, RN, Assistant
of Nursing, National Taipei College of Nursing; Shu-Chiung Lee, Professor, Department of Nursing, Oriental Institute of Technology,
MSN, RN, Assistant Head Nurse, Department of Nursing, Taipei Taipei, Taiwan
Veterans General Hospital; Shu-Yuan Liang, PhD, RN, Associate Correspondence: Tsae-Jyy Wang, Associate Professor, Department of
Professor, Department of Nursing, National Taipei College of Nursing, National Taipei College of Nursing, Taipei, Taiwan.
Nursing; Heng-Hsin Tung, PhD, RN, Assistant Professor, Telephone: +886 2 28227101 ext. 3193.
Department of Nursing, National Taipei College of Nursing; Shu- E-mail: tsaejyy@[Link]
Fang V Wu, PhD, RN, Assistant Professor, Department of Nursing,

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2609–2622 2609
doi: 10.1111/j.1365-2702.2010.03675.x
T-J Wang et al.

Roddy et al. (2005) also reviewed 19 randomised clinical

Introduction
trials investigating effects of land-based exercise for knee or
Osteoarthritis (OA) is the most prevalent rheumatic disease hip OA. They concluded that both strengthening and
and affects older adult populations worldwide (Dawson aerobic exercises performed on land could reduce pain
et al. 2004), and knees are the most commonly affected and improve function and health status in patients with
joints. In the USA alone, it has been estimated that knee and hip OA. There was not enough evidence,
9Æ3 million adults in 2005 had symptomatic knee OA however, to support or recommend against specific types
(American Academy of Orthopaedic Surgeons 2008a). Pain, of exercise.
loss of function and a reduction in quality of life are often Regarding the effects of aquatic exercise for knee and hip
associated with knee OA (Dawson et al. 2004, Williams & OA, pooled data from four trials (672 participants) showed
Spector 2006). Globally, knee OA alone is expected to be that aquatic exercise vs. no exercise had a small-to-moderate
the fourth and eighth principle cause of disability in women effect on function (SMD = 0Æ26, 95% CI = 0Æ11–0Æ42), qual-
and men, respectively (Williams & Spector 2006). This ity of life (SMD = 32, 95% CI = 0Æ03–0Æ61) and mental
chronic and disabling condition not only diminishes indi- health (SMD = 0Æ16, 95% CI = 0Æ01–0Æ32) as well as a minor
vidual quality of life but also exhausts considerable health effect on pain (3% absolute reduction and 6Æ6% relative
care resources and results in societal costs. The burden of reduction from baseline) (Bartels et al. 2007). Aquatic
OA is likely to augment with an ageing population. In exercise seems to have beneficial short-term effects for adults
Taiwan, OA is the second most common chronic disease with hip or knee OA (Bartels et al. 2007). However, the
among older adults. For 2002, the burden of OA in randomised controlled trials in this area are still too few to
disability-adjusted life years was 34,150 person years (Office draw definite conclusions.
of Statistics, Republic of China Department of Health To date, research comparing the effects of different types
2004). of exercise for OA populations has been limited. Four
Studies (Fransen et al. 2001, Smidt et al. 2005) have studies, using a total of 294 adults, have compared the
shown that exercises seem to improve activities of daily effects of aquatic and land-based exercise for knee or hip
living (ADL) and reduce pain in patients with knee OA. OA. Two of the studies (Wyatt et al. 2001, Silva et al.
Therapeutic exercise is recommended in recent guidelines 2008) reported greater reductions in pain in the aquatic
as a non-pharmacological treatment for symptomatic knee group. The other two studies (Foley et al. 2003, Lund et al.
OA (Zhang et al. 2005, Misso et al. 2008, Zhang et al. 2008) found greater gains on leg muscle strength from land-
2008, American Academy of Orthopaedic Surgeons 2008b). based exercises. These results indicated the possibility of
However, the most favourable exercise for specific joint specificity of effect from different types of exercise, with
impairments has not yet been identified (Fransen et al. greater reductions in pain from aquatic programmes and
2001, Smidt et al. 2005). Knowledge of the effects of greater gains in leg muscle strength from land-based
different types of exercise for OA is essential to health care exercises. However, these previous studies were limited by
professionals when making evidence-based recommenda- short durations of the exercise training (six–eight weeks)
tions and for patients with OA when making informed and combining knee and hip OA groups. Therefore, in the
choices. current study, we compared the ameliorative effects of a
three-month aquatic exercise programme and a land-based
exercise programme to a non-exercise comparison condition
Background
for patients with a knee OA. We tested the following three
The Cochrane group (Fransen et al. 2001) systematically hypotheses:
reviewed and combined the study results of 17 OA exercise 1 Participants in both exercise groups would show pain
studies (a total of 2562 participants). They found that land- reduction over time.
based exercise had a small-to-moderate beneficial effect 2 Aquatic exercise would be superior compared with land
on pain (SMD = 0Æ39; 95% CI = 0Æ30–0Æ47) and on self- exercise on the pain reduction.
reported physical function (Fransen et al. 2001) (SMD 0Æ31; 3 Participants in both exercise groups would also show
95% CI = 0Æ23–0Æ39) for people with symptomatic OA of positive changes over time on secondary outcomes, other
the knee. However, because of great variability in the disease-specific syndromes, ADL function, sport and
contents of these exercise programmes, the reviewers could recreation function, knee-related quality of life (QOL),
not come up with specific recommendations regarding an knee range of motions (ROMs) and six-minute walk test
optimal dosage or specific types of exercise for knee OA. (6MWT).

2610  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2609–2622
Clinical issues Efficacy of aquatic vs. land exercises for knee OA

of the Knee Injury and Osteoarthritis Outcome Score

Methods
(KOOS). In this study, 28 participants per group were
recruited.
Design

The study is a randomised trial. After informed consent and a

Study interventions
pretest, participants were randomly assigned to the control,
aquatic or land-based exercise group. A simple randomisa- Aquatic exercise programme
tion method was used. A research assistant who was not A standardised aquatic exercise protocol was developed
recruiting participants carried out the allocation sequence by based on the Arthritis Foundation Aquatics Program (AFAP)
using a computer-generated random number list. There were instructor’s manual (Arthritis Foundation 2002). The main
two small groups in each of the exercise programmes with the components of the programme include a 60-minute flexibility
starting dates being staggered three months apart. Exercise and aerobic training class, three times a week for 12 weeks.
classes in both exercise programmes ran for 60 minutes, The exercise training focuses on joint in the trunk, shoulders,
three days a week on alternative days for 12 weeks. Data arms and legs and emphasises the muscle groups of the upper
were collected at baseline, week 6 and week 12 during 2006– and lower limbs as well as balance and coordination. The
2007. mechanisms for fitness training involve changes in speed,
surface area, direction of movement and turbulence in water
to increase the exercise resistance and to create intensity
Setting and participants
variation. A trained exercise instructor taught the group
Eighty-four participants with knee OA were recruited over a classes at the public swimming pools of the Taipei City Beitou
six-month period from local community centres and sport Sports Centre, Taipei. Pool temperatures were maintained at
centres in Taipei, Taiwan. Flyers and posters were distributed 30 C (86 F). The details of the programme were described
in local community centres and orthopaedic clinics to recruit in the Wang et al. (2007) study.
participants. A recruitment social event was held at the Taipei
City Beitou Sports Centre. During the event, one of the Land-based exercise programme
researchers gave a speech on what is OA and how to protect A standardised land-based exercise protocol was developed
joints and a family physician provided free joints check-up based on the People with Arthritis Can Exercise (PACE)
for participants. This event was reported by a sport TV programme instructor’s manual (Arthritis Foundation 1999).
channel that promoted the study programme. The main components of the programme include a 60-minute
Inclusion criteria were as follows: (1) age over 55 years, (2) flexibility and aerobic training class, three times a week for
diagnosed with knee OA by physician assessment based on 12 weeks. The exercise training focuses on joints in the trunk,
symptoms and X-ray and (3) consented to participate. shoulders, arms and legs and emphasises the muscle groups of
Exclusion criteria were as follows: (1) having a medical the upper and lower limbs as well as balance and coordina-
condition precluding exercise (i.e. uncontrolled arrhythmias, tion. The exercises for each section are summarised in Table 1.
third-degree heart block, myocardial infarction within To assure safe performance of the exercise, the classes include
six months, unstable angina, acute congestive heart failure instruction about basic principles of arthritis exercise, correct
and uncontrolled epilepsy), (2) having intra-articular corti- body mechanics and joint protection. Movement against
costeroid injections in the past 30 days, (3) received a joint gravity and variations in speed, level of leg or arm raising, or
replacement previously, or (4) currently exercising more than moving both extremities simultaneously were used to create
60 minutes per week for the past two months. different levels of training intensity. The average number of
repetitions for each exercise begins with 10 and gradually
increases to 15. Classes were taught to a group of participants
Sample size
by the trained instructor at the indoor basketball court of
Sample size was estimated using G*power software (version Taipei City Beitou Sports Centre, Taipei, ROC.
2.0) (Buchner et al. 1997, Faul et al. 2007) for three repeated Participants in both groups monitored their own exercise
measures, within and between interaction among three intensity using the Borg CR10 scale (Borg 1998). On a scale
groups, a significant level at 0Æ05, a small-to-moderate effect of 0–10, participants maintained their perceived exertion at
size (f = 0Æ20), correlations of 0Æ50 and power of 80%. A levels 3 (moderate) – 4 (somewhat strong). The exercise
sample size of 18 per group would be required for analysing instructors in both programmes took class attendance
exercise effects on the primary outcome, the pain dimension and monitored potential adverse effects of the exercise

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T-J Wang et al.

Table 1 Description of the aquatic and land-based exercise programmes

Aquatic exercises Land-based exercises

Focus (duration) Types of exercise Focus (duration) Types of exercise

Warm-up Walk, march and sidestep with Warm-up Joint check, deep breathing instruction, gentle
(5 minutes) variations in movement (5 minutes) muscle stretches, as well as gentle endurance
directions, arm movements, and exercises including walk, march and sidestep, with
by alternatively lifting the bent variations in moving directions, arm movements.
knee or lifting the straight leg like
a toy soldier.
Flexibility training Twenty-four sets of stretching and Upper body training Exercise in a standing position, including 20 sets of
(10 minutes) flexibility exercises in neck, (10 minutes) stretching and flexibility exercises in neck, trunk,
trunk, shoulders and pelvic area, shoulders, arms, hands and waist with 10–15
with 10–15 repetitions for each repetitions for each exercise.
exercise.
Aerobic training Repeat walk moves, as done in the Lower body training Exercise in a standing position by using a chair for
(10 minutes) warm-up section, for 5 minutes (10 minutes) support or in a sitting position, including 15 sets of
and then move in place for an exercises in hips, knees, ankles and toes with 10–15
other 5 minutes, including repetitions of each exercise.
alternatively moving heels, feet Examples of the sitting exercises: sitting pelvic tilt,
and legs in side steps, forwards rocking chair, curl down-elbow to knee, buttocks
and backwards, concurrent with squeeze, hip walk (pelvic mobility), knee lift (hip
arm movements. flexion), leg bend and lift, hip flexor stretch (psoas
stretch), hip abduction, heel to shin bone slide,
thigh firmer (quadriceps set), heel-toe lift, ankle
circles, hamstring and ankle stretch.
Examples of the standing exercises: march, back leg
lift, side leg lift, hip turns, squeeze and bend, standing
ankle circles, tiptoe, leg swings and calf stretch.
Lower body training Exercise by using the wall for Flexibility training Ten sets of floor exercises for stretching and
(10 minutes) support, including 17 sets of (10 minutes) strengthening back, abdominal, hip, knee and
exercises in hips, knees, ankles shoulder muscles, with 10–15 repetitions of each
and toes, with 10–15 repetitions exercise.
of each exercise.
Examples of the 17 sets of the
exercises include forward kick,
side leg lift, hamstring curl,
buttocks squeeze, kick out, leg
lift, small squats, toes in and toes
out, Flamingo, crossovers, leg
circles, side to side weight shift,
front lunge weight shift, push
away, point/flex toes, heel-toe lift,
ankle circles, inversion/ eversion
and toe curls.
Upper body training Twelve sets of exercises for arms, Aerobic training Repeat walk moves, as done in the warm-up section,
(10 minutes) elbows, wrists, hands and fingers, (10 minutes) but with a faster pace for 5 minutes and then move
with 10–15 repetitions of each in place for another 5 minutes, including
exercise. ‘swimming’ in place, doing the forward, back,
breast and sidestroke in the air; write the alphabet
with foot and leg; touch fingers to head, shoulders,
knees and toes; paint different shapes in the air
with fingers, elbow, knee, or foot.
Cool down Repeat walk moves, squat and Cool down Repeat walk, march and sidestep with variations in moving
(5 minutes) stand, as well as hug and pat. (5 minutes) directions, arm movements.

Joint check = seven manoeuvres including using hands to touch mouth, leg, upper buttocks, back, top of the head, behind the neck and make a
fist to quick assess mobility of neck, back, spine, upper and lower extremities.

2612  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2609–2622
Clinical issues Efficacy of aquatic vs. land exercises for knee OA

programmes, including dizziness, chest pain, falls, fracture, KOOS construct validity has been determined in compar-
muscle cramps or exacerbation of pain during or after ison with the Medical Outcomes Study (MOS) 36 short-
exercise. At the post-test, participants were also asked to form Health Survey (SF-36) (Roos et al. 1998, Roos &
indicate any concerns or discomfort from the exercise Toksvig-Larsen 2003). Cronbach’s alpha coefficient for the
programmes in the study questionnaire. One of the research- KOOS was 0Æ88 in current study.
ers audited classes in both programmes every other week to
ensure the fidelity of the interventions. The execution of both Goniometer
programmes followed the study protocols. The knee ROMs were measured using a standard plastic
goniometer. The measurement positions and technique fol-
lowed the Norkinn and White (1985) protocol. Two repeated
Data collection
measurement trials for active ROMs of knee extension and
Pain is one of the most common complaints and disabling flexion were taken consecutively. The mean of two repeated
symptoms in OA populations. Pain reduction is one of the measurements was used for analysis. Good test–retest reli-
most important goals of OA management. Therefore pain abilities were reported as r = 0Æ96–0Æ99 in the Wang et al.
dimension of the KOOS was selected as the primary outcome (2007) study. The baseline data of the two consecutive ROM
measure in the study for testing and comparing the efficacies measures had correlation coefficients of 0Æ78–0Æ97, which
of the exercise programmes. Other dimensions of OA-specific indicate good test–retest reliability (Table 2).
health-related quality of life, knee ROMs and timed walk
distance were also important for assessing efficacy of exercise 6MWT
interventions and were measured as the secondary outcomes The 6MWT was used to measure the distance that partici-
of the study. Questions on demographics and disease pants can walk within six minutes on level ground. Details of
variables were also included in the study questionnaire. Five the 6MWT procedure were presented in the Wang et al.
blinded outcome assessors who were nursing students, using (2007). To avoid potential learning effects, a separate prac-
standardised instructions, collected data on the 10-page self- tice session of the 6MWT was conducted a day before the
report questionnaire as well as physical measures. To be baseline measures. During the test, all participants walked
consistent, these outcome measurements were carried out in independently without using walking aids. Good test–retest
the following order for each participant: questionnaire, knee reliabilities were reported in previous studies, as the ICCs =
ROM tests and the 6MWT. 0Æ94 and r = 0Æ91 for the Montgomery and Gardner (1998)
and Rejeski et al. (2000) studies, respectively. The correlation
coefficient during practice section was 0Æ85 for the current
Validity and reliability of instruments
study.
KOOS
The KOOS was used to measure knee OA-specific health-
Ethical considerations
related quality of life. The scale was developed and validated
for patients with knee injury or knee OA (Roos et al. 1998, Ethics committee approval was obtained from a nursing
Roos & Toksvig-Larsen 2003). The 42-item questionnaire college (NTCNIRB number: 94A032). Each participant
measures five dimensions of health: pain (nine items), other
disease-specific syndromes (seven items), ADL function (17 Table 2 Test–retest reliabilities, errors of measurement and coeffi-
items), sport/recreation function (five items) and QOL cient of variation for knee ROM tests
(4 items). A five-point Likert scale scored from 0 (no prob-
Variables Person correlation ME CV
lems) – 4 (extreme problems) is used for all items. A score in
each of the five dimensions is calculated as the sum of the ROMs ()
Knee extension
items included and then transformed to a 0–100 scale, with 0
Left 0Æ855*** 0Æ67 17Æ3
representing extreme knee problems and 100 representing no
Right 0Æ784*** 0Æ75 20Æ5
knee problems. Knee flexion
The KOOS has demonstrated good test–retest reliability Left 0Æ964*** 0Æ46 0Æ4
[Intraclass correlations (ICCs) = 0Æ78–0Æ97] when used with Right 0Æ966*** 1Æ69 1Æ3
patients after total knee replacement (Roos & Toksvig- ***p < 0Æ001.
Larsen 2003) and (ICCs = 0Æ70–0Æ93) in patients with ROM, range of motion; ME, method error; CV, coefficient of vari-
anterior cruciate ligament injury (Roos et al. 2001). The ance.

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2609–2622 2613
T-J Wang et al.

received an oral explanation of the research and signed a demographics, body mass index (BMI), disease severity or
consent form before participation. The risks/benefits and the outcome variables at baseline. Data on those who lost to
right to drop out from the study at any time were fully follow-up were excluded from final analyses. Characteristics
explained to participants before they signed the consent form. of the participants were summarised by percentages, means
To protect participants’ confidentiality, a study identification and standard deviations (SDs). Value changes of study
number, instead of patient’s name, was used for the data outcomes (dimensions of KOOS, knee ROMs and 6MWT)
record. from baseline, week 6, to week 12 were expressed in three
study groups. A general linear model was used to model these
outcomes as a function of main group effect and main time
Data analysis
effect. An interaction term (group difference by time) was
All statistical analyses were carried out using the SPSS added into each model to investigate the synergistic effect of
statistical package version 17.0 (SPSS Inc., Chicago, IL, the exercise interventions with time. Both the stability
USA). Mann–Whitney U tests and chi-square tests were used analysis and the analysis of repeated relationships were
to test differences between completers and non-completers in performed by generalised estimation equations (GEE). GEE

Assessed for eligibility (n = 237)

Excluded (n = 153)
Not meeting inclusion criteria (n = 88) Enrollment
Refused to participate (n = 65)

Simple randomisation (n = 84)

Allocated to control
Allocated to land group (n = 28)
Allocation

Allocated to aquatic group (n = 28) group (n = 28)

Received allocated intervention (n = 27)
Received allocated intervention (n = 28)
Did not receive allocated intervention
Did not receive allocated intervention
(n = 1) [due to not interesting in land
(n = 0)
exercise]
6th week follow-up

Lost to follow (n = 1) Lost to follow-up (n = 2) [due to not Lost to follow-up (n = 1)

[due to having a herpes flare-up interesting in land exercise (n = 1); [due to other obligations
(n = 1)] other obligations (n = 1)] (n = 1)]
Discontinued intervention (n = 0) Discontinued intervention (n = 0)
12th week follow-up

Lost to follow-up (n = 2) Lost to follow-up (n = 2) [due to not Lost to follow-up (n = 2)

[due to travel (n = 1)] interesting in land exercise (n = 1); [due to other obligations
Discontinued intervention (n = 0) other obligations (n = 1)] (n = 1); admit to a hospital
Discontinued intervention (n = 0) for treating pneumonia
(n = 2)]

Analysed (n = 26) Analysed (n = 26) Analysed (n = 26)

Analysis

Excluded from analysis (n = 2) Excluded from analysis (n = 2) Excluded from analysis

[due to lost to follow-up] [due to lost to follow-up] (n = 2) [due to lost to
follow-up]

Figure 1 Flow diagram of the progress of the study (enrolment, intervention allocation, follow-up and data analysis).

2614  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2609–2622
Clinical issues Efficacy of aquatic vs. land exercises for knee OA

was selected because the study data on several outcome completers (n = 78) and non-completers (n = 6) (p > 0Æ05)
variables followed non-normal distribution and because their at baseline.
variances across time were not equal, as required by RMA- The demographics, BMI and disease variables of the
NOVA model. sample are presented in Table 3. Participants were mainly
women (85Æ9%, n = 67), homemaker or retired (94Æ8%,
n = 74), living with family (82Æ1%, n = 64) and having an
Results
individual monthly income of <10,000 NT dollars (52Æ6%,
n = 41). The mean age of participants was 67Æ7 years (SD 5Æ9;
Demographics and baseline equivalence
range = 54–81). The educational level ranged from illiterate
Eighty-four adults with knee OA were recruited over to postcollege. The majority (41%) of participants had an
six months. Seven participants dropped out of the study, education level of primary school or below. The participants’
including two in the aquatic group, two in the land-based BMI ranged from 20Æ5–31Æ5, with a mean of 26Æ2 (SD 2Æ4).
group and two in the control group (Fig. 1). The dropout rate Mean length of time diagnosed with OA was 6Æ8 years
was about 7%. This left 78 valid cases, with 26 cases in each (SD = 6Æ4; range = 0–26). The number of comorbid condi-
of the three groups. There were no differences in demo- tions ranged from 0–4, with a mean of 1Æ0 (SD 1Æ0). The
graphics, BMI, disease severity or outcome variables between descriptive data of the participants’ pain, symptoms, ADL,

Table 3 Demographic characteristics and disease variables of participants by group

Total
Variables (n = 78) Aquatic (n = 26) Land (n = 26) Control (n = 26) v2/F p

Demographics
Age (mean ± SD) 67Æ7 ± 5Æ9 66Æ7 ± 5Æ6 68Æ3 ± 6Æ4 67Æ9 ± 5Æ9 0Æ495 0Æ612
Sex [f (%)]
Female 67 (85Æ9) 22 (84Æ6) 23 (88Æ5) 22 (84Æ6) 0Æ212 0Æ900
Male 11 (14Æ1) 4 (15Æ4) 3 (11Æ5) 4 (15Æ4)
Education [f (%)]
Primary school and below 32 (41Æ0) 12 (46Æ2) 10 (38Æ5) 10 (38Æ5) 1Æ576 0Æ813
Middle to high school 25 (32Æ1) 6 (23Æ1) 10 (38Æ5) 9 (34Æ6)
College and above 21 (26Æ9) 8 (30Æ8) 6 (23Æ1) 7 (26Æ9)
Living arrangement [f (%)]
Alone 11 (14Æ1) 2 (7Æ7) 5 (19Æ2) 4 (15Æ4) 3Æ49 0Æ479
With family 64 (82Æ1) 23 (88Æ5) 21 (80Æ8) 20 (76Æ9)
With friends or room-mates 3 (3Æ8) 1 (3Æ8) 0 2 (7Æ7)
Current employment status [f (%)]
Employed part time 2 (2Æ6) 1 (3Æ9) 0 1 (3Æ8) 2Æ205 0Æ900
Homemaker 32 (41Æ0) 11 (42Æ2) 11 (40Æ0) 10 (38Æ5)
Retired 42 (53Æ8) 13 (50Æ0) 14 (56Æ0) 15 (57Æ7)
Other 2 (2Æ6) 1 (3Æ9) 1 (4Æ0) 0
Individual monthly income
<10,000 41 (52Æ6) 15 (57Æ6) 14 (53Æ8) 12 (46Æ2) 0Æ286 0Æ991
10,000–19,999 14 (17Æ9) 4 (15Æ4) 4 (15Æ4) 6 (23Æ1)
20,000–29,999 10 (12Æ8) 2 (7Æ7) 5 (19Æ2) 3 (11Æ5)
30,000–39,999 5 (6Æ4) 3 (11Æ5) 0 2 (7Æ7)
40,000–49,999 3 (3Æ8) 1 (3Æ9) 0 2 (7Æ7)
50,000–59,999 5 (6Æ4) 1 (3Æ9) 3 (11Æ5) 1 (3Æ8)
Body mass index 26Æ2 (2Æ4) 26Æ6 (2Æ5) 25Æ4 (2Æ4) 26Æ6 (2Æ08) 2Æ205 0Æ117
Disease variables [mean (SD)]
Years diagnosed with osteoarthritis 6Æ8 (6Æ4) 7Æ1 (6Æ3) 7Æ0 (7Æ4) 6Æ2 (5Æ4) 0Æ140 0Æ870
Number of joints tendered 3Æ2 (2Æ1) 3Æ3 (2Æ3) 3Æ8 (2Æ1) 2Æ7 (1Æ8) 1Æ731 0Æ184
Number of joints swollen 1Æ8 (2Æ0) 1Æ5 (1Æ6) 2Æ2 (2Æ2) 1Æ7 (2Æ0) 0Æ951 0Æ391
Number of comorbid conditions 1Æ0 (1Æ0) 1Æ0 (1Æ0) 0Æ8 (0Æ9) 1Æ1 (1Æ1) 0Æ627 0Æ537

SD, standard deviation; f (%), frequency (percentage); v2, value of chi-square; F, value of one-way ANOVA .

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T-J Wang et al.

Table 4 Pain, disease-specific symptoms, ADL, sport/recreation function, QOL, knee ROM and walk distance at baseline, week 6 and week 12
(n = 78)

Aquatic (n = 26) Land (n = 26) Control (n = 26)

Variables Time Mean SD Mean SD Mean SD F p

KOOS (0–100)
Pain Baseline 61 20 65 14 66 18 0Æ584 0Æ560
Week 6 70 19 72 15 67 19 0Æ521 0Æ596
Week 12 72 18 76 15 68 18 1Æ517 0Æ226
Symptoms Baseline 62 20 63 15 63 18 0Æ041 0Æ960
Week 6 66 20 67 16 61 17 0Æ817 0Æ445
Week 12 69 20 71 16 61 17 2Æ325 0Æ105
ADL Baseline 73 20 75 16 70 19 0Æ405 0Æ668
Week 6 75 18 79 15 70 19 1Æ607 0Æ207
Week 12 76 16 82 14 69 18 3Æ954* 0Æ023
Sport/recreation Baseline 59 22 62 17 60 20 0Æ096 0Æ908
Week 6 64 22 65 16 59 20 0Æ577 0Æ564
Week 12 70 20 68 17 57 20 3Æ220* 0Æ046
QOL Baseline 67 13 66 11 68 13 0Æ201 0Æ818
Week 6 70 13 71 11 67 14 0Æ485 0Æ618
Week 12 73 12 74 11 67 13 2Æ740 0Æ071
ROM ()
Knee extension Baseline 3Æ7 1Æ3 3Æ7 1Æ2 3Æ4 1Æ2 0Æ564 0Æ571
Week 6 2Æ7 1Æ2 2Æ7 1Æ2 3Æ4 1Æ2 3Æ249* 0Æ044
Week 12 2Æ4 2Æ2 2Æ0 1Æ4 3Æ3 1Æ1 4Æ292* 0Æ017
Knee flexion Baseline 121Æ9 3Æ7 122Æ2 5Æ7 121Æ7 5Æ1 0Æ073 0Æ929
Week 6 123Æ4 4Æ2 123Æ9 5Æ5 121Æ8 5Æ1 1Æ266 0Æ288
Week 12 125Æ0 4Æ2 125Æ0 6Æ1 122Æ3 5Æ6 2Æ124 0Æ127
6MWT Baseline 330Æ9 76Æ5 339Æ8 72Æ7 321Æ5 85Æ8 0Æ353 0Æ703
Week 6 368Æ2 71Æ3 351Æ8 77Æ6 325Æ0 83Æ4 2Æ053 0Æ135
Week 12 386Æ0 75Æ8 381Æ0 70Æ4 329Æ1 82Æ3 4Æ436* 0Æ015

*p < 0Æ05.
df (2, 75).
The ROM of knee extension was measured by how many degrees of an extended knee close to a straight position (zero degree). A greater degree
represents a worse extension ability, while a zero degree represents the best extension.
KOOS, Knee Injury and Osteoarthritis Outcome Score (KOOS is 0–100 points, worst to best); ADL, activity of daily living; QOL, knee-related
quality of life; ROM, range of motion; 6MWT, six-minute walk test.

sport/recreation and QOL scores, knee ROMs and the

Comparisons of changes over time among three study
6MWT among the groups at different times are showed in
groups on outcome measures
Table 4. The demographics, disease variables and outcome
variables at baseline were balanced between groups. Results of GEE showed statistically significant group-by-time
interactions in the pain dimension of KOOS (Table 5).
Taking the control group as the reference group and the
Exercise adherence and adverse effect
baseline as the reference time, the aquatic group had
The adherence to the exercise programme was calculated by significantly less problem with pain (a higher score) than
the number of exercise classes attended divided by 36 (three the control group by 9Æ86 (p < 0Æ001) at week 12 and 7Æ91
times per week for 12 weeks) for each participant. The (p < 0Æ001) at week 6. The land group also had significantly
adherence rates were 86Æ4% (SD 10Æ9%) and 86Æ5% (SD less problem with pain than the control group by 9Æ3
13Æ5%) in the aquatic group and in the land-based group, (p < 0Æ001) at week 12 and 6Æ02 (p = 0Æ002) at week 6.
respectively. Two participants in the land group reported The profile of changes in pain differed among the three
increased pain after exercise, and one aquatic participant groups. For those in the aquatic or in the land group, problem
reported feeling dizziness during exercise. There were no with pain declined gradually from baseline through midway
other exercise-related adverse events reported in either group. to postintervention. In contrast, for those in the control

2616  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2609–2622
Clinical issues Efficacy of aquatic vs. land exercises for knee OA

Table 5 Generalised linear model on the effect of pain, disease-specific symptoms, ADL, sport/recreation function and QOL measured with
KOOS (n = 78)

Pain Symptoms ADL Sport/recreation QOL

Variables b SE p b SE p b SE p b SE p b SE p

Group
Aquatic vs. control 4Æ99 4Æ82 0Æ301 1Æ18 4Æ91 0Æ811 2Æ12 4Æ86 0Æ662 1Æ23 5Æ39 0Æ819 1Æ09 3Æ45 0Æ752
Land vs. control 1Æ09 4Æ82 0Æ820 0Æ09 4Æ91 0Æ986 4Æ66 4Æ86 0Æ337 1Æ19 5Æ39 0Æ825 2Æ16 3Æ45 0Æ531
Time
Week 12 vs. baseline 1Æ20 1Æ35 0Æ372 2Æ26 1Æ79 0Æ208 1Æ43 1Æ86 0Æ440 3Æ11 2Æ09 0Æ137 1Æ46 1Æ53 0Æ341
Week 6 vs. baseline 0Æ91 1Æ35 0Æ497 2Æ21 1Æ79 0Æ217 0Æ28 1Æ86 0Æ880 1Æ25 2Æ09 0Æ551 0Æ97 1Æ53 0Æ529
Group · time
Aquatic at week 12 9Æ86*** 1Æ90 <0Æ001 9Æ15*** 2Æ54 <0Æ001 4Æ84 2Æ63 0Æ066 13Æ50*** 2Æ96 <0Æ001 7Æ12** 2Æ17 0Æ001
vs. control at baseline
Aquatic at week 6 vs. 7Æ91*** 1Æ90 <0Æ001 5Æ74* 2Æ54 0Æ024 2Æ43 2Æ63 0Æ356 5Æ52 2Æ96 0Æ062 3Æ88 2Æ17 0Æ074
control at baseline
Land at week 12 vs. 9Æ31*** 1Æ90 <0Æ001 9Æ85*** 2Æ54 <0Æ001 8Æ01** 2Æ63 0Æ002 9Æ62** 2Æ96 0Æ001 9Æ64*** 2Æ17 <0Æ001
control at baseline
Land at week 6 vs. 6Æ02** 1Æ90 0Æ002 5Æ92* 2Æ54 0Æ019 4Æ04 2Æ63 0Æ125 4Æ29 2Æ96 0Æ147 5Æ36* 2Æ17 0Æ014
control at baseline

*p < 0Æ05, **p < 0Æ01, ***p < 0Æ001.

Using generalised estimation equations for repeated measurements and the correlation structure exchangeable.
b, Coefficient of modelling; KOOS, Knee Injury and Osteoarthritis Outcome Score (KOOS is 0–100 points, worst to best); ADL, activity of
daily living; QOL, knee-related quality of life.

group, problem with pain remained basically unchanged sport centres and might be different from those seen in
throughout the study (Fig. 2). This finding supports the first clinical settings. Specifically, the study participants might
study hypothesis that participants in both exercise groups have fewer restrictions in physical functioning than clinical
would show pain reduction over time. populations. The mean KOOS subscales scores were between
Moreover, to compare the pain reduction effects of the two 60Æ1 (SD 20Æ2) and 74Æ1 (SD 18Æ4) in the current study
interventions further, taking the land-based group as the compared with between 20Æ1 (SD 29Æ1) and 41Æ7 (SD 16Æ0)
reference group and baseline as the reference time, the reported by patients with OA recruited from four physical
aquatic group did not show any significant difference from therapy outpatient clinics in the Gonçalves et al. (2010)
the land group both at weeks 12 and 6 (Table 6). The results study. Our study participants are community-dwelling well-
were not able to support the second study hypothesis in functioning OA populations. Thus, the results may not be
favour of aquatic exercise for reducing pain. generalisable to clinical OA populations with a greater
The statistical significant group-by-time interaction effects functional decline.
were also found on all the secondary outcome measures other Second, there may have been a selection bias because we
than ADL (Tables 5 and 7). Changes in these variables were excluded people who are currently exercising regularly,
generally proportional and increased consistently across time having intra-articular corticosteroid injections or received a
in both exercise groups; no change was observed in the joint replacement previously to avoid potential confounding
control group (Fig. 2). These results partially support the effects from these variables. Third, we assessed study
third study hypothesis that participants in both groups would outcomes only on mid-point and post-test, so we were not
also show positive changes over time on other dimensions of able to determine the long-term outcomes of these pro-
KOOS, knee ROMs and the 6MWT. grammes.
Fourth, no between-group difference raises a concern of
type II error. Although, it is quite possible that the both
Discussion
exercise programmes are equally effective, the prior estima-
tion of desired sample size was calculated based on detecting
Study limitations
a small-to-moderate between-group effects in pain reduction.
The study design had several limitations. First, the study We cannot exclude the possibility of lacking statistical power
participants were recruited from local community centres and for detecting between-group differences in the study. For

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2609–2622 2617
T-J Wang et al.

(a) (b) (c)

(d) (e) (f)

(g) (h)

Figure 2 Changes in pain, disease-specific symptoms, activities of daily living, sport/recreation function, knee-related quality of life, knee range
of motion and walk distance over time at baseline and during exercise (week 6) and post-test (week 12). The data are shown as mean ± 95%
confidence interval (error bars). (a) Changes in pain over time. (b) Changes in disease-specific symptoms over time. (c) Changes in activities of
daily living over time. (d) Changes in sport/recreation function over time. (e) Changes in knee-related quality of life over time. (f) Changes in
range of motion (ROM) of knee extension over time. (g) Changes in ROM of knee flexion over time. (h) Changes in six-minute walk distance
over time.

future studies, the size of the sample should be estimated, Finally, many other variables that are not controlled in
based on a non-inferiority study design, to have adequate the current study may explain the lack of difference in the
power for confirming the equivalent effect of the two exercise two interventions. These possible confounding variables
interventions for knee OA. include age of onset, OA severity, presence of skeletal

2618  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2609–2622
Clinical issues Efficacy of aquatic vs. land exercises for knee OA

Table 6 Generalised linear model for comparing the effect of pain Tests of intervention effect
measured with KOOS between the aquatic and land-based exercise
group (n = 78) We found that pain decreases after 12 weeks of exercise in
both groups. The mean changes in the pain dimension of
Pain
the KOOS were 8Æ8 (95% CI = 4Æ8–12Æ8) and 9Æ1 (95%
Variables b SE p CI = 5Æ1–13Æ2) for the aquatic and land group, respectively.
Group The magnitude of these changes should be considered
Aquatic vs. land 3Æ89 4Æ72 0Æ409 clinically significant because they are greater than
Time eight, which is the cut-off point for minimal perceptible
Week 12 vs. baseline 10Æ5*** 1Æ54 <0Æ001 clinical improvement of the KOOS, as suggested by Roos
Week 6 vs. baseline 6Æ9*** 1Æ54 <0Æ001
and Lohmander (2003). The small beneficial effect is
Group · time
Aquatic at week 12 vs. 0Æ55 2Æ18 0Æ801
consistent with findings in previous studies (Fransen et al.
land at baseline 2001, Roddy et al. 2005, Bartels et al. 2007, Silva et al.
Aquatic at week 6 vs. 1Æ88 2Æ18 0Æ389 2008).
land at baseline Both groups also showed positive changes over time in the
***p < 0Æ001. symptoms, sport/recreation and QOL dimension of the
Using generalised estimation equations for repeated measurements KOOS. These were consistent with the common finding of
and the correlation structure exchangeable. small beneficial effects on self-reported disability outcome
b, coefficient of modelling; KOOS, Knee Injury and Osteoarthritis measures in the OA exercise literature (Roddy et al. 2005,
Outcome Score (KOOS is 0–100 points, worst to best).
Bartels et al. 2007, Silva et al. 2008). The absence of change
in the ADL of the KOOS, however, may be as a result of few
difficulties in performing targeted activities (with mean scores
mal-alignment or joint laxity and types of daily routine. of 73–75 on a 0–100 scale) before the interventions and thus
Without measuring or assessing these potential cofounders, there was relatively little room for improvement. The ADL
it was impossible to test or control their impacts on the dimension of the KOOS tapped relatively basic ADLs, which
study outcomes. Future studies might want to address these were less restricted by joint disorders in community-dwelling
issues. populations.

Table 7 Generalised linear model on the effect of knee ROM and six-minute walk distance (n = 78)

Knee extension Knee flexion 6MWT

Variables b SE p b SE p b SE p

Group
Aquatic vs. control 0Æ34 0Æ38 0Æ376 0Æ22 1Æ41 0Æ875 9Æ41 21Æ49 0Æ662
Land vs. control 0Æ29 0Æ38 0Æ449 0Æ52 1Æ41 0Æ712 18Æ31 21Æ49 0Æ394
Time
Week 12 vs. baseline 0Æ06 0Æ22 0Æ785 0Æ63 0Æ36 0Æ083 7Æ58 7Æ89 0Æ337
Week 6 vs. baseline 0Æ06 0Æ22 0Æ798 0Æ07 0Æ36 0Æ852 3Æ52 7Æ89 0Æ655
Group · time
Aquatic at week 12 vs. 1Æ25*** 0Æ31 <0Æ001 2Æ45*** 0Æ51 <0Æ001 47Æ56*** 11Æ17 <0Æ001
control at baseline
Aquatic at week 6 vs. 1Æ10*** 0Æ31 <0Æ001 1Æ39** 0Æ51 0Æ007 33Æ79** 11Æ17 0Æ002
control at baseline
Land at week 12 vs. 1Æ58*** 0Æ31 <0Æ001 2Æ12*** 0Æ51 <0Æ001 33Æ56** 11Æ17 0Æ003
control at baseline
Land at week 6 vs. 0Æ97** 0Æ31 0Æ002 1Æ56** 0Æ51 0Æ002 8Æ42* 11Æ17 0Æ450
control at baseline

*p < 0Æ05, **p < 0Æ01, ***p < 0Æ001.

Using generalised estimation equations for repeated measurements and the correlation structure exchangeable.
The ROM of knee extension was measured by how many degrees of an extended knee close to a straight position (zero degree). A greater degree
represents a worse extension ability, while a zero degree represents the best extension.
b, Coefficient of modelling; 6MWT, six-minute walk test; ROM, range of motion.

 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2609–2622 2619
T-J Wang et al.

We also found that both interventions were effective in land-based exercise programmes are effective for reducing
improving the knee ROMs, similar to what was reported in pain, improving knee ROMs and 6MWT, as well as
other studies (Wyatt et al. 2001, Foley et al. 2003). Both consequently increasing QOL in people with knee OA. The
exercise groups showed significant improvements on the aquatic exercise is not superior to land-based exercise in pain
6MWT over time. The 6MWT increased 19Æ7 and 12Æ5% reduction. These results can be informative for both clinicians
from baseline values in the aquatic and land-based exercise and patients with OA in selecting appropriate types of
groups, respectively. These changes were similar to what exercises.
were found in previous studies Wyatt et al. (2001) and Wang
et al. (2007).
Relevance to clinical practice
However, the study results were not able to support the
third study hypothesis in favour of aquatic exercise for Exercising in moderate intensity, three times a week is safe
reducing pain. This is different from the Wyatt et al. (2001) for OA patients without medical conditions that preclude
and Silva et al. (2008) study, where the aquatic group did exercise. These recreational exercise programmes were also
better for pain reductions. The different pain measures used well accepted by community populations of OA in Taiwan.
in these studies may partially explain the different results. A These programmes did not require expensive resources,
visual analogue scale (VAS) was used to measure pain at rest making them clinically suitable for patients with OA.
in the Wyatt et al. (2001) study and before and after the Similar outcomes could be possible with the two pro-
50FWT in the Silva et al. (2008) study, but Foley et al. grammes, one or more of which may not be feasible for
(2003) compared group differences in the pain dimension of some people. Therefore, health care professionals who are
the Western Ontario and McMaster Universities Osteoar- taking care of patients with OA should consider suggesting
thritis Index (WOMAC). It is possible that the pain VAS was well-designed aquatic or land-based exercise classes for
more sensitive to changes than was the pain dimension of the patients, based on their preferences and convenience.
KOOS or WOMAC. This may be seen in the Lund et al. However, the benefits of exercise take time and regular
(2008) study, which found no group differences in the pain participation to become evident. Patients should be encour-
dimension of the KOOS. The land groups, however, had a aged to maintain regular exercise and to maintain realistic
greater reduction in the pain score at rest when measured expectations. The goals of exercise are to prevent further
with a 100-mm VAS. Therefore, we suggest that future deterioration and to have a better quality of life, instead of
studies may want to use a VAS for pain measurement at rest curing their OA.
in addition to the KOOS.
Additionally, even though the results showed no group
Acknowledgements
difference in pain reduction, it is important to differentiate
the finding of no significant differences in improvement The authors thank all the participants in this study and the
between interventions from the finding of no significant staff of Taipei City Beitou Sports Center. The study is
differences in improvement at all. Because both interventions supported by the funding of the National Science Council of
generate favourable outcomes, the between-group difference Republic of China (NSC, 94-2314-B-227-005).
might have been minimised.

Contributions
Conclusion
Study design: T-JW, S-CL; data collection and analysis:
Many previous studies have compared one exercise pro- T-JW, S-CL, S-YL, Y-PL and manuscript preparation: T-JW,
gramme group with one control group and have concluded S-YL, H-HT, S-FVW.
that there is a difference, but there is no indication of how the
programme compares with other exercise programmes. Our
Conflict of interest
study compared two popular community-based exercise
programmes. The study results show that both aquatic and The authors declare that they have no conflict of interests.

2620  2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2609–2622
Clinical issues Efficacy of aquatic vs. land exercises for knee OA

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