Ma et al.

Journal of Orthopaedic Surgery and Research (2022) 17:190

[Link]

RESEARCH ARTICLE Open Access

Overall treatment effects of aquatic

physical therapy in knee osteoarthritis:
a systematic review and meta‑analysis
Ji Ma1, Xiaoyu Chen2, Juan Xin1, Xin Niu1, Zhifang Liu3* and Qian Zhao3*

Abstract
Objective: To determine the benefits of aquatic physical therapy as a rehabilitation strategy for knee osteoarthritis
patients.
Methods: Electronic databases systematically searched up to July 2021.
Results: 580 RCTs were selected. A total of thirteen studies comprising 883 participants were included in the study.
For pain, meta-analyses showed that aquatic physical therapy is associated with a significant change in Western
Ontario and McMaster University Osteoarthritis Index (WOMAC) pain (SMD = − 1.09, 95%CI − 1.97, − 0.21, p = 0.02)
and visual analog scale (VAS) (SMD = − 0.55, 95%CI − 0.98, − 0.12, p = 0.01). In addition, for physical function, meta-
analyses showed that aquatic physical therapy effectively improved WOMAC physical function (SMD = − 0.57, 95%CI
− 1.14, − 0.01, p = 0.05). However, our findings showed no significant improvements in symptoms of joints, quality of
life (QOL), flexibility, and body composition with knee osteoarthritis. For muscle strength, we found that aquatic physi-
cal therapy can only improve knee extension muscle strength (MD = 2.11, 95%CI 0.02, 4.20, p = 0.05). Additionally,
for walking ability, we observed that aquatic physical therapy effectively reduced Timed-Up-and-Go Test (TUGT) in a
large degree (MD = − 0.89, 95%CI − 1.25, − 0.53, p < 0.05).
Conclusions: According to the findings reported in the studies analyzed in the review, aquatic physical therapy had
a positive effect on the pain, physical function, knee extension muscle strength, and walking ability among people
with knee osteoarthritis.
Keywords: Knee osteoarthritis, Aquatic physical therapy, Meta-analysis

Introduction [1, 2]. Additionally, with the combined effects of aging,

Osteoarthritis (OA) is the most prevalent form of arthri- increasing obesity in the global population, and increas-
tis and the main cause of disability in the older adults, and ing numbers of joint injuries, the burden of osteoar-
the knee is its most frequently affected weight-bearing thritis is becoming more common. According to global
joint [1]. This chronic and disabling condition not only estimates, 250 million people are currently affected [3].
reduces individual quality of life (QOL), but also exhausts Therefore, there is an urgent need to explore methods of
a lot of health care resources and socioeconomic costs slowing down the progression of the disease.
The guidelines have strongly recommended that exer-
cise is an effective non-pharmacological intervention
*Correspondence: lzf13546444276@[Link]; zhaoqian_sara@[Link] for OA patients, which can relieve pain and enhance
3
Department of Nursing, Shanxi Provincial People’s Hospital, 29th
Shuangta Temple Street, Taiyuan 030012, Shanxi, People’s Republic physical function [4]. Although both land and aquatic
of China exercises can alleviate pain and improve the physical
Full list of author information is available at the end of the article function of patients with OA [5], patients experience

© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
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Ma et al. Journal of Orthopaedic Surgery and Research (2022) 17:190 Page 2 of 15

pain, stiffness, and muscle weakness during land exer- Materials and methods
cises [6, 7], which limits their physical activity levels This is a meta-analysis of randomized trials involving
and leads them to a sedentary lifestyle [8, 9]. Corre- the overall treatment effect of aquatic physical therapy
spondingly, lack of exercise will aggravate the progres- in knee OA. The systematic review and meta-analysis
sion of the disease. were reported in accordance with the recommenda-
In light of this, aquatic physical therapy would be an tions of the Preferred Reporting Items for Systematic
ideal form of physical activity for patients with OA. Review and Meta-Analyses: The PRISMA Statement
Because the buoyancy of water reduces the weight that and Cochrane Handbook for Systematic Reviews of
joints, bones and muscles must bear [10], the warmth Interventions [20, 21]. The selected search strategy and
and pressure of water can also promote blood circula- methods of analysis were registered at the PROSPERO
tion and reduce joint pain and stiffness [11]. In addi- database (ref: CRD42021267364).
tion, compared with other forms of treatments, aquatic
physical therapy does not worsen joint condition [12]
and leads to a higher level of treatment compliance Search strategy
[11]. And it is widely used as part of rehabilitation We searched the following databases including Med-
interventions for many diseases [13], such as rheumatic line/PubMed, Web of Science, Embase, Cochrane
disease, fibromyalgia, stroke, and Parkinson disease Library and Chinese databases of the CNKI Scholar,
[14–16]. VIP and WanFang. The relevant studies were searched
There has been a meta-analysis of 11 trials for knee from the inception of each database to July 2021. The
and hip OA patients and showed the positive effects search terms and strategy used were as follows: (hydro-
of aquatic exercise on pain, stiffness, physical func- therapy OR aquatic exercise OR water-based exercise)
tion, and QOL [17]. And another Cochrane review of AND (osteoarthrosis OR arthritis degenerative OR
13 clinical trials also reached a similar conclusion [11]. arthritis) AND (randomized controlled trial OR RCT).
However, a recent meta-analysis explored whether Additionally, to search all relevant studies, the refer-
aquatic exercise is superior to land-based exercise in ence lists were also manually reviewed.
knee OA patients that showed comparable effects on
the above outcomes [18]. Therefore, a consistent con- Inclusion and exclusion criteria
clusion for the effect of aquatic physical therapy on The study inclusion criteria were as follows: (1) partici-
knee OA alone could not be drawn [11]. Further, lack pants have a clinical diagnosis of knee OA; (2) partici-
of sufficient evidence for the benefits of aquatic physi- pants aged ≥ 40 years; (3) participants have no medical
cal therapy, which limits recommendation on knee OA. conditions that prevent increased physical activities;
Although pain is the most prominent symptom of (4) participants have not participated in an organized
knee OA, it is often associated with other functional exercise program in the past 3 months; (5) during the
impairments, such as muscle weakness, reduced joint intervention period, participants can actively partici-
range of motion (ROM) and joint instability [12]. So pate in the treatment; (6) at least one group of inter-
the purposes of exercise in knee OA are not only to vention methods was aquatic physical therapy; (7) the
reduce pain and stiffness and restore impaired physi- study was reported at least one of the outcomes: pain,
cal function and functional status, but also to improve symptoms of joints, physical function, QOL, flexibility,
ROM and maintain joint function and integrity. Addi- muscle strength, walking ability, and body composi-
tionally, Bliddal and Christensen reported that a 10% tion; (8) the type of study design was the RCT. Studies
reduction in body weight could reduce OA symptoms were excluded if (1) the type of article was conference
by 28% [19], and it is necessary to investigate the effec- abstracts, case reports, comments, letters to editor,
tiveness of aquatic physical therapy on body fat. There- review articles, or family-based studies; (2) the full text
fore, in addition to including pain, symptoms of joints, of the study was not available; (3) studies without avail-
physical function, and QOL, we also included outcome able data; (4) the type of study design was not the RCT.
measures of flexibility, muscle strength, walking abil-
ity, and body composition would provide a more com-
prehensive picture of the therapeutic value associated Data extraction and quality assessment
with aquatic physical therapy. For this purpose, we Two independent researchers screened all abstracts
performed a systematic review and meta-analysis of identified in the initial search, excluded studies that
randomized controlled trials (RCTs) to evaluate over- violated the inclusion criteria, and removed all the
all treatment effects of aquatic physical therapy in knee duplicated references. If it was unclear whether the
OA. study met the selection criteria, advice could be sought
Ma et al. Journal of Orthopaedic Surgery and Research (2022) 17:190 Page 3 of 15

from a third researcher and a consensus of opinion was if I2 < 50%, it could be considered that there was homo-
made. geneity among the trials, and the fixed-effects model
Information on first author and publication year, coun- was used; otherwise, a random-effects model was used
try, sample size, exercise type of experimental group and (I2 ≥ 50%). A z test was adopted to test the combined
control group, intervention time, follow-up time and out- effect and statistical significance was set at p < 0.05 [22].
comes measures were extracted from the original reports. In addition, subgroup analyses were used to compare the
The quality of the trials included was assessed by the two hip abduction muscle strength (left and right), and evalu-
independent researchers according to the Cochrane Col- ation instruments (body composition: BMI and fat mass).
laboration Handbook recommendations and items such
as: randomization, allocation concealment, blinding, Results
incomplete outcome data and selective reporting [21]. Study selection and characteristics
It means low risk if the thesis clearly described, high A total of 580 studies were obtained by searching electri-
risk if not described and unclear if described indetermi- cal databases, and thirteen trials [12, 23–34] were finally
nate in the text. Researchers achieved consensus by dis- included (Fig. 1). There were 883 patients in total and
cussion, and if researchers didn’t achieve, a third reviewer involved for meta-analysis (357 aquatic physical ther-
was consulted. apy and 526 no aquatic physical therapy). A summary
of characteristics of the included studies is shown in
Outcome measures Table 1. All of the studies were published in English. Pub-
The main outcomes that were examined included: pain, lished in 2003–2019, the studies come from 10 different
symptoms of joints, physical function, QOL, flexibility, countries and regions. The duration of the interventional
muscle strength, and walking ability and body composi- programs ranged from 6 to 18 weeks.
tion. Across the studies, Western Ontario and McMas-
ter University Osteoarthritis Index (WOMAC) pain, Critical appraisal
visual analog scale (VAS) score, and Knee Injury and The results of quality assessment of the included stud-
Osteoarthritis Outcome Score (KOOS) pain were used ies by Cochrane Collaboration Handbook are shown in
to measure pain. Symptoms of joints were measured by Figs. 2 and 3. Ten had random sequence generation, ten
the WOMAC stiffness and KOOS for symptoms. Physi- had allocation concealment, no trials had blinding of
cal function was measured by using the KOOS for activi- participants and personnel, six had blinding of outcome
ties of daily living (ADL), KOOS for sport/recreation, assessment, no trials were assessed to have incomplete
WOMAC physical function, and the medical outcomes outcome data, and risk of selective reporting and other
study short form-36 (SF-36) physical function. QOL bias in all trials were low.
was measured by using the KOOS for QOL. Flexibility
was measured by tests of joint range of motion (ROM) Effect of intervention
of knee extension and knee flexion. Knee extension and Pain
flexion and hip abduction muscle strength were used to Eleven studies were included in the meta-analysis with
measure muscle strength. Walking ability was quantified outcome assessed pain. WOMAC pain [24, 28, 31, 33,
by the 6-min walk test (6MWT), walking speed, step test, 34], VAS score [12, 29–31, 34], and KOOS pain [12, 23,
or the Timed-Up-and-Go Test (TUGT). Body composi- 26, 27] were used to measure pain. Studies which used
tion was evaluated by the body mass index (BMI) or the WOMAC pain and VAS showed high heterogeneity
fat mass. (WOMAC pain: p < 0.1, I2 = 93%, VAS: p < 0.1, I2 = 73%),
whereas KOOS pain showed low heterogeneity (p = 0.85,
Statistical analysis and risk of bias assessment I2 = 0%). There were statistically significant differences
The data were analyzed by RevMan software (version in WOMAC pain (SMD = − 1.09, 95%CI − 1.97, − 0.21,
5.4.1). A meta-analysis intended to carry out RCTs, if the p = 0.02), and VAS (SMD = − 0.55, 95%CI − 0.98, − 0.12,
same outcomes had been assessed in at least two studies p = 0.01) in the aquatic physical therapy group compared
in a similar way, and at least one group received aquatic to the no aquatic physical therapy group, but no signifi-
physical therapy. The mean difference (MD) and 95% cant difference in KOOS pain (MD = 0.31, 95%CI − 2.12,
confidence interval (CI) were calculated for continuous 2.75, p = 0.80) (Fig. 4).
data to assess the change. For continuous outcomes with
different scoring units, the standardized mean differ- Symptoms of joints
ence (SMD) with 95% confidence intervals (CI) was used Seven studies assessed symptoms of joints using
to pool each outcome measure for estimating the effect WOMAC stiffness [24, 31, 33] and KOOS symptoms
size. The heterogeneity among studies was assessed by I2;
Ma et al. Journal of Orthopaedic Surgery and Research (2022) 17:190 Page 4 of 15

Fig. 1 Flow diagram based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement

[12, 23, 26, 27]. Studies which used WOMAC stiffness Physical function
showed substantial heterogeneity (p < 0.1, I2 = 69%), Physical function was measured by using KOOS ADL
whereas KOOS symptoms showed low heterogeneity [12, 23, 26, 27], KOOS sport/recreation [12, 23, 26,
(p > 0.1, I2 = 0%). There were no significant differences 27], WOMAC physical function [24, 28, 31, 33], and
in WOMAC stiffness (SMD = − 0.42, 95%CI − 0.94, SF-36 physical function [32, 34]. Whereas KOOS ADL
0.09, p = 0.1), and KOOS symptoms (MD = 2.47, 95%CI or KOOS sport/recreation showed low heterogeneity
− 0.19, 5.14, p = 0.07) between aquatic physical therapy (KOOS ADL: p = 0.31, I2 = 16%, KOOS sport/recreation:
and no aquatic physical therapy (Fig. 5). p = 0.44, I2 = 0%), there were no significant differences in
KOOS ADL (MD = 1.37, 95%CI − 1.27, 4.01, p = 0.31),
Ma et al. Journal of Orthopaedic Surgery and Research (2022) 17:190 Page 5 of 15

Table 1 Characteristics of studies included in the meta-analysis

First author (year) Country of study ne1/nc1 Experimental group Control group (type of Intervention time Outcomes measures
ne2/nc2 (type of exercise) exercise)

Dias [28] Brazil 33/32 Aquatic exercise and an An educational protocol Six weeks WOMAC
educational protocol muscle strength
Power and resistance
Silva [9] Brazil 32/32 Aquatic physical therapy Land-based exercise 18 weeks Lequesne Index Scores
WOMAC, VAS, 50FWT
Kars Fertelli [24] Turkey 60/60 Aquatic physical therapy Not receive any inter- 8 weeks WOMAC, ASS
vention Muscle strength
Hale [33] New Zealand 23/16 Aquatic physical therapy Computer skills training 12 weeks Falls risk ratio
Step test, TUGT, ABC Scale
AIMS2-SF 26, WOMAC
Hinman [31] Australia 36/35 Aquatic physical therapy Usual care 6 weeks VAS, WOMAC, AQOL, PASE
Muscle strength
step test, TUGT, 6MWT
Lim [32] Korea 24/22 Aquatic physical therapy Land-based exercise 8 weeks Body weight, BMI, lean
24/22 Home-based exercise body mass, body fat mass,
body fat proportion,
abdominal fat, BPI
WOMAC
SF-36
Peak torque, knee exten-
sor and flexor
Lund [12] Denmark 27/25 Aquatic physical therapy Land-based exercise 8 weeks VAS
27/27 Not receive any inter- KOOS
vention
Rantalainen [26] Finland 42/42 Aquatic physical therapy Usual care 16 weeks T2 relaxation time, DGEM-
RIC index
Cardiorespiratory fitness,
force
KOOS
Suomi [25] WI 10/10 Aquatic physical therapy Land-based exercise 8 weeks Flexibility, hand–eye
10/10 Not receive any inter- coordination
vention Right arm curls, Left arm
curls
RSHab isometric, LSHab
isometric, LHab isometric
Functional capacity evalu-
ation
Taglietti [34] Brazil 31/29 Aquatic physical therapy Educational program 8 weeks VAS, WOMAC, SF-36
Depression, TUGT​
Waller [27] Finland 43/44 Aquatic physical therapy Usual care 4 months Walking speed, body
mass, BMI, lean mass, fat
mass
KOOS
Wang [30] USA 20/18 Aquatic physical therapy Usual care 12 weeks Flexibility, muscle strength
6MWT, MDHAQ, VAS
Wang [23] Taiwan 26/26 Aquatic physical therapy Land-based exercise 12 weeks KOOS, ROM, 6MWT
26/26 Not receive any inter-
vention
WOMAC, Western Ontario and McMaster University Osteoarthritis Index; VAS, Visual Analog Scale; 50FWT, 50-foot (15.24-m) Walk Test; ASS, Arthritis Self-Efficacy Scale;
TUGT, Timed-Up-and-Go Test; ABC, activity-specific balance confidence; AIMS2-SF, Arthritis Impact Measurement Scales 2-Short Form; AQoL, Assessment of Quality
of Life Scale; PASE, Physical Activity Scale for the Elderly; 6MWT, 6-Min walk test; BMI, body mass index; BPI, brief pain inventory; SF-36, medical outcomes study short
form-36; KOOS, Knee Injury and Osteoarthritis Outcome Score; T2, transverse relaxation time; DGEMRIC, delayed gadolinium-enhanced magnetic resonance imaging
of cartilage; RSHab, right shoulder abduction; LSHab, left shoulder abduction; LHab, left hip abduction; MDHAQ, multidimensional Health Assessment Questionnaire;
ROM, range of motion

and KOOS sport/recreation (MD = 3.31, 95%CI − 0.43, high heterogeneity (WOMAC physical function: p < 0.1,
7.05, p = 0.08) between aquatic physical therapy and no I2 = 81%, SF-36 physical function: p < 0.1, I2 = 95%), and
aquatic physical therapy. However, WOMAC physi- there was statistically significant difference in WOMAC
cal function and SF-36 physical function demonstrated physical function (SMD = − 0.57, 95%CI − 1.14, − 0.01,
Ma et al. Journal of Orthopaedic Surgery and Research (2022) 17:190 Page 6 of 15

Fig. 2 Risk of bias graph

Fig. 3 Risk of bias summary

p = 0.05) in the aquatic physical therapy group compared flexion (MD = − 1.97, 95%CI − 7.97, 4.03, p = 0.52) in
to the no aquatic physical therapy group, but no signifi- the aquatic physical therapy group compared to the no
cant difference in SF-36 physical function (MD = 4.54, aquatic physical therapy group (Fig. 8).
95%CI − 5.60, 14.69, p = 0.38) (Fig. 6).
Muscle strength
Quality of life Six studies were included in the meta-analysis with
Four studies assessed QOL using KOOS QOL [12, 23, 26, outcome measured muscle strength. Knee extension
27]. Heterogeneity was not observed in the analyses for muscle strength [24, 28, 30–32], knee flexion mus-
QOL (p = 0.6, I2 = 0%), and the meta-analysis (MD = 0.07, cle strength [24, 28, 30, 32], and hip abduction mus-
95%CI − 2.67, 2.81, p = 0.96) demonstrated that there cle strength [25, 31] were used to measure muscle
was no significant difference in the improvement of QOL strength. Due to the different muscle strength between
between the 2 groups (Fig. 7). the left and right sides in hip abduction studies, a sub-
group analysis should be conducted for comparison.
Flexibility Heterogeneity was not apparent for knee extension
Flexibility was measured by tests of joint ROM of knee (p = 0.14, I2 = 41%) and hip abduction muscle strength
extension and knee flexion [23, 30]. Studies which used (left: p = 0.75, I2 = 0%, right: p = 0.84, I2 = 0%); how-
joint ROM of knee extension showed high heterogene- ever, knee flexion muscle strength demonstrated high
ity (p = 0.05, I2 = 67%), whereas knee flexion showed heterogeneity (p < 0.01, I2 = 71%). And pooled analysis
low heterogeneity (p = 0.78, I2 = 0%). There were no results demonstrate that aquatic physical therapy has
significant differences in joint ROM of knee extension no statistically significant differences than no aquatic
(MD = − 0.64, 95%CI − 1.86, 0.58, p = 0.30) and knee physical therapy in improving knee flexion muscle
Ma et al. Journal of Orthopaedic Surgery and Research (2022) 17:190 Page 7 of 15

Comparison 1. WOMAC pain: aquatic physical therapy versus no aquatic physical

therapy

Comparison 2. VAS: aquatic physical therapy versus no aquatic physical therapy

Comparison 3. KOOS pain: aquatic physical therapy versus no aquatic physical

therapy

Fig. 4 Forest plot of aquatic physical therapy versus no aquatic physical therapy interventions in pain

strength (MD = − 2.14, 95%CI − 6.91, 2.63, p = 0.38), Walking ability

and hip abduction muscle strength (left: MD = 1.30, Walking ability was evaluated by 6-min walk test [23,
95%CI − 2.44, 5.04, p = 0.50, right: MD = 2.46, 95%CI 30, 31], walking speed [27, 29], step test [31, 33], and
− 0.98, 5.90, p = 0.16). But there was a statistically sig- Timed-Up-and-Go Test [31, 33, 34]. Heterogene-
nificant difference in knee extension muscle strength ity was not apparent for 6MWT (p = 0.19, I2 = 37%),
between the 2 groups (MD = 2.11, 95%CI: 0.02, 4.20, step test (p = 0.23, I2 = 30%), and TUGT (p = 0.24,
p = 0.05) (Fig. 9). I2 = 31%); however, walking speed demonstrated
Ma et al. Journal of Orthopaedic Surgery and Research (2022) 17:190 Page 8 of 15

Comparison 1. WOMAC stiffness: aquatic physical therapy versus no aquatic

physical therapy

Comparison 2. KOOS symptoms: aquatic physical therapy versus no aquatic physical

therapy

Fig. 5 Forest plot of aquatic physical therapy versus no aquatic physical therapy interventions in symptoms of joints

high heterogeneity (p = 0.02, I2 = 81%). The aquatic Discussion

physical therapy has no statistically significant differ- This systematic review and meta-analysis aimed to
ence in improving the scores of 6MWT (MD = 15.58, determine the overall treatment effect of aquatic physi-
95%CI − 5.82, 36.98, p = 0.15), walking speed cal therapy in patients with knee OA. Based on the
(MD = 0.32, 95%CI − 0.27, 0.92, p = 0.29), and step test included RCTs (n = 13), for pain, we found that aquatic
(MD = − 0.37, 95%CI − 1.65, 0.91, p = 0.57) compared physical therapy is associated with a significant change
to no aquatic physical therapy. But there was a statis- in WOMAC pain and VAS but not KOOS pain in peo-
tically significant difference in TUGT between the 2 ple with knee OA. For symptoms of joints, our meta-
groups (MD = − 0.89, 95%CI − 1.25, − 0.53, p < 0.05) analysis showed that aquatic physical therapy did not
(Fig. 10). significantly relieve WOMAC stiffness and KOOS
symptoms. Compared with no aquatic physical ther-
apy, aquatic physical therapy cannot improve three test
Body composition scores of physical function (KOOS ADL, KOOS sport/
Two studies assessed body composition using BMI recreation and SF-36 physical function), but it has sig-
[27, 32] and fat mass [27, 32]. Because the evaluation nificant statistical differences in WOMAC physical
methods are different among these studies, a subgroup function, and the effect size was moderate (WOMAC:
analysis should be conducted for comparison. Whereas SMD = − 0.57, 95%CI − 1.14, − 0.01, p = 0.05). Our
BMI or fat mass showed low heterogeneity (BMI: findings also showed no significant improvements
p = 0.47, I2 = 0%, fat mass: p = 0.38, I2 = 0%), there were in QOL, flexibility, and body composition with knee
no significant differences in BMI (MD = − 0.30, 95%CI OA. For muscle strength, we found that aquatic physi-
− 0.98, 0.39, p = 0.39), and fat mass (MD = − 0.62, cal therapy can only improve knee extension muscle
95%CI − 2.20, 0.96, p = 0.44) between the 2 groups strength. In addition, for walking ability, we observed
(Fig. 11). that aquatic physical therapy effectively reduced TUGT
Ma et al. Journal of Orthopaedic Surgery and Research (2022) 17:190 Page 9 of 15

Comparison 1. KOOS ADL: aquatic physical therapy versus no aquatic physical

therapy

Comparison 2. KOOS sport/recreation: aquatic physical therapy versus no aquatic

physical therapy

Comparison 3. WOMAC physical function: aquatic physical therapy versus no

aquatic physical therapy

Comparison 4. SF-36 physical function: aquatic physical therapy versus no aquatic

physical therapy

Fig. 6 Forest plot of aquatic physical therapy versus no aquatic physical therapy interventions in physical function
Ma et al. Journal of Orthopaedic Surgery and Research (2022) 17:190 Page 10 of 15

Comparison 1. KOOS QOL: aquatic physical therapy versus no aquatic physical

therapy

Fig. 7 Forest plot of aquatic physical therapy versus no aquatic physical therapy interventions in quality of life

Comparison 1. Joint ROM of knee extension: aquatic physical therapy versus no

aquatic physical therapy

Comparison 2. Joint ROM of knee flexion: aquatic physical therapy versus no aquatic
physical therapy

Fig. 8 Forest plot of aquatic physical therapy versus no aquatic physical therapy interventions in flexibility

in a large degree. However, we also found that aquatic Joint pain and stiffness are the most common symp-
physical therapy cannot improve scores of the other toms in patients with knee OA and are the primary barri-
three tests in walking ability (6MWT, walking speed, ers for performing activities of daily living in this patient
and step test). This may be due to the training was not population [8]. Aquatic physical therapy is based on the
intense or long enough, which is not enough to produce buoyancy and temperature of water, which may encour-
a significant statistical difference. Therefore, we con- age muscle relaxation, enhance greater movement to
cluded that aquatic physical therapy can improve pain, reduce joint and soft-tissue stiffness and, therefore,
physical function, knee extension muscle strength, and improve pain and physical function [31, 35]. Our study
walking ability to a certain extent. demonstrated that aquatic physical therapy can have a
Ma et al. Journal of Orthopaedic Surgery and Research (2022) 17:190 Page 11 of 15

Comparison 1. Knee extension muscle strength: aquatic physical therapy versus no

aquatic physical therapy

Comparison 2. Knee flexion muscle strength: aquatic physical therapy versus no

aquatic physical therapy

Comparison 3. Hip abduction muscle strength: aquatic physical therapy versus no

aquatic physical therapy

Fig. 9 Forest plot of aquatic physical therapy versus no aquatic physical therapy interventions in muscle strength
Ma et al. Journal of Orthopaedic Surgery and Research (2022) 17:190 Page 12 of 15

Comparison 1. 6MWT: aquatic physical therapy versus no aquatic physical therapy

Comparison 2. Walking speed: aquatic physical therapy versus no aquatic physical

therapy

Comparison 3. Step test: aquatic physical therapy versus no aquatic physical therapy

Comparison 4. TUGT: aquatic physical therapy versus no aquatic physical therapy

Fig. 10 Forest plot of aquatic physical therapy versus no aquatic physical therapy interventions in walking ability

small and significant effect on pain and physical function, differences in the characteristics of the included stud-
thus strengthening previous meta-analysis [11, 17, 36]. In ies. Therefore, our results may not accurately represent
addition, contrary to the previous findings [11, 17], our the true changes in joints stiffness and QOL within this
meta-analysis revealed that aquatic physical therapy can- population.
not improve joints stiffness and QOL among people with Meanwhile, the above changes were accompanied by
knee OA. These differences in results can stem from the the improvements in muscle strength and flexibility, as
Ma et al. Journal of Orthopaedic Surgery and Research (2022) 17:190 Page 13 of 15

Comparison 1. Body mass index and fat mass: aquatic physical therapy versus no
aquatic physical therapy

Fig. 11 Forest plot of aquatic physical therapy versus no aquatic physical therapy interventions in body composition

well as reductions in body composition. Muscle strength participants to investigate the impact of aquatic physi-
is clinically important as strong muscles act as shock cal therapy on knee OA patients over a longer period of
absorbers and joint stabilizers, assisting to protect dis- time. Additionally, our review is unable to demonstrate
eased joints [37]. The previous review [17] did not find the optimal intervention dose, type of exercise and
any effect on muscle strength, whereas our study is the training intensity for this population group.
first to show that aquatic physical therapy can have
a small but significant effect on knee extension mus-
cle strength. The gradually and consistently increase in Conclusion
strength of knee extensor was a promising outcome of In conclusions, this meta-analysis confirmed that
the program for preventing OA-associated disabilities in aquatic physical therapy is an effective treatment option
later life. The aquatic physical therapy, on the other hand, for persons with severe symptoms of knee OA and
showed no effect on other major muscle groups, possibly should be considered as an important initial treatment
due to too insufficient intervention intensity or duration option for rehabilitation programs. Researchers plan-
to cause physiological changes in muscle structure [12]. ning an aquatic physical therapy study should ensure
A great improvement in walking ability of this study that all aspects of the disease are considered, not just
is a reduction in the TUGT, reflecting better control of pain and physical function, and they need to refer to
the knee joint during walking and standing. Although the current recommendations when measuring results to
other three tests (6MWT, walking speed, and step test) promote the effectiveness of treatment. Future studies
used to evaluate walking ability have not been improved, should aim to improve program content by maximizing
this indicates that TUGT has greater specificity to the hydrostatic and hydrodynamic properties of water,
patients with OA compared to the other three tests and so as to maximize the potential benefits of aquatic
consequently better responsiveness. physical therapy for patients with knee OA.

Study limitations Abbreviations

However, some potential limitations of this study ADL: Activities of daily living; BMI: Body mass index; KOOS: Knee Injury and
Osteoarthritis Outcome Score; 6MWT: 6-Min walk test; QOL: Quality of life;
should be noted. First, more participants are needed ROM: Range of motion; SF-36: Short form-36; TUGT​: Timed-Up-and-Go Test;
to further study how aquatic physical therapy affects VAS: Visual analog scale; WOMAC: Western Ontario and McMaster University
muscle strength of knee OA in a more systematic Osteoarthritis Index.
way. It may also be beneficial to follow the progress of
Ma et al. Journal of Orthopaedic Surgery and Research (2022) 17:190 Page 14 of 15

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