Clinician Article

Effect of therapeutic aquatic exercise on symptoms and function associated with lower limb osteoarthritis: systematic review with meta-analysis.

  • Waller B
  • Ogonowska-Slodownik A
  • Vitor M
  • Lambeck J
  • Daly D
  • Kujala UM, et al.
Phys Ther. 2014 Oct;94(10):1383-95. doi: 10.2522/ptj.20130417. Epub 2014 Jun 5. (Review)
PMID: 24903110
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  • Geriatrics
    Relevance - 6/7
    Newsworthiness - 5/7
  • Physical Medicine and Rehabilitation
    Relevance - 6/7
    Newsworthiness - 5/7
  • Family Medicine (FM)/General Practice (GP)
    Relevance - 5/7
    Newsworthiness - 4/7
  • General Internal Medicine-Primary Care(US)
    Relevance - 5/7
    Newsworthiness - 4/7
  • Rheumatology
    Relevance - 5/7
    Newsworthiness - 4/7
  • Surgery - Orthopaedics
    Relevance - 5/7
    Newsworthiness - 4/7


BACKGROUND: Current management of osteoarthritis (OA) focuses on pain control and maintaining physical function through pharmacological, nonpharmacological, and surgical treatments. Exercise, including therapeutic aquatic exercise (TAE), is considered one of the most important management options. Nevertheless, there is no up-to-date systematic review describing the effect of TAE on symptoms and function associated with lower limb OA.

PURPOSE: The purpose of this study was to conduct a systematic review with meta-analysis to determine the effect of TAE on symptoms and function associated with lower limb OA.

DATA SOURCES: The data sources used in this study were: MEDLINE, PubMed, EMBASE, CINAHL, PEDro, and SPORTDiscus.

STUDY SELECTION: All studies selected for review were randomized controlled trials with an aquatic exercise group and a nontreatment control group. In total, 11 studies fulfilled the inclusion criteria and were included in the synthesis and meta-analysis.

DATA EXTRACTION: Data were extracted and checked for accuracy by 3 independent reviewers.

DATA SYNTHESIS: Standardized mean difference (SMD) with 95% confidence interval (95% CI) was calculated for all outcomes. The meta-analysis showed a significant TAE effect on pain (SMD=0.26 [95% CI=0.11, 0.41]), self-reported function (SMD=0.30 [95% CI=0.18, 0.43]), and physical functioning (SMD=0.22 [95% CI=0.07, 0.38]). Additionally, a significant effect was seen on stiffness (SMD=0.20 [95% CI=0.03, 0.36]) and quality of life (SMD=0.24 [95% CI=0.04, 0.45]).

LIMITATIONS: Heterogeneity of outcome measures and small sample sizes for many of the included trials imply that conclusions based on these results should be made with caution.

CONCLUSIONS: The results indicate that TAE is effective in managing symptoms associated with lower limb OA.

Clinical Comments


Therapeutic aquatic exercise, for 50 minutes 2 or 3 times a week improved pain, function, and quality of life in 1,000 60- to 70-year old men and women with significant hip and/or knee osteoarthritis. There was benefit magnitude comparable to acetaminophen, with few adverse effects.


Looks like a well done review showing a clear but modest benefit. It must have been very difficult to control observer bias in the studies. Publication bias could be important; a funnel plot might have been useful.


It's most important to do exercise every day for 30 minutes.

Surgery - Orthopaedics

This comprehensive systematic review notes that therapeutic aquatic exercises have a significant benefit for osteoarthritis. However, little comment is made on the strength of that effect, which is small and not necessarily clinically relevant. This shortcoming is important and should be taken into consideration when interpreting the results.

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