Healthy Aging

Aquatic Exercise for the Treatment and Management of Osteoarthritis
by Haley Crutcher

Osteoarthritis (OA) is a chronic health problem and the most common cause of disability and hip and knee joint replacement (Wang, Belza, Thompson, Whitney, Bennett, 2007). No known cure for osteoarthritis exists at this time. Treatment is therefore designed to improve quality of life by reducing pain, maintaining and/or improving joint mobility and limiting functional impairment (Arthritis Foundation, 2007). This paper serves to contribute to collection of appropriate information, research and resources to combat osteoarthritis by exploring the role of aquatic exercise in the treatment and management of osteoarthritis.

Osteoarthritis is the most prevalent type of arthritis afflicting 1 in 10 Canadians, men and woman equally. OA is caused by the breakdown of cartilage, the tough elastic material that covers and protects the end of bones. Cartilage acts as a cushioning shock absorber when a joint it weighted. The slippery nature of cartilage allows bones to move smoothly. As cartilage degrades, becoming rough and thin the bone underneath can thicken, develop spurs. The complete depletion of cartilage allows bones to rub directly on one another (Arthritis Society, 2007). Though classified as non-inflammatory arthritis, swelling in the later stage of arthritis can occur. As the disease progresses, pieces of cartilage may break off and float within the joint. This interferes with other soft tissues, causing swelling and pain between bones, resulting in difficulty moving the joint. Most commonly, OA develops after the age of 45, but can occur anytime after the age of 15. OA is a disease that affects the joints of the body, particularly the hands and weight bearing joints such as the hips, knees, feet and spine. Individuals with OA experience pain that typically worsens with weight bearing and activity, improving with rest. Pain is also commonly worsened by morning stiffness and gelling of involved joints after a prolonged period of inactivity (Arthritis Society, 2007). Upon examination, swelling is usually mild and localized to the afflicted joint. Those with OA have localized swelling, tenderness on palpitation, bony enlargements, crepitus or grating sounds on motion and limitation of joint movement. Consequently, underused joints can cause muscle weakening leading to loss of joint shape and stability, completing impairing joint use. OA limits activities of daily living such as walking, dressing and bathing.

Exercise is essential for the prevention and management of the functional limitation associated with osteoarthritis (Wang, 2007). Effective management of OA includes a regular exercise regime. Moderate physical activity on a regular basis leads to decreased fatigue and improved stamina, a sense of well being, improved self esteem, feelings of self empowerment, and the strengthening of muscles and bones. Notably, regular exercise also leads to restoration and/or preservation joint flexibility (Arthritis Foundation, 2007). A balanced exercise regime includes three types of activity: flexibility exercises, strengthening exercises, and cardiovascular (aerobic) exercise.

Joint flexibility is of particular importance to those with osteoarthritis because limited range of motion due to the disease leads to inability to perform daily tasks such as dressing and bathing (Arthritis Foundation, 2007). Gentle flexibility exercises performed daily can help protect joints by reducing the risk of joint injury, provide a warm up for more strenuous activity and help promote relaxation and release of tension. Such exercises are particularly useful for easing stiff joints after prolonged periods of inactivity (Arthritis Foundation, 2007). Such exercises can be done on land or in water.

Strong muscles are needed to lessen the stress places on arthritic joints. Strong muscles help to absorb shock and protect joints from injury. Additionally, strength is essential for mobility. Strengthening exercises use weight or resistance to make muscle work harder than normal, causing them to become stronger (Arthritis Foundation, 2007). Isometric and isotonic are two types of strengthening exercises. Isometric exercises are particularly beneficial for people with OA because they work by tightening the muscle around a joint, without and joint movement. Isotonic exercises strengthen muscles by moving the joint. These exercises promote joint mobility can be adapted to comfort level, being made less strenuous or more difficult depending on severity of pain or symptoms.

Aerobic exercise makes the heart, lungs, blood vessels and muscles work more efficiently by recruiting the large muscles of the body into rhythmic, continuous motion. Examples of aerobic exercise include walking, running, dancing, bicycling, and swimming. Aerobic exercise results in improved endurance, stronger bones, improved sleep, and weight control. Other benefits include stress, depression and anxiety reduction.

Osteoarthritis patients are able to pursue a high level of physical activity, so long as the activity is not painful or predispose to trauma (Wang, 2007). Aquatic exercise is a gentle way to exercise joints and muscles, preventing trauma and blending all three recommended forms of activity: flexibility exercise, strengthening exercise, and aerobic exercise. Recent research has shown improved knee and hip flexibility, strength and aerobic fitness as a result of aquatic exercise (Wang, 2007). Additionally, participation in water activities often creates a playful, social environment, fostering positive relationships (Rogerson, 2008). Submersion in water creates a uniform pressure (hydrostatic pressure), across the body’s entire surface. Hydrostatic pressure reduces swelling, improving range of motion in joints, particularly the feet. The reduction of swelling can provide tremendous relief for those suffering from later stage OA. Intercostal muscles must work harder to breath under hydrostatic pressure, improving the strength of respiratory muscles. This allows individuals with OA to receive cardiovascular benefits without strenuous activity because no movement is necessary to receive this respiratory benefit (Rogerson, 2008). Submersion of the body in water creates a feeling of apparent weight loss due to the effects of buoyancy. Buoyancy decreases compressive forces allowing the participant to move more freely with less joint impact, relieving arthritic pain and stiffness (Arthritis Foundation, 2007). Research has confirmed that subjective pain levels are significantly decreased during aquatic exercise when compared with the land-based exercise (Wyatt, Milam, Manske, Deere, 2001). Submersion in warm water raises the body temperature which causing blood vessels to dilate which increasing circulation. Additionally, submersion in water provides a safe and comfortable environment, decreasing the fear of falling during exercise. Movement in water requires the recruitment of additional muscle fibers to overcome water resistance. This leads to improved muscle tone, increases in oxygen consumption and increase in caloric usage, proving a gentle way to strengthen joints and muscles (Rogerson, 2008).

Hinman and Heywood (2007), found that following a 6 week aquatic exercise program, compared with no intervention, individuals with osteoarthritis reported significantly less pain and joint stiffness, improved physical function, hip muscle strength and quality of life. Aquatic exercise has also been shown useful in managing knee or hip OA as moderate to strong beneficial effects with discovered in range of motion, muscle strength and walking distance following an aquatic exercise program (Wang, 2004). Small improvements in functional status, pain and psychological distress were also noted by participants in this study. Wang (2004) explains that these changes were roughly proportional to the length of adherence to the exercise program. Such research suggests that benefits acquired from participating in aquatic exercise increase proportionally to the duration of regular participation. Kostopoulos (2000) explains that aquatic exercise is both beneficial for increasing mobility and providing a pleasurable activity that provides an occasion for social interaction. This serves as further advocating for the participation of persons with osteoarthritis in an aquatic exercise program.

Studies have shown that consistent participation in aquatic exercise programs results in great benefits and does not worsen the joint condition or result in injury, contrary to popular thought. Deterioration of benefits does occur however if exercise is stopped (Wang, 2007). Consequently, attention to the role of intrinsic factors such as self-efficacy and belief systems is needed and that professional assistance can be useful in fostering initial compliance and perseverance. Large bodies of research suggest that aquatic exercise has beneficial short term effects (Wang, 2007). Based on this suggestion is given that aquatic exercise is implemented early in the exercise program for osteoarthritis patients ( Bartels, Lund, Hagen, Dagfinrud, Christensen, Danneskiold-Samsoe, 2007). Wang (2004) suggests that aquatic exercise three times a week is safe and effective for the maintenance and improvement of functional capacity of individuals with osteoarthritis. Individuals should work up to 15 minutes of flexibility exercise a day to improve and maintain joint mobility. Once this has been obtained begin to implement strengthening and aerobic exercises into your routine. These exercises are incorporated into aquatic programs by professionals who tailor programs to suit the needs of arthritic symptoms. A goal of working in your target heart rate for 30 minutes each session is ideal. This can be worked up to gradually, starting with 5 increment goals, increasing as one becomes stronger and are able (Arthritis Foundation, 2007). Picking programs that are easy to work into one’s schedule and having an exercise partner are simple ways of improving adherence and enjoyment of aquatic activity.

Before beginning any exercise regime it is important for participants to consult their physician to assure that the activity is appropriate. Physical therapists can provide personal assessment of one’s specific exercise and joint protection needs. This is a valuable service that can improve the safety and compliance of participants. This service also informs one of exercise modification to aid in further protection (Arthritis Foundation, 2007). Several precautions should be noted prior to engaging in aquatic activity. Hydrostatic pressure applied to the surface of the body when submerged can cause discomfort for those with high blood pressure of breathing disorders. Those with either of these complications should begin in the shallow end of the pool and gradually move deeper (Rogerson, 2008). Buoyancy, experienced during submersion in water can reduce stability. This can be problematic for those with flaccid of less toned body parts, creating a problem of too much buoyancy. This compromise of balance can be addressed by staying in the shallow end, using a buddy system or using assistive weighted devices. To reduce the effect of weight bearing pain, completely submerge the afflicted area to reduce biomechanical stress (Rogerson, 2008). The resistance of water has the tendency to rush some individuals, while frailer people may have difficulty moving through the water due to resistance. Both circumstances increase the potential for injury. Therefore, it is important for participants to set an appropriate pace of movement. Skills and safety should always take priority over speed. A slower pace can minimize these problems (Rogerson, 2008). Pool decks are slippery and precaution should be taken at all times to avoid falls. Wearing pool shoes can help minimize the risk of slipping. Water temperatures of 29-31 degrees should be maintained for comfort. If a participant is easily chilled in the water they could wear neoprene clothing. It is important for individuals to stay warm to improve joint laxity and enhance circulation. Participants should exit the pool slowly as blood pressure drops when exiting the water, causing feelings of light headed and dizziness. Considering these precautions will help to improve the experience of participants in aquatic exercise (Rogerson, 2008).

Significantly more detailed research is required to build further understanding o the role of aquatic exercise in the management and treatment of osteoarthritis. Specifically, investigation is needed for the different biomechanical subtypes of hip and knee OA. Also exploration of access and environmental issues for physical activity programs for the elderly is needed. Further study should also include the societal costs of alternative approaches to the management of OA and long term trends in outcome measures ( Cochrane, Davey, Edwards 2005). Controlled and randomized studies in this field are lacking to provide further recommendations on how to apply aquatic therapy to patients with OA based on patient and disease characteristics (Bartels et al., 2007). Furthermore, research into methods of fostering aquatic exercise adherence is of necessity ( Belza, Topolski, Kinne, Patrick, Ramsey, 2002).

Osteoarthritis affects 10% of the Canadian population (Arthritis Society, 2007). It is of utmost importance that research is diligently carried out to explore the possibilities of treatment and management of the disease’s debilitating symptoms. Current research has shown that aquatic exercise can play a significantly positive role in the maintenance and improvement of flexibility, strength and aerobic fitness of individuals with osteoarthritis (Wang, 2004). Additionally, reports of decreased pain and improved functionality highlight the benefits of an aquatic exercise regime. Specific aquatic program recommendations still need to be developed. Promotion of aquatic exercise in the treatment and maintenance of osteoarthritis should be of high importance in the osteoarthritis community.

References

The Arthritis Foundation (2007). Top Three Types of Exercise. Retrieved March 20, 2008 from http://www.arthritis.org/types-exercise.php

The Arthritis Society (2007). Introduction to Arthritis. Retrieved March 20, 2008 from http://www.arthritis.ca/types%20of%20arthritis/default.asp?s=1

Bartels, E.M., Lund, H., Hagen, K.B., Dagfinrud, H., Christensen, R., Danneskiold-Samsoe, B. (2007). Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database of Systematic Reviews (4).

Belza, B., Topolski, T., Kinne, S., Patrick, D.L., Ramsey, S.D. (2002). Does adherence make a difference? Results from a community-based aquatic exercise program. Nursing Research 51 (5), 285-291.

Cochrane, T., Davey R.C., Edwards, S.M.M. (2005). Randomized controlled trial of the cost-effectiveness of water-based therapy for lower limb osteoarthritis. Health Technology Assessment 9 (31), 1-114 .

Hinman, R.S., Heywood, S.E. (2007). Aquatic physical therapy for hip and knee osteoarthritis: results of a single-blind randomized controlled trial. Journal of Physical Therapy 87 (1), 32-43.

Kostopoulos, D. (2000) Comparative effects of aquatic recreational and aquatic exercise programs on mobility, pain perception and treatment satisfaction among elderly persons with osteoarthritis of the knee. New York University ; Ph.D. doctoral dissertation research, 88.

Rogerson, M.A. (2008, W). KNES 369 February 28, 2008 Lecture. Faculty of Kinesiology, U of C, AB

Wang, T.T. (2004). Aquatic exercise improves flexibility, strength and walk time in osteoarthritis. University of Washington , Ph.D. doctoral dissertation research, 157.

Wang, T., Belza, B., Elaine Thompson, F., Whitney, J.D., Bennett, K. (2007) Effects of aquatic exercise of flexibility, strength and aerobic fitness in adults with osteoarthritis of the hip or knee. Journal of Advanced Nursing, 57 (2), 141-152.

Wyatt, F.B., Milam, S., Manske, R.C., Deere, R. (2001). The effects of aquatic and traditional exercise programs on persons with knee osteoarthritis. Journal of Strength and Conditioning Research 15 (3), 337-340.