Discuss the typica l clinical presentation of the diagnosis , Hip Osteoarthritis(OA), included possible therapeutic exercise treatment intervention, also recommendations for the management of the condition.

Introduction: First about OA and then write about Hip OA

Describe the pathophysiology of the diagnosis and the expected clinical presentation anticipated. If it varies, them describe common variations.

Discuss etiology and demographics related to the diagnosis(I.e., is this dx more common in men than women, what age, group ect)

Very important only use the articles provides, not citation work submitted via turnitin!!!!  

Exercise for Osteoarthritis of the Hip
Nolwenn Poquet, Matthew Williams, Kim L. Bennell

highlights the findings and
application of Cochrane reviews and
other evidence pertinent to the
practice of physical therapy. The
Cochrane Library is a respected
source of reliable evidence related to
health care. Cochrane systematic
reviews explore the evidence for and
against the effectiveness of appropri-
ate interventions—medications, sur-
gery, education, nutrition, exercise—
and the evidence for and against the
use of diagnostic tests for specific
conditions. Cochrane reviews are
designed to facilitate the decisions of
clinicians, patients, and others in
health care by providing a careful
review and interpretation of research
studies published in the scientific lit-
erature.1 Each article in this PTJ series
summarizes a Cochrane review or
other scientific evidence on a single
topic and presents clinical scenarios
based on real patients or programs to
illustrate how the results of the
review can be used to directly inform
clinical decisions. This article focuses
on an adult patient with osteoarthri-
tis of the hip. Can exercise help this
patient?

Osteoarthritis (OA) is the most common
form of arthritis and is characterized by a
progressive degeneration of the joint,
affecting most frequently the hands,
knees, and hips. Radiographic signs of
OA include joint space narrowing, sub-
chondral bone sclerosis, and osteophyte
formation. The loss of cartilage is often
associated with synovium inflammation,2

thickening of the capsule, and muscle
weakness.3,4 Osteoarthritis is a leading
cause of disability, especially in the
elderly population, with pain and func-
tional limitation being the main associ-
ated symptoms.5

Management strategies for OA of the hip
include a combination of nonpharmaco-
logical and pharmacological modalities.
Education, exercise, and weight loss are
considered to be core treatments by
international guidelines6 –10 and should
be considered as the first management
option, before medications. When med-
ication is needed, the treatment starts
with paracetamol or nonsteroidal anti-
inflammatory drugs (NSAIDs), with opi-
oids reserved for patients with refractory
severe pain. Prescription of NSAIDs
should always follow a close consider-
ation of the patient’s comorbidities and
the related risk factors. Joint replace-
ment surgery should be considered for
patients with substantial pain or func-
tional limitation despite optimal conser-
vative care.

Land-based therapeutic exercises are
used to relieve symptoms of hip OA, aim-
ing to improve muscle strength, joint
range of motion, physical function, and
aerobic capacity. Fransen et al11 con-
ducted a Cochrane systematic review to
assess the effectiveness of exercise on
pain, physical function, and quality of life
for adults with hip OA. The review
included studies evaluating any type of
land-based exercise programs, super-
vised or performed at home. The inter-
vention had to be compared with any
other active treatment (excluding
another exercise program) or a placebo.
Outcome data were extracted at the end
of the treatment and at longer-term

follow-up. Treatment compliance and
adverse events also were assessed. The
search was up-to-date on February 2013.

Take-Home Message
Ten randomized controlled trials (549
participants) were included in this
Cochrane review,11 half of these trails
(419 participants) focusing on people
with hip OA only12–16 and the rest includ-
ing a mixed population with knee and
hip OA.17–21 Seven of the 10 included
studies were considered at low risk of
bias based on methodological rating.
High-quality evidence supported a signif-
icantly greater reduction in pain and
physical function in the exercise group
compared with the control group at the
end of the treatment and at longer-term
follow-up (3– 6 months). Low-quality evi-
dence showed no difference in terms of
quality of life compared with the control
group. There was large variability in
exercise treatment dosage, from 6 to 36
sessions over 6 to 12 weeks, each session
lasting 30 to 60 minutes. Treatment ses-
sions were provided to groups of
patients15,16,18 –20 or individually13,14,17,21

and could be completed via a home exer-
cise program.14,16 One study specifically
evaluated a tai chi program for arthritis19;
the other studies included traditional
exercise programs with muscle strength-
ening, functional training, and fitness
training. Additional descriptions of the
results are presented in Table 1.

Case #29: Applying
Evidence to a Patient With
Osteoarthritis of the Hip
Can exercise help this patient?
Mrs J is a 71-year-old woman with 10
years’ insidious onset of bilateral hip
pain, right side worse than left side.
Symptoms initially settled but have
returned over the last 10 months and
have progressively worsened. Previously
very active, Mrs J retired as a nurse 2
years ago and has become more and
more sedentary, increasing her weight
by 5 kg (weight�65.8 kg, body mass
index [BMI]�26.89 kg/m2). She lives at
home alone and has some difficulty in

�LEAP�
LINKING EVIDENCE AND PRACTICE

Find the case archive at
http://ptjournal.apta.org/
collection/leap-linking-evidence-
and-practice.

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http://ptjournal.apta.org/collection/leap-linking-evidence-and-practice

http://ptjournal.apta.org/collection/leap-linking-evidence-and-practice

http://ptjournal.apta.org/collection/leap-linking-evidence-and-practice

Table 1.
Key Results From the 2014 Cochrane Review by Fransen et al11,a

10 RCTs were included, with a total of 549 participants. Only 2 RCTs had more than 50 participants in each allocation group.

The search was up-to-date on February 2013.

7 of the 10 included trials were at low risk of bias according to the Cochrane risk of bias scale.

Participants were adults with hip OA diagnosed using the American College of Rheumatology clinical and radiographic criteria or on the basis of
chronic anterior joint pain without radiographic confirmation. They were recruited from the community, general practice, or specialist clinics.

Intervention was any land-based therapeutic exercise program; one study included a specific tai chi program. Exercise dosage varied widely:
– Frequency: 5 studies – 1 time/wk; 3 studies – 2 times/wk; 2 studies – 3 times/wk.

With eventual additional booster sessions or daily home exercises.
– Intensity: not specified in the majority of the studies. When provided, it was the number of repetitions, the level of effort, or a progression scale.
– Duration of each session: from 30 min (3 studies) to 60 min (3 studies).
– Duration of the program: half of the studies included a 12-wk program, and the other half included shorter programs of 6, 7, or 8 wk.

Comparators included usual care, patient education, and wait-list controls.

Exercise interventions showed significantly better outcomes compared with the control groups immediately after treatment, with small but clinically
important effect on pain and physical function.

➢ Pain 9 studies–549 participants

Quality of the evidence: high (GRADE)

SMD�–0.38; 95% CI�–0.55, –0.2

The effect size was considered small to moderate, favoring exercise over the control group to reduce pain, equivalent to a
reduction of 8 points (95% CI�4, 11) on a 0 to 100 pain scale.

Pain was measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale
(4 studies), the visual analog scale (VAS) (4 studies), or the numerical rating scale (NRS) (1 study).

➢ Physical function 9 studies–521 participants

Quality of the evidence: high (GRADE)

SMD�–0.33; 95% CI�–0.54, –0.05

The effect size was considered small to moderate, favoring exercise over the control group to improve physical function,
equivalent to an improvement of 7 points (95% CI�1, 12) on a 0 to 100 physical function scale.

Physical function was measured using the WOMAC physical function subscale (6 studies), the Influence of Rheumatic Disease
on General Health and Lifestyle (IRGL) mobility subscale (2 studies), and the Groningen Activity Restriction Scale (GARS)
(1 study).

➢ Quality of life 3 studies–183 participants

Quality of the evidence: low (GRADE)

SMD�0.07; 95% CI�–0.23, 0.36

No statistically significant difference was found between groups.

➢ Withdrawals 7 studies–715 participants

Quality of the evidence: moderate (GRADE)

Risk difference�0.01; 95% CI�–0.01, 0.04

There was no significantly increased risk of withdrawal in the exercise group compared with the control group.

Similar results were found at longer-term follow-up (3–6 mo), with sustained significant reduction of pain and improvement of physical function for
the exercise group.

➢ Pain 6 studies–391 participants

Quality of the evidence: high (GRADE)

SMD�–0.38; 95% CI�–0.58, –0.18

➢ Physical function 6 studies–365 participants

Quality of the evidence: high (GRADE)

SMD�–0.37; 95% CI�–0.57, –0.16

a RCTs�randomized controlled trials; OA�osteoarthritis; GRADE�Grading of Recommendations Assessment, Development and Evaluation;
SMD�standardized mean difference; CI�confidence interval.

Case #29 OA Hip Exercise

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managing housework (vacuuming,
changing bed linens, cleaning bath-
room). She has to negotiate 30 steps with
a rail to enter her unit and is no longer
able to play lawn bowls, which she
ceased 6 months previously due to pain.
Mrs J reports right hip pain as being 40
on a 0 to 100 visual analog scale. The
aggravating factors are going up and
down stairs, below-knee activities such
as squatting and kneeling (eg, cleaning
the bathroom, reaching for items out of
low cupboards), walking over 10 min-
utes, and prolonged standing (ie, over 10
minutes). Pain is eased by heat, rest, acet-
aminophen, and celecoxib. Mrs J did not
report any falls or disturbed sleep. She
was on medication for associated comor-
bidities: Avapro (irbesartan) (Sanofi US,
Bridgewater, New Jersey) for hyperten-
sion, Lipitor (atorvastatin calcium)
(Pfizer, New York, New York) for hyper-
cholesterolemia, and Nexium (esomepra-
sol) (AstraZeneca, London, United King-
dom) for gastroesophageal reflux disease
(GORD). She was prescribed radiographs
that revealed moderate right hip OA with
reduced superolateral joint space and
acetabular osteophytes.

The physical therapist evaluation
included objective measures of hip range
of motion, muscle strength (knee exten-
sor, hip flexor and extensor, hip abduc-
tor, hip external and internal rotator),
walking and stair-climbing abilities, and
related disability. There was no limita-
tion of hip movements but a bilateral
muscle weakness of the gluteal muscle
leading to a moderate limp with a posi-
tive Trendelenburg sign. The Six-Minute
Walk Test resulted in a distance of
428 m, and Mrs J performed the Timed
“Up & Go” Test in 9.2 seconds. Her
results fall into published norms of these
2 tests for community-living older peo-
ple.22,23 The Hip Disability and Osteoar-
thritis Outcome Score (HOOS)24 was
used to assess the disability associated
with OA of the hip. The HOOS question-
naire is composed of 40 items divided
into 5 subscales: Pain, Symptoms, Activ-
ity Limitations in Daily Living, Function
in Sport and Recreation, and Hip-Related
Quality of Life. Each item is scored using
a 5-point Likert scale from 0 to 4 (none,
mild, moderate, severe, and extreme).
Each subscale gives a score from 0 to

100, with 0 indicating the worst situation
and 100 the best condition. For Mrs J, the
HOOS revealed moderate outcomes for
Pain (50), Symptoms (55), Activity Limi-
tations in Daily Living (47), and Function
in Sport and Recreation (55) but severe
consequences on Hip-Related Quality of
Life (25). The goals of Mrs J were to
complete weekly lawn bowls with mini-
mal pain, to return to a body weight of
60 kg, and to be able to walk for more
than 30 minutes with minimal pain.

How did the results of the
Cochrane systematic review
apply to Mrs J?
Using the PICO (Population, Interven-
tion, Comparator, Outcome) format, Mrs
J’s physical therapist asked the following
question: Will land-based therapeutic
exercise (compared with no exercise) be
beneficial for a 71-year-old woman with
OA of the hip to reduce joint pain and
improve physical function and quality of
life? The results of the Cochrane system-
atic review from Fransen et al11 were
used to support the intervention plan for
Mrs J.

Population. The included population
in the systematic review was adults with
OA of the hip diagnosed using the Amer-
ican College of Rheumatology (ACR)
clinical or radiographic criteria25 (Tab. 2)
or on the basis of chronic anterior joint
pain. According to these criteria, Mrs J
fits the target population of the review.

Intervention. The review focused on
any type of home-based or supervised

land-based exercise aiming to ease hip
symptoms. Mrs J was involved in a
9-month therapeutic program with 4 ses-
sions: an initial session of 90 minutes and
60-minute follow-up sessions every 3
months. This time frame was chosen
because recent OA trials focusing on
reducing weight, improving function,
and embedding self-management strate-
gies have shown that programs exceed-
ing 6 months promoted long-term behav-
ior change.26,27 She started with a
strengthening program targeting hip
muscles, especially gluteal muscles,
including bridging exercise, side-lying
hip abduction, sit-to-stand exercise with
yellow Thera-Band (The Hygenic Corp,
Akron, Ohio) above knees, and standing
hip extension. Fifteen repetitions of each
movement were performed twice and
completed 3 times per week. In progres-
sion, subsequent sessions included
single-leg bridge exercise, isometric hip
abduction against a wall, standing
resisted hip abduction and hip extension
with yellow Thera-Band, and single-leg
squat. In addition, Mrs J used an exercise
bike to train from 5 minutes with mini-
mal resistance to 20 minutes with inter-
val training (30 seconds of resistance fol-
lowed by 30 seconds of recovery), twice
a week. Her walking program included a
progression from 20 minutes of walking,
split into four 5-minute intervals with 1
minute of rest 3 times per week, to 40
minutes of walking daily. In addition to
land-based exercise, Mrs J benefited from
hydrotherapy for strengthening and
range-of-motion exercises twice per
week for 6 weeks. Thereafter, she con-

Table 2.
American College of Rheumatology Criteria for the Diagnosis of Osteoarthritis of the
Hip25,a

Clinical Criteria
(Specificity: 86%; Sensitivity: 75%)

Clinical and Radiological Criteria
(Specificity: 89%;
Sensitivity: 91%)

Set A Set B ● Hip pain
And at least 2 of the following features:

● ESR �20 mm/h
● Radiographic femoral or acetabular

osteophytes
● Radiographic joint space narrowing

(superior, axial, or medial)

● Hip pain
● Hip internal rotation

�15°
● ESR �45 mm/h (OR

hip flexion �115°,
if ESR not available)

● Hip pain
● Hip internal rotation

�15°
● Hip internal rotation

painful
● Morning stiffness of

the hip �60 min
● Age �50 y

a Clinical (2 sets possible) or clinical and radiological criteria can be used. ESR�erythrocyte
sedimentation rate.

Case #29 OA Hip Exercise

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tinued her own water-based program
twice per week. To facilitate adherence
to the exercise program, an exercise
diary was used. Mrs J was encouraged to
fill it out and bring it in to her follow-up
appointments. She also was encouraged
to call the physical therapist if she had
any questions pertaining to the exercise
program. Furthermore, she was provided
with education on the importance of
low-impact exercise for the management
of her OA, dispelling misconceptions
that exercise would lead to further joint
deterioration. Referral was made to a
dietitian for weight loss management
strategies.

Comparator. Studies included in the
meta-analysis of the Cochrane review
compared the exercise program with
usual care or a wait-list control group.
Mrs J had a sedentary lifestyle and was
not previously engaged in a formalized
exercise program. Taking these factors
into consideration, decisions about the
program proposed were made in con-
junction with Mrs J according to her
expectations, preferences, and specific
condition.

Outcome. Outcome measures consid-
ered in the review were all patient-
reported outcome measures, including
hip pain, self-reported physical function,
and quality of life. These measures were
assessed at the end of the treatment (10
weeks on average) and at longer-term
follow-up (16 weeks on average). These

3 outcome measures were of interest for
the assessment of Mrs J’s response to the
9-month treatment period, in addition to
other outcome measures such as her
weight, qualitative gait analysis, and the
Six-Minute Walk Test.

How well do the outcomes of the
intervention provided to the
patient match those suggested
by the systematic review?
After 4 physical therapy sessions spaced
over 9 months with a daily, multimodal
home exercise program, Mrs J reached
her goals. She had returned to playing
lawn bowls once per week and experi-
enced only mild discomfort toward the
end of the game. She was able to walk 40
minutes on a flat surface with minimal
pain, and stairs were managed with only
minor discomfort. She had lost 7.9% of
her body weight (5.2 kg), reaching a
weight of 60.6 kg (BMI�25.22 kg/m2).

Mrs J’s outcomes were similar to those
found in the Cochrane review and were
clinically relevant according to the min-
imal clinically important difference
(MCID) defined for each outcome mea-
sure (Tab. 3). The assumed MCID was 15
points on a 0 to 100 pain scale and 10
points on a 0 to 100 function scale.11 Mrs
J’s hip pain improved by 30 points. Phys-
ical function and quality of life also were
significantly improved according to the
HOOS score. Final scores of the 5 HOOS
subscales were 72 for Pain (improve-

ment of 22 points), 65 for Symptoms
(improvement of 10 points), 66 for Activ-
ities of Daily Living (improvement of 19
points), 67 for Function in Sport and Rec-
reation (improvement of 20 points), and
55 for Hip-Related Quality of Life
(improvement of 30 points).

In addition, her gait pattern improved,
resulting in a negative Trendelenburg
sign and no limp. Mrs J improved her
outcomes for the Six-Minute Walk Test
with a distance of 485 m (improvement
of 57 m), which represents a substantial
meaningful change according to the pub-
lished MCID for older adults.28 She per-
formed the Timed “Up & Go” Test in 5.9
seconds (improvement of 3.3 seconds),
also showing a clinically significant
change. Starting with a time of less than
10 seconds, an improvement of at least 3
seconds was expected to demonstrate a
clinically important difference.29 Mrs J
also had hired a cleaner to assist with
heavier activities of daily living around
the house. For medication, she only used
acetaminophen when necessary and did
not require celecoxib any longer.

Can you apply the results of this
systematic review to your own
patients?
The findings of the Cochrane review can
be applied to adults with symptomatic
hip OA, like Mrs J. She had experienced
a worsening of her symptoms over the
last 10 months with significant effects on
her physical function and activities of
daily living and was willing to follow an
exercise program to improve her health
condition. Mrs J was motivated to suc-
cessfully complete the 9-month exercise
program and reached her goals. It is com-
mon for physical therapists to see
patients with similar histories to that of
Mrs J. Clinically significant improve-
ments should be expected for most
patients with OA of the hip following an
exercise program. The review showed
the benefits of exercise on pain and
physical function at both short- and long-
term follow-up. However, no significant
change was found concerning patients’
quality of life. The studied population
had a mean age of 66 years with an age
range from the available data of 37 to 92
years, allowing the possibility of apply-
ing the conclusions to younger adults.

Table 3.
Summary of the Outcomes for Mrs Ja

Outcome Measures

Value at:

Change in
Value (MCID)Baseline

End of
Treatment (9 mo)

Visual analog scale (0–100) 40 10 30 (15)

Six-Minute Walk Test 428 m 485 m 57 m (50 m)

Timed “Up & Go” Test 9.2 s 5.9 s 3.3 s (3.1 s)

Hip Disability and Osteoarthritis
Outcome Score (HOOS)

P: 50 P: 72 22 (10)

S: 55 S: 65 10 (10)

ADL: 47 ADL: 66 19 (10)

SP: 55 SP: 67 12 (10)

QoL: 25 QoL: 55 30 (10)

a MCID�minimal clinically important difference; subscales of the HOOS: P�Pain, S�Symptoms,
ADL�Activity Limitations in Daily Living, SP�Function in Sport and Recreation, QoL�Hip-Related
Quality of Life.

Case #29 OA Hip Exercise

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What can be advised based on
the results of this systematic
review?
People with hip OA can benefit from
exercise to reduce pain and improve
physical function. Osteoarthritis is a very
common and disabling chronic condi-
tion, particularly affecting the elderly
population. It is essential, therefore, to
keep people active and involved in their
daily activities over an extended period.
Thus, patient adherence needs to be
encouraged and reinforced in order to
maintain long-term benefits. The
Cochrane systematic review assessed any
land-based therapeutic exercise pro-
gram; most of the included programs
contained muscle strengthening, func-
tional training, and aerobic exercises.
Frequency, intensity, duration, and deliv-
ery mode varied among studies. The
range of exercise programs available
allows physical therapists to adapt and
choose the best exercise set for their
patients according to their needs and
preferences. It should be a shared deci-
sion between the patient and the
clinician.

Although the Cochrane review did not
show any difference in outcomes
depending on the type of exercise
included, which may be due to the small
number of trials, it seems that the best
exercise option should be to combine
muscle strengthening with flexibility and
aerobic exercises.30 It has been shown
elsewhere31 that the benefits of exercise
decline with time; thus, attention to
adherence strategies is important. Clini-
cians should work with the patient to
identify individual barriers to exercise
and develop proactive approaches to
facilitate successful outcomes.32

N. Poquet, PT, MSc, is in private practice in
physical therapy in Orléans, France. Address
all correspondence to Ms Poquet at:
poquet.nolwenn@gmail.com.

M. Williams, PT, BAppSc(Phty), BHuman-
MoveSt, Royal North Shore Hospital, Osteo-
arthritis Chronic Care Program, St Leonards,
New South Wales, Australia.

K.L. Bennell, PT, PhD, Department of Phys-
iotherapy, Centre for Health, Exercise and
Sports Medicine, University of Melbourne,
Parkville, Victoria, Australia.

[Poquet N, Williams M, Bennell KL. Exercise
for osteoarthritis of the hip. Phys Ther.
2016;96:1689 –1694.]

© 2016 American Physical Therapy Association

Published Ahead of Print:
April 21, 2016

Accepted: April 14, 2016
Submitted: October 23, 2015

Ms Poquet provided concept/idea/project
design, data collection, data analysis, project
management, and participants. All authors
provided writing. Mr Williams and Professor
Bennell provided consultation (including
review of manuscript before submission).

DOI: 10.2522/ptj.20150597

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arch 2020

http://www.thecochranelibrary.com/view/0/index.html

http://www.thecochranelibrary.com/view/0/index.html

http://www.racgp.org.au/your-practice/guidelines/musculoskeletal/hipandkneeosteoarthritis/

http://www.racgp.org.au/your-practice/guidelines/musculoskeletal/hipandkneeosteoarthritis/

http://www.racgp.org.au/your-practice/guidelines/musculoskeletal/hipandkneeosteoarthritis/

22 Steffen TM, Hacker TA, Mollinger L. Age-
and gender-related test performance in
community-dwelling elderly people: Six-
Minute Walk Test, Berg Balance Scale,
Timed Up & Go Test, and gait speeds.
Phys Ther. 2002;82:128 –137.

23 Lusardi MM, Pellecchia GL, Schulman M.
Functional performance in community liv-
ing older adults. J Geriatr Phys Ther.
2003;26:14 –22.

24 Klässbo M, Larsson E, Mannevik E. Hip
disability and osteoarthritis outcome score
An extension of the Western Ontario and
McMaster Universities Osteoarthritis
Index. Scand J Rheumatol. 2003;32:46 –
51.

25 Altman R, Alarcón G, Appelrouth D, et al.
The American College of Rheumatology
criteria for the classification and reporting
of osteoarthritis of the hip. Arthritis
Rheum. 1991;34:505–514.

26 Messier SP, Loeser RF, Miller GD, et al.
Exercise and dietary weight loss in over-
weight and obese older adults with knee
osteoarthritis: the arthritis, diet, and activ-
ity promotion trial. Arthritis Rheum.
2004;50:1501–1510.

27 Messier SP, Mihalko SL, Legault C, et al.
Effects of intensive diet and exercise on
knee joint loads, inflammation, and clini-
cal outcomes among overweight and
obese adults with knee osteoarthritis: the
IDEA randomized clinical trial. JAMA.
2013;310:1263–1273.

28 Perera S, Mody SH, Woodman RC, Studen-
ski SA. Meaningful change and responsive-
ness in common physical performance
measures in older adults. J Am Geriatr
Soc. 2006;54:743–749.

29 Kristensen M, Henriksen S, Stie S, Band-
holm T. Relative and absolute intertester
reliability of the timed up and go test to
quantify functional mobility in patients
with hip fracture. J Am Geriatr Soc. 2011;
59:565–567.

30 Uthman OA, van der Windt DA, Jordan JL,
et al. Exercise for lower limb osteoarthri-
tis: systematic review incorporating trial
sequential analysis and network meta-anal-
ysis. BMJ. 2013;347:f5555.

31 Pisters MF, Veenhof C, van Meeteren NL,
et al. Long-term effectiveness of exercise
therapy in patients with osteoarthritis of
the hip or knee: a systematic review.
Arthritis Rheum. 2007;57:1245–1253.

32 Bennell KL, Dobson F, Hinman RS. Exer-
cise in osteoarthritis: moving from pre-
scription to adherence. Best Pract Res
Clin Rheumatol. 2014;28:93–117.

Case #29 OA Hip Exercise

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Aquatic Physical Therapy for
Hip and Knee Osteoarthritis:
Results of a Single-Blind
Randomized Controlled Trial
Rana S Hinman, Sophie E Heywood, Anthony R Day

Background and Purpose
Aquatic physical therapy is frequently used in the management of patients with hip
and knee osteoarthritis (OA), yet there is little research establishing its efficacy for
this population. The purpose of this study was to evaluate the effects of aquatic
physical therapy on hip or knee OA.

Subjects
A total of 71 volunteers with symptomatic hip OA or knee OA participated in this
study.

Methods
The study was designed as a randomized controlled trial in which participants
randomly received 6 weeks of aquatic physical therapy or no aquatic physical
therapy. Outcome measures included pain, physical function, physical activity levels,
quality of life, and muscle strength.

Results
The intervention resulted in less pain and joint stiffness and greater physical function,
quality of life, and hip muscle strength. Totals of 72% and 75% of participants
reported improvements in pain and function, respectively, compared with only 17%
(each) of control participants. Benefits were maintained 6 weeks after the comple-
tion of physical therapy, with 84% of participants continuing independently.

Discussion and Conclusion
Compared with no intervention, a 6-week program of aquatic physical therapy
resulted in significantly less pain and improved physical function, strength, and
quality of life. It is unclear whether the benefits were attributable to intervention
effects or a placebo response.

RS Hinman, BPhysio(Hons), PhD,
is Lecturer, Centre for Health Ex-
ercise and Sports Medicine, Uni-
versity of Melbourne, Melbourne,
Victoria, Australia. Address all cor-
respondence to Dr Hinman at:
ranash@unimelb.edu.au.

SE Heywood, BPhysio(Hons),
MPhysio(Sports), Cert Hydrother-
apy, is Senior Aquatic Physiother-
apist, Physiotherapy Department,
Sunshine Hospital, and Physio-
therapist, Melbourne Sports Med-
icine Centre, Melbourne, Victoria,
Australia.

AR Day, BAppSci(Human Move-
ment), BAppSci(Physio), MSports
Physio, is Principal Physiotherapist,
ProCare Physiotherapy, Newport,
and Physiotherapist, ISIS

Primary

Care, Altona Meadows, Melbourne,
Victoria, Australia.

[Hinman RS, Heywood SE, Day
AR. Aquatic physical therapy for
hip and knee osteoarthritis: re-
sults of a single-blind randomized
controlled trial. Phys Ther. 2007;
87:32– 43.]

© 2007 American Physical Therapy
Association

Research Report

For The Bottom Line:
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Osteoarthritis (OA) is one ofthe most prevalent musculo-skeletal conditions affecting
the elderly population worldwide,1

and its prevalence is predicted to
rise significantly in the future as the
population ages.2 Knee OA currently
affects about 40% of people aged
over 75 years, and hip OA affects
about 10%.3 People with OA fre-
quently report joint pain, stiffness,
loss of physical function, increasing
immobility, and muscle weakness.
Such signs and symptoms of the dis-
ease often culminate in reductions in
quality of life. Contemporary man-
agement of OA aims to alleviate pain
and disability while avoiding adverse
effects of therapy.4 Current guide-
lines recommend nonpharmacologic
methods, such as physical therapy,
as first-line options in the manage-
ment of OA.5 Physical therapy for
OA may be provided on land or in an
aquatic environment.

“Hydrotherapy” is a term encom-
passing a range of therapeutic and
exercise activities carried out in
heated pools by a variety of provid-
ers. Experts rate hydrotherapy as
one of the least toxic of 33 potential
treatments for knee OA.6 Aquatic
physical therapy incorporates indi-
vidual assessment, evidence-based
practice, and clinical reasoning skills
to devise treatment plans based on
the principles of hydrostatics and
hydrodynamics and the physiologic
effects of immersion.7 Aquatic phys-
ical therapy offers several benefits
over land-based physical therapy for
people with OA. Buoyancy reduces
loading across joints affected by pain
and allows the performance of func-
tional closed-chain exercises that
otherwise may be too difficult on
land. Water turbulence can be used
as a method of increasing resistance,
and percentage of body weight
borne across the lower limbs can be
decreased or progressed in propor-
tion to the depth of immersion.8,9

The warmth and pressure of the

water may further assist with pain
relief, swelling reduction, and ease
of movement.

Despite the widespread provision of
aquatic physical therapy for people
with hip or knee OA, there is little
evidence attesting to its efficacy in
this population. Although many stud-
ies have reported positive effects of
hydrotherapy interventions in cohorts
with various arthritic conditions,10 few
have evaluated a sample selected on
the basis of knee or hip OA alone. A
recent study found no significant ben-
efit of hydrotherapy over a gym-based
program or no intervention for symp-
toms in people with hip or knee OA.11

However, the program tested by the
authors made use of nonfunctional
body positions and had a limited
capacity for progression, features that
may explain their nonsignificant find-
ings. Methodological limitations in
other published studies on OA include
inadequate sample size, nonrandom
allocation, and no intention-to-treat
analysis.12–15 Furthermore, most hydro-
therapy programs demonstrate little
consideration of hydrostatic or hydro-
dynamic principles in their choice of
exercises, thus reducing the potential
for benefit from the overall program.
The present study was designed to ad-
dress the limitations of previous stud-
ies through the use of an adequately
powered randomized controlled trial
with intention-to-treat analysis and a
functional progressive intervention that
maximized the unique properties of
water to optimize outcomes.

The aim of this study was to test the
efficacy of a 6-week aquatic physical
therapy program in a group of peo-
ple with symptomatic hip OA, knee
OA, or both. The primary hypothesis
was that aquatic physical therapy
would result in greater improve-
ments in pain and physical function
than would no aquatic physical ther-
apy. The secondary hypothesis was
that aquatic physical therapy would
result in greater improvements in

stiffness, quality of life, physical activ-
ity, and muscle strength. Finally, we
aimed to determine whether partici-
pants were adherent to ongoing in-
dependent aquatic physical therapy
once the program had ceased and
whether any benefits of the program
remained 6 weeks later.

Method
Participants
Diagnosis was based on American
College of Rheumatology classifica-
tion criteria.16,17 Volunteers aged 50
years and older and with hip OA or
knee OA were recruited by adver-
tisements in local clubs, libraries,
general practitioner’s rooms, print
and radio media, and the orthopedic
clinic at a metropolitan hospital. Par-
ticipants with knee OA were
included if they had knee pain on
most days of the previous month and
osteophytes on radiographs. Partici-
pants with hip OA were included if
they had hip pain and osteophytes
and joint space narrowing on radio-
graphs. Other inclusion criteria for
all participants were an average
severity of pain of greater than 3 cm
on a 10-cm visual analog scale (VAS)
and difficulty with stair climbing,
walking, or getting in or out of a
chair. Exclusion criteria included
contraindications to aquatic physical
therapy7; significant back or other
joint pain; recent (preceding 6
months) joint injections, surgery,
physical therapy, or hydrotherapy;
lower-limb joint replacement; inabil-
ity to understand English; and inabil-
ity to safely enter and exit the pool.

Between October 2003 and April
2004, 312 volunteers were screened.
Of these volunteers, 71 fulfilled the
selection criteria and were enrolled
in the study. Thirty-six participants
were randomly assigned to an
aquatic physical therapy group
(intervention group), and 35 partici-
pants were randomly assigned to a
control group. One aquatic physical
therapy participant withdrew after

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randomization, did not undergo the
intervention as allocated, and did not
return for reassessment. Four con-
trol participants withdrew prior to
reassessment; however, 2 of them
completed reassessment question-
naires only. All participants provided
written informed consent.

Protocol
The trial comprised a 6-week inter-
vention period (Fig. 1). Participants
were assessed immediately before
treatment (0 weeks) and immedi-
ately after treatment was completed
(6 weeks). Furthermore, the aquatic
physical therapy group underwent
follow-up assessment at 12 weeks
(ie, 6 weeks after the intervention
was completed) to determine
whether any benefits of the interven-
tion were maintained in the short
term and to assess adherence to
independent aquatic physical ther-
apy. Every effort was made to obtain
reassessment data on primary out-
comes from any participant who
withdrew from the study.

Assignment
Following the baseline assessment,
participants were randomly assigned
to either the aquatic physical ther-
apy group or the control group. Block
randomization (randomly alternating
blocks of 4 and 6) stratified for sex
was set up with a computer-generated
table of random numbers. Assignment
was concealed in sequential opaque
envelopes and was revealed by an
independent researcher not involved
in eligibility assessment, outcome as-
sessment, or intervention following
the baseline assessment.

Aquatic Physical Therapy
Intervention
The aquatic physical therapy pro-
gram comprised functional weight-
bearing and progressive exercises
(Tab. 1) provided twice weekly
(45– 60 minutes each) for 6 weeks.
An experienced aquatic physical
therapist individually instructed par-

ticipants in the hydrotherapy pool
(water temperature�34°C), with a
maximum of 6 participants per ses-
sion. Quality of movement was em-
phasized, and the therapist palpated
the lower-limb musculature to en-
sure appropriate contraction through-
out the exercises. Balance without
the aid of rails to maximize postural
and isometric leg stance control was
achieved with all participants. A neu-
tral spinal position also was taught;
feedback was provided on posture,
transversus abdominis muscle contrac-
tion, and trunk control. Individual pro-
gression to subsequent phases of the
program was clinically determined by
the therapist and occurred upon com-
pletion of the prior phase with either

no or minimal symptom exacerbation.
Attendance at intervention sessions
and adverse effects of the intervention
were recorded by the aquatic physical
therapist.

Upon completion of the 6-week pro-
gram, participants were encouraged
to continue independent aquatic phys-
ical therapy twice weekly at a local
pool and were provided with details
of local pools and a written descrip-
tion of the exercises to maximize ad-
herence. During the follow-up period,
between week 6 and week 12, partic-
ipants recorded in a logbook the ses-
sions of independent aquatic physical
therapy that they undertook. Partici-
pants continued with their usual med-

Figure 1.
Flow of participants through the trial.

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ication regimen over the entire 12-
week period.

Control Group
The control group did not receive
any aquatic physical therapy over
the 6-week trial; however, these par-
ticipants were offered the interven-
tion following the 6-week assess-
ment to minimize dropouts from this
group. Thus, these participants did
not complete a 12-week assessment.
Participants were instructed to con-
tinue with their usual daily activities
and medication regimen and not to

commence any new exercise pro-
grams or treatments for their OA-
affected joints.

Masking
An examiner who was unaware of
group assignment performed all out-
come assessments. The statistician
was unaware of treatment allocation
until completion of the statistical
analyses.

Primary Outcomes
Pain on movement (over the preced-
ing week) in the primary OA joint

was measured with a VAS numbered
in 1-cm intervals. Previous research
indicated that such a scale is a valid,
reliable, and responsive technique
for assessing pain in subjects with
OA when completed by those sub-
jects.18,19 Subject-perceived global
changes (since trial commencement)
in pain and physical function were
recorded on 5-point Likert scales rang-
ing from 1 (much worse) to 5 (much
better). Participants who scored their
global changes as 4 or 5 were classi-
fied as showing improvement, and
those scoring their changes as 1, 2, or

Table 1.
Aquatic Physical Therapy Programa

Phase Water Depth Lower-Limb Exercises Sets and
Repetitions
(Each Leg)

Walking

1 Xiphisternum
(28%–35% WB)8

1. Double-leg squats
2. Double-leg calf raises
3. Dynamic lunge

2�10

2�10
2�10

6 min

2 ASIS (47%–54% WB)8 As for phase 1 As for phase 1 8 min

3 ASIS As for phase 1, plus:
4. Single-leg stance, contralateral knee

flexion/extension
5. Single-leg stance, contralateral hip

abduction/adduction
6. Single-leg stance, contralateral hip

hitching

2�10
2�10
2�10

10 min

4 ASIS 1. Single-leg squats
2. Sincle-leg calf raises
3. Dynamic lunge
Plus exercises 4, 5, and 6 from phase 3

2�10
2�10
2�10

10 min

5 ASIS As for phase 4, plus:
7. Step-ups 2�10

10 min

6 ASIS As for phase 5, but modify:
7. Step-downs 2�10

10 min

7 ASIS As for phase 6, but for exercises 4 and
5, increase speed (resistance) of
moving leg as able

2�10
followed by 1�5

10 min

8 ASIS As for phase 7 3�10 10 min

9 ASIS As for phase 7 3�10
followed by 1�5

10 min

10 ASIS As for phase 7 4�10 10 min

11 ASIS As for phase 7 4�10
followed by 1�5

10 min

12 ASIS As for phase 7 5�10 10 min

a Each session incorporated a warm-up and a cool-down (2 widths of the pool walking forward, backward, and sideways and high stepping) conducted at
the depths indicated. Walking immediately followed the completion of lower-limb exercises. All single-leg exercises were performed with both the left and
the right legs. The step height was 145 mm. ASIS�anterior superior iliac spine, WB�weight bearing.

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3 were classified as not showing
improvement.

Secondary Outcomes
Questionnaires. The 24-item disease-
specific Western Ontario and McMas-
ter Universities Osteoarthritis Index
(WOMAC) was used to assess pain,
stiffness, and physical function in the
primary OA joint over the previous
48 hours. This measure has been vali-
dated with respect to reliability, face
validity, content validity, construct
validity, and responsiveness for peo-
ple with OA of the hip or knee.20

Health-related quality of life over the
previous week was assessed with the
15-item Assessment of Quality of Life
scale.21 This scale has been validated
for use in the general population.
Physical activity levels over the previ-
ous week were assessed with the
Physical Activity Scale for the Elderly
(PASE) (with supervised aquatic phys-
ical therapy sessions excluded from
the analyses to accurately measure
independent activity). The PASE dem-
onstrated good test-retest reliability,
convergent validity, and construct va-
lidity in older adults with knee pain.22

Muscle strength. Isometric hip ab-
duction and knee extension strength
(force-generating capacity) was as-
sessed bilaterally with a Nicholas Man-
ual Muscle Tester (model 01160)*
according to the protocol of Bohan-
non.23 The hip abductors were chosen
because some data have suggested
that stronger hip abductors may assist
in reducing the knee adduction mo-
ment.24 The quadriceps femoris mus-
cles were assessed because knee ex-
tensor strength has been correlated
with both pain severity and physi-
cal function in knee OA.25–27 The
peak strength of each muscle group
was assessed 3 times, and the high-
est score was recorded (in kilograms).
Handheld dynamometry demon-

strated adequate test-retest reliability
for the muscles of the lower limbs in
a community-dwelling group of
older people (intraclass correlation
coefficients [ICCs]�.95–1.00).28

Balance. Dynamic standing bal-
ance was assessed with the step test,
a reliable and valid measure in older
people (ICC�.9)29 that is sensitive
enough to discriminate between
those with knee OA and those with-
out knee OA.30 Participants stood
barefoot on the osteoarthritic limb in
front of a 7.5-cm step and were
instructed to move the opposite foot
on and off the step as many times as
possible over 15 seconds. This test
does not require the participant to
move body weight over the step but
simply to perform a potentially
destabilizing foot placement activity.
The number of times the participant
could place the foot on the step and
return it to the floor was recorded,
with higher scores indicating better
balance.

Physical function. The Timed
“Up & Go” Test was used to assess
functional ability.31 This test demon-
strated good intratester and inter-
tester reliability (ICC�.99) for a geri-
atric population as well as criterion
validity. Participants were instructed
to rise from a standard armchair,
walk to a point on the floor 3 m
away, return to the chair, and sit
down again while being timed with a
stopwatch. Participants performed
the test only once and at their own
pace.

Gait. The Six-Minute Walk Test
was used to evaluate how far partic-
ipants could walk at a fast, comfort-
able pace. This test was validated as
a measure of physical function in
people with heart failure and respi-
ratory disease.32 Participants walked
back and forth over a 50-m stretch of
carpeted corridor for 6 minutes, and
the total distance walked was
recorded (in meters).

Sample Size
A pain reduction of 1.75 cm on a
VAS is recommended as the mini-
mum clinically important difference
to be detected in OA trials.33 With
58 participants, the study had 90%
power to detect a difference in pain
reduction of 1.75 cm between groups,
assuming a standard deviation of 2.0
cm and a significance level of 5%.
Numbers were increased to 71 par-
ticipants to allow for dropouts.

Data Analyses
Data analyses were performed with
SPSS software† and an alpha level of
.05 on an intention-to-treat basis. The
last observation carried forward was
used to impute data missing at reas-
sessment; a score of 3 (“unchanged”)
was allocated for missing global
change measures. Data were checked
for normality and homogeneity of
variance prior to analyses. Baseline
comparability between groups was
determined with independent t tests
(because most data were normally dis-
tributed) or chi-square tests. Mean
scores at 6 weeks were compared
between groups by use of univariate
analysis of variance; baseline scores
were included as covariates to control
for any group differences at baseline.
Effect sizes were calculated; effect
sizes of .2 were regarded as small,
those of .5 were regarded as medium,
and those of .8 were regarded as large.
A comparison of the numbers of par-
ticipants showing improvement be-
tween groups was made with chi-
square tests, and odds ratios (OR)
(with 95% confidence intervals [CI])
were calculated. Outcomes at 6 and
12 weeks in the intervention group
were compared by use of paired t
tests.

Results
Groups were found not to be signif-
icantly different at baseline with
regard to demographic characteris-

* Lafayette Instrument Co, 3700 Sagamore
Pkwy North, PO Box 5729, Lafayette, IN
47903.

† SPSS Inc, 233 S Wacker Dr, Chicago, IL
60606.

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tics or outcome measures (Tab. 2),
with the exception of quality of life,
which was significantly poorer in
the aquatic physical therapy partici-
pants (P �.01).

Primary Outcomes
Aquatic physical therapy partici-
pants reported a mean reduction in

pain on movement of 33% from base-
line and thus demonstrated signifi-
cantly less pain at 6 weeks than con-
trol participants (P �.01) (Tab. 3).
This finding represented a small
effect size (.24) for this outcome.
Seventy-two percent (26 of 36) of
the intervention participants re-
ported a global improvement in

pain; only 17% (6 of 35) of the con-
trol participants did so (P �.001)
(Fig. 2). Similarly, 75% (27 of 36)
of the intervention participants re-
ported a global improvement in
physical function; only 17% (6 of 31)
of the control participants did so
(P �.001) (Fig. 2). Aquatic physical
therapy participants were more than

Table 2.
Baseline Comparability of Participant Groupsa

Parameter Control Group (n�35) Aquatic Physical
Therapy Group (n�36)

Age, y 61.5 (7.8) 63.3 (9.5)

Height, m 1.61 (0.01) 1.63 (0.09)

Weight, kg 85 (17) 88 (15)

Body mass index, kg/m2 32.9 (6.6) 33.8 (6.5)

Symptom duration, y 8.0 (10.6) 8.0 (9.3)

Sex, no. (%) 24 (69) female, 11 (31) male 24 (67) female, 12 (33) male

Symptomatic joint, no. (%) 24 (69) knee, 11 (31) hip 31 (86) knee, 5 (14) hip

Medications, no. (%) 16 (46) analgesics,
14 (40) NSAIDs,
14 (40) nutraceuticalsb

20 (56) analgesics,
18 (50) NSAIDs,
14 (39) nutraceuticals

Primary outcomes

VAS movement pain, 0–10 cm 5 (2) 6 (2)

Secondary outcomes

WOMAC pain, 0–500 mm 199 (85) 202 (79)

WOMAC stiffness, 0–200 mm 100 (46) 99 (46)

WOMAC function, 0–1,700 mm 630 (315) 757 (327)

AQoL, �0.04 to 1.00 0.52 (0.20) 0.38 (0.17)c

PASE, 0–400 153 (79) 165 (80)

Hip abductor strength, kg

Right 21.0 (7.2) 20.3 (8.2)

Left 22.3 (8.3) 20.6 (8.4)

Quadriceps femoris muscle strength, kg

Right 24.5 (8.2) 26.6 (9.1)

Left 24.3 (8.3) 23.2 (9.3)

Timed “Up & Go” Test, s 10.38 (2.82) 11.26 (2.37)

Six-Minute Walk Test, m 448.09 (82.88) 420.56 (91.10)

Step test, no. of steps 13 (4) 13 (4)

a Data are presented as mean (SD) unless otherwise indicated. AQoL�Assessment of Quality of Life (with higher scores indicating better quality of life),
NSAIDs�nonsteroidal anti-inflammatory drugs, PASE�Physical Activity Scale for the Elderly (with higher scores indicating greater physical activity),
VAS�visual analog scale (with higher scores indicating more pain), WOMAC�Western Ontario and McMaster Universities Osteoarthritis Index (with higher
scores indicating worse pain, stiffness, or physical function).
b Nutraceutical can be defined as a food (or part of a food) that provides medical or health benefits, including the prevention or treatment of a disease;
typically glucosamine in this population.
c Significantly different from value for control group (P �.01).

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12 times as likely as control partici-
pants to report global improvements
in pain (OR�12.6, 95% CI�4.0 –
39.4), corresponding to a number
needed to treat of 2 (95% CI�1–3),
and physical function (OR�12.5,
95% CI�3.9 – 40.2), corresponding
to a number needed to treat of 2
(95% CI�1–3).

Secondary Outcomes
The aquatic physical therapy partic-
ipants reported significantly less
pain and significantly superior phys-
ical function on many secondary out-
comes (Tab. 3). Hip muscle strength
and quality of life also were signifi-
cantly greater in this group than in
the control group at 6 weeks. Out-
comes that were not significantly dif-
ferent following the intervention
were quadriceps femoris muscle

Figure 2.
Global improvement in pain and physical function at 6 weeks across groups.

Table 3.
Outcome Scores at 6 Weeks Across Groupsa

Outcome X (SD) P Effect
Size

Control Group
(n�35)

Aquatic Physical
Therapy Group
(n�36)

Primary

VAS movement pain, 0–10 cm 5 (2) 4 (2) .003 .24

Secondary

WOMAC pain, 0–500 mm 198 (108) 143 (79) �.001 .28

WOMAC stiffness, 0–200 mm 95 (44) 73 (45) .007 .24

WOMAC function, 0–1,700 mm 656 (373) 598 (316) �.001 .08

AQoL, �0.04 to 1.00 0.50 (0.20) 0.43 (0.20) .018 .17

PASE, 0–400 142 (77) 165 (70) .351 .15

Hip abductor strength, kg

Right 20.3 (6.8) 22.7 (8.3) .012 .16

Left 21.0 (8.0) 22.2 (8.5) .011 .07

Quadriceps femoris muscle strength, kg

Right 24.7 (9.5) 29.9 (12.5) .059 .23

Left 24.9 (10.3) 25.7 (10.6) .193 .04

Timed “Up & Go” Test, s 10.30 (2.78) 10.32 (1.94) .053 .00

Six-Minute Walk Test, m 440.38 (79.03) 441.72 (87.25) .001 .01

Step test, no. of steps 14 (4) 13 (3) .998 .14

a AQoL�Assessment of Quality of Life (with higher scores indicating better quality of life), PASE�Physical Activity Scale for the Elderly (with higher scores
indicating greater physical activity), VAS�visual analog scale (with higher scores indicating more pain), WOMAC�Western Ontario and McMaster
Universities Osteoarthritis Index (with higher scores indicating worse pain, stiffness, or physical function).

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strength, the step test, the Timed
“Up & Go” Test, and the PASE. Effect
sizes for secondary outcomes were
small at best.

Attendance and Adverse Effects
Only 2 participants failed to attend
all 12 aquatic physical therapy ses-
sions (excluding the participant who
withdrew before attending any ses-
sions); 1 of these 2 participants
attended 10 sessions (83%), and the
other participant attended 11 ses-
sions (92%). Adverse effects were
minor and did not affect ongoing
participation. Seventeen (49%) par-
ticipants reported mild joint discom-
fort, 3 (9%) reported mild lumbar
pain, and 2 (6%) reported cramps in
the calf or foot. Upon completion of
the program, 11 participants (31%)
had reached phase 12, and 1 (3%), 1
(3%), 1 (3%), 2 (5%), 10 (29%), and 9

(26%) had reached phases 6, 7, 8, 9,
10, and 11, respectively.

Ongoing Participation and
Outcome at Follow-up in the
Aquatic Physical Therapy Group
At follow-up, 84% of participants (28
of 33) had continued to undertake
aquatic physical therapy indepen-
dently since ceasing the supervised
program. Over the 6-week follow-up
period, 24% (8 of 33) attended the
local pool less than once per week
on average, 45% (15 of 33) attended
1 or 2 times per week, and 15% (5 of
33) attended 2 or 3 times per week;
only 16% (5 of 33) failed to attend at
all. Follow-up scores at 12 weeks for
the aquatic physical therapy group
were generally unchanged from
scores obtained at 6 weeks (Tab. 4),
suggesting that the benefits of the

program were maintained in the
short term.

Discussion
This randomized controlled trial
evaluated the efficacy of aquatic
physical therapy for hip OA and
knee OA. Our findings demonstrated
that a 6-week, twice-weekly pro-
gram leads to reduced pain and joint
stiffness as well as improved physi-
cal function, hip muscle strength,
and quality of life in people with
OA. Furthermore, the benefits of
aquatic physical therapy appear to
remain 6 weeks after the cessation
of the supervised program. Despite
statistically significant differences
between groups, effect size calcula-
tions revealed only small benefits of
aquatic physical therapy for pain,
stiffness, right hip abductor strength,
and quality of life and doubtful clin-

Table 4.
Outcome Scores at Follow-up (12 Weeks) in the Aquatic Physical Therapy Group (n�36)a

Outcome 6 wk 12 wk P

Primary

VAS movement pain, 0–10 cm 4 (2) 4 (2) .45

Secondary

WOMAC pain, 0–500 mm 143 (79) 132 (89) .23

WOMAC stiffness, 0–200 mm 73 (45) 65 (46) .05

WOMAC function, 0–1,700 mm 598 (316) 556 (341) .08

AQoL, �0.04 to 1.00 0.43 (0.20) 0.45 (0.22) .31

PASE, 0–400b 140 (104) 160 (150) .63

Hip abductor strength, kg

Right 22.7 (8.3) 23.4 (10.7) .44

Left 22.2 (8.5) 21.8 (8.8) .46

Quadriceps femoris muscle strength, kg

Right 29.9 (12.5) 29.2 (11.7) .47

Left 25.7 (10.6) 24.5 (9.4) .21

Timed “Up & Go” Test, s 10.32 (1.94) 9.98 (1.93) .03

Six-Minute Walk Test, m 441.72 (87.25) 447.39 (89.07) .18

Step test, no. of steps 13 (3) 14 (4) .03

a Data are presented as mean (SD) unless otherwise indicated. AQoL�Assessment of Quality of Life (with higher scores indicating better quality of life),
PASE�Physical Activity Scale for the Elderly (with higher scores indicating greater physical activity), VAS�visual analog scale (with higher scores indicating
more pain), WOMAC�Western Ontario and McMaster Universities Osteoarthritis Index (with higher scores indicating worse pain, stiffness, or physical
function).
b Data are presented as median (interquartile range) and were analyzed with the Wilcoxon signed rank test.

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ical benefits for physical function
and left hip abductor strength.

Few randomized controlled trials have
evaluated hydrotherapy interventions
in a sample selected on the basis of hip
or knee OA alone.11,12,14,15 Our find-
ings of reduced pain and improved
function with aquatic physical therapy
concur with the findings of others.14,15

However, the most rigorously de-
signed randomized controlled trial
published to date found no significant
change in WOMAC scores (pain, stiff-
ness, or function) with hydrotherapy
compared with a gym-based strength-
ening program or no intervention in
105 participants with clinical hip or
knee OA.11 Nevertheless, hydrother-
apy did result in improved walking
distance and left quadriceps femoris
muscle strength compared with no
intervention.

In contrast to the program of Foley
et al,11 our aquatic physical therapy
program primarily focused on exer-
cises in functional positions, was
progressed by increasing resistance
(weight bearing or turbulence), and
incorporated a walking component,
features that may explain our find-
ings of significant improvements in
pain and most self-reported and
observed physical function mea-
sures. Differences in study partici-
pants also may account for the
conflicting findings. Participants in
our study were younger, were more
frequently female, and predomi-
nantly had knee OA. Importantly,
our volunteers were recruited pri-
marily from the community rather
than from an orthopedic surgery
waiting list (44% of participants in
the study of Foley et al11), suggest-
ing that aquatic physical therapy
may be more effective for less
severe OA rather than end-stage
disease.

Several reasons may account for the
improvements in pain observed in
the aquatic physical therapy group.

Quadriceps femoris muscle strength
is associated with knee pain severity
in knee OA,25,27 although whether
muscle weakness causes knee pain
or vice versa is unclear at present.
Recent work demonstrated an associ-
ation between hip abductor strength
and the knee adduction moment. It
has been postulated that stronger hip
abductors help to stabilize the con-
tralateral pelvis during walking and,
by virtue of the effect on the body’s
center of mass, can reduce the adduc-
tion moment (or compressive force)
at the knee.24 Thus, it is possible that
improvements in hip and knee muscle
strength were partially responsible for
the improvements in knee pain ob-
served in the present study.

Although changes were not statisti-
cally significant, aquatic physical
therapy did demonstrate a small
effect size (.23) for right quadriceps
femoris muscle strength and a small
but statistically significant effect for
the right hip abductors. Conversely,
it is also possible that reductions in
knee pain were responsible for the
small strength gains evident in the
present study with aquatic physical
therapy. It is difficult to identify the
mechanism underlying the observed
improvements in strength, but im-
proved recruitment of motor units,
muscle hypertrophy, pain allevia-
tion, or reduced knee joint swelling
are all possibilities.

A placebo effect of aquatic physical
therapy cannot be ruled out because
of the lack of a placebo control in
the present study. Placebo effects
are common in knee OA; reported
improvements with sham interven-
tion range from 16% to 40%.34 –37

However, a meta-analysis of placebo-
controlled clinical trials38 demon-
strated that placebos have the great-
est effect on continuous subjective
outcomes and in the treatment of
pain, with no significant effect on
objective measures. Given that our
study demonstrated beneficial ef-

fects of aquatic physical therapy on
observed objective measures (hip
muscle strength and 6-minute walk),
it is unlikely that our findings are
attributable to a placebo response
alone and likely that they may be
attributed, at least partially, to the
intervention itself.

Joint stiffness was reduced with
aquatic physical therapy, and this
result may be at least partially attrib-
utable to the warm-water environ-
ment of the hydrotherapy pool.
Warm water may encourage muscle
relaxation, thus reducing guarding
around joints and enhancing move-
ment. It is also possible that pain
relief was achieved by the tempera-
ture and pressure of the water on the
skin.39 Although it is possible that
some benefits of aquatic physical
therapy may be attributable to warm-
water immersion alone, a previous
randomized controlled trial in rheu-
matoid arthritis demonstrated supe-
rior effects of hydrotherapy over
seated immersion alone.40 Perhaps
the most important aspect of the
aquatic environment is the buoyancy
of the water, rather than its warmth,
which reduces the weight-bearing
stresses on the lower limbs and thus
promotes more pain-free and effective
exercise of the muscles and joints than
would otherwise be possible.

To our knowledge, this is the first
study of aquatic physical therapy
that has encouraged ongoing inde-
pendent aquatic therapy following
cessation of the supervised program
and incorporated a follow-up period.
As part of the intervention, our par-
ticipants were instructed in the ben-
efits of ongoing therapy and exercise
self-management principles, provided
with detailed written instructions on
how to perform aquatic physical ther-
apy exercises independently as well
as how to modify or progress their
program according to symptoms, and
given written directions on conve-
nient local pools in which to exercise.

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Although ongoing adherence among
participants was variable, 60% con-
tinued aquatic physical therapy inde-
pendently at least once per week on
average. It was not possible to monitor
control participants at 12 weeks in
the present study, as most of the con-
trol group had commenced aquatic
physical therapy by this stage. How-
ever, follow-up (without a control
group) of the aquatic physical therapy
group at this time appeared to demon-
strate that benefits at 6 weeks were
maintained.

Like that of land-based exercise pro-
grams, the success of water-based
exercise programs is probably par-
tially dependent on adherence to the
prescribed exercises. Given the al-
most perfect attendance demon-
strated by our participants during
the intervention period, it was not
possible to evaluate the relationship
between adherence and outcome. In
this trial, it is likely that adherence
was enhanced by virtue of the close
monitoring associated with partici-
pation in a research study, and such
extremely high levels of adherence
should not be expected in the clini-
cal setting. Thus, strategies to maxi-
mize adherence are essential for suc-
cess in clinical practice.

Setting specific exercise-related goals
that are relatively easy to achieve has
been shown to increase aquatic exer-
cise adherence in people with arthri-
tis.41 In addition, as people improve in
their ability to exercise in the aquatic
environment, adherence to exercise
increases. Strategies that may promote
self-efficacy include beginning slowly
with exercises that are easily accom-
plished, progressing exercise pro-
grams slowly, and providing frequent
encouragement.42 Our program was
designed to educate participants
about the appropriate progression of
aquatic exercises, thus optimizing the
ability of people to adjust resistance
and advance the program themselves
or modify it according to symptoms.

Adverse effects associated with our
aquatic physical therapy interven-
tion were minor and transient, and
over half of the participants experi-
enced no adverse effects at all. As
expected, the most frequent com-
plaint was aggravation of joint symp-
toms with exercise. Some partici-
pants also described back pain after
commencing exercises; the back
pain may have been related to the
prompts that they were given to
improve their posture and spinal
position while walking and exercis-
ing in the pool.

Our program did not involve the use
of any specific exercise equipment
other than a step, which is a feature
of most hydrotherapy pools. This
study design was used to facilitate
participants’ understanding of exer-
cise progression in the aquatic envi-
ronment in order to improve confi-
dence as well as to maximize
adherence to the program indepen-
dently at a local pool during follow-
up. The use of equipment (flippers,
boots, and floats) can be beneficial
for resistance training in the water,
and greater strength gains might
have been obtained in our study had
equipment been incorporated into
the program. The fact that quadri-
ceps femoris muscle strength did not
increase significantly with our pro-
gram may argue for the need for
equipment for this muscle group in
particular. However, the additional
benefits of equipment might be off-
set by increased financial costs of the
intervention or by reduced ongoing
adherence to the program by partic-
ipants.

There are a number of limitations of
the present study. The lack of a pla-
cebo group necessitated a single-
blind design, which may have influ-
enced the study outcomes. The
follow-up period was short, and in
chronic conditions such as OA,
much longer periods are warranted
to evaluate lasting treatment effects.

Furthermore, the follow-up period
lacked a control group because of
funding constraints. Relatively few
of our study participants presented
with hip OA primarily; thus, it was
not possible to perform subgroup
analyses to determine outcomes for
hip OA and knee OA separately. It is
possible that knee OA and hip OA
responded differently to our aquatic
physical therapy program, but the
present study did not have sufficient
power to detect such differences.

The question remains as to whether
aquatic physical therapy is superior
to land-based physical therapy for
OA. Other authors have failed to
demonstrate any additional benefit
of hydrotherapy over home exercis-
es12 or over a gym-based strengthen-
ing program11 for people with OA;
those results may have been related
to the aquatic physical therapy pro-
gram content in those published tri-
als. Given the association of quadri-
ceps femoris muscle strength with
pain severity and physical function
in OA,25,27 it is essential that aquatic
programs incorporate a resistance
training intensity comparable to that
of land-based programs. To increase
resistance for muscle strengthening
in the water, it may be necessary to
further decrease the depth of immer-
sion with closed-chain exercises, to
use floats in buoyancy-resisted posi-
tions, or to increase resistance from
turbulence by increasing speed or
surface area (with the addition of
flippers or boots) with open-chain
exercises. Further studies of aquatic
physical therapy should aim to refine
program content by maximizing the
use of the hydrostatic and hydro-
dynamic properties of water and
thus the potential benefits of aquatic
physical therapy for people with
lower-limb OA. Future research also
should be directed toward evaluat-
ing the characteristics of people
who respond to land- and water-
based exercises, as it is possible that
certain types of exercise regimens

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are more suitable for particular sub-
groups of people.

Conclusion
The present study demonstrated that
a 6-week program of aquatic physi-
cal therapy results in small improve-
ments in pain, stiffness, hip strength,
and quality of life in people with hip
OA or knee OA compared with no
intervention. Aquatic physical ther-
apy is a useful intervention option
for such people; many people may
adhere to the intervention indepen-
dently once the supervised program
ceases.

Dr Hinman and Ms Heywood provided con-
cept/idea/research design and writing. Mr
Day provided data collection, and Dr Hin-
man provided data analysis. Ms Heywood
provided project management and fund
procurement. The authors thank Kathryn
Ritchie for her assistance with data entry,
Jenny Geytenbeek for her guidance, and the
Sunshine Hospital and Western Hospital
physiotherapy department staff for their
support.

The local Human Research Ethics Committee
approved the study.

This research, in part, was presented at the
47th Annual Scientific Meeting of the Aus-
tralian Rheumatology Association/Rheuma-
tology Health Professionals Association; May
22–25, 2005; Melbourne, Victoria, Australia.

This study was supported by a National
Arthritis and Musculoskeletal Conditions
Improvement Grant from the Australian
Government Department of Health and
Aging.

This article was received January 5, 2006, and
was accepted August 11, 2006.

DOI: 10.2522/ptj.20060006

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