Effectiveness of Hydrotherapy on Balance and Paretic Knee Strength in Patients With Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The glamor of and insights regarding hydrotherapy, from simple immersion to advanced computer-assisted exercises: A narrative review

Water-based therapy has been gaining attention in recent years and is being widely used in clinical settings. Hydrotherapy is the most important area of water-based therapy, and it has distinct advantages and characteristics compared to conventional land-based exercises. Several new techniques and pieces of equipment are currently emerging with advances in computer technologies. However, comprehensive reviews of hydrotherapy are insufficient. Hence, this study reviewed the status quo, mechanisms, adverse events and contraindications, and future prospects of the use of hydrotherapy. This study aims to comprehensively review the latest information regarding the application of hydrotherapy to musculoskeletal diseases, neurological diseases, and COVID-19. We have attempted to provide a "take-home message" regarding the clinical applications and mechanisms of hydrotherapy based on the latest evidence available.

The immediate and lasting balance outcomes of clinical falls-prevention programs: A non-randomised study

PURPOSE

Exercise-based falls-prevention programs are cost-effective population-based approaches to reduce the risk of falling for older adults. The aim was to evaluate the short-term and long-term efficacy of three existing falls-prevention programs.

METHODS

A non-randomized study design was used to compare the immediate-post and long-term physical outcome measures for three falls prevention programs; one high-level land-based program, one low-level land-based program and a water-based Ai Chi program. Timed-up-and-go (TUG), five-times sit-to-stand (5xSTS), six-minute walk test (6MWT) and six-meter walk test were assessed at baseline, post-program, and at six-months follow-up. Linear mixed models were used to analyze between- and within- group differences, with the high-level land-based program used as the comparator.

RESULTS

Thirty-two participants completed post-program assessment and 26 returned for follow-up. There was a difference in the age (years) of participants between programs (p = 0.049). The intercept for TUG and six-meter walk test time was 47.70% (23.37, 76.83) and 32.31s (10.52, 58.41), slower for the low-level group and 40.49% (17.35, 69.89) and 36.34s (12.75, 64.87), slower for the Ai Chi group (p < 0.01), compared with the high-level group. Mean time taken to complete the TUG was less both immediately post-program and at 6-month follow-up (p = 0.05). Walking speed for the six-meter walk test was only faster at six-months (p < 0.05). The 5xSTS duration was significantly reduced only at post-intervention (p < 0.05).

CONCLUSION

These results indicate land-based and water-based falls-prevention programs improve physical outcome measures associated with falls-risk and many improvements are maintained for six months after the completion of the program. (Retrospective trial registration: ACTRN1262300119069).

The efficacy and safety of hydrotherapy in patients with knee osteoarthritis: a meta-analysis of randomized controlled trials

BACKGROUND

Currently, there is poor evidence of the effect of hydrotherapy on patients with knee osteoarthritis (OA). The authors performed a meta-analysis from randomized controlled trials to determine the efficacy and safety of a hydrotherapy program on measures of pain and knee function in individuals living with knee OA.

METHODS

A literature review included PubMed, EMBASE, Cochrane Library, Science Citation Index, ScienceDirect, and Ovid. Studies evaluating the efficacy of hydrotherapy for knee OA up to August 2023 were included. The research was reported based on the preferred reporting items for systematic reviews and meta-analysis guidelines to ensure the reliability and verity of results. Statistical analysis was performed using Stata/SE version 15.0.

RESULTS

A total of six randomized controlled trials were included for data extraction and meta-analysis. The present study revealed that there were significant differences between the two groups regarding the pain intensity at 1 week (WMD=-0.429; 95% CI: -0.679 to -0.179; P =0.001), 4 week (WMD=-0.308; 95% CI: -0.587 to -0.030; P =0.030) and 8 week (WMD=-0.724; 95% CI: -1.099 to -0.348, P <0.001). Furthermore, hydrotherapy was associated with improved outcome of the Western Ontario and McMaster Universities Arthritis index at 1 week (WMD=-3.314; 95% CI: -6.484 to -0.145, P =0.040), 4 week (WMD= -3.630; 95% CI: -6.893 to -0.366, P =0.029) and 8 week (WMD=-3.775; 95% CI: -7.315 to -0.235; P =0.037). No serious adverse events were observed in all patients who received hydrotherapy.

CONCLUSION

Hydrotherapy is efficacious and safe for reducing pain and improving functional status in individuals with knee OA, without increasing the risk of adverse effects.

Occupational Therapy Practice Guidelines for Adults With Stroke

IMPORTANCE

Stroke is a leading cause of disability. Occupational therapy practitioners ensure maximum participation and performance in valued occupations for stroke survivors and their caregivers.

OBJECTIVE

These Practice Guidelines are meant to support occupational therapy practitioners' clinical decision making when working with people after stroke and their caregivers.

METHOD

Clinical recommendations were reviewed from three systematic review questions on interventions to improve performance and participation in daily activities and occupations and from one question on maintaining the caregiving role for caregivers of people after stroke.

RESULTS

The systematic reviews included 168 studies, 24 Level 1a, 90 Level 1b, and 54 Level 2b. These studies were used as the basis for the clinical recommendations in these Practice Guidelines and have strong or moderate supporting evidence.

CONCLUSIONS AND RECOMMENDATIONS

Interventions with strong strength of evidence for improving performance in activities of daily living and functional mobility include mirror therapy, task-oriented training, mental imagery, balance training, self-management strategies, and a multidisciplinary three-stages-of-care rehabilitation program. Constraint-induced therapy has strong strength of evidence for improving performance of instrumental activities of daily living. Moderate strength of evidence supported cognitive-behavioral therapy (CBT) to address balance self-efficacy, long-term group intervention to improve mobility in the community, and a wearable upper extremity sensory device paired with training games in inpatient rehabilitation to improve social participation. Practitioners should incorporate problem-solving therapy in combination with CBT or with education and a family support organizer program. What This Article Adds: These Practice Guidelines provide a summary of strong and moderate evidence for effective interventions for people with stroke and for their caregivers.

Exercise for Adults With Stroke to Improve ADL and/or Functional Mobility Performance (2012-2019)

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on interventions to improve activities of daily living (ADL) and functional mobility performance for people with stroke. This theme reports on exercise interventions.

Effects of aquatic exercise on the improvement of lower-extremity motor function and quality of life in patients with Parkinson's disease: A meta-analysis

Objective: To systematically evaluate the effect of aquatic exercise interventions on the improvement of lower-extremity motor function and quality of life in patients with Parkinson's disease. Methods: Two researchers independently searched the literature using the PubMed, Web of Science, Embase, and Cochrane Library databases. The search period was from the establishment of the database to December 2021. The subject heading search included "hydrotherapy," "hydro therapies," "hydro therapeutics," "water therapy," "aquatic exercise therapy," "aquatic therapy," "water-based exercise," "Parkinson," "Parkinson disease," "Parkinson's disease," "Parkinson's syndrome," "primary Parkinsonism," "paralysis agitans," and "randomized controlled trial (RCT)." Result: A total of 698 articles were retrieved from the four databases by searching for subject headings, and 10 RCT articles were finally included. The balance ability of aquatic exercise in patients with Parkinson's disease (weighted mean differences [WMD] = 2.234, 95% CI: 1.112-3.357, Z = 3.9, p < 0.01), walking ability (WMD = -0.911, 95% CI: -1.581 to -0.241, Z = 2.67, p < 0.01), and quality of life (WMD = -5.057, 95% CI: -9.610 to -0.504, Z = 2.18, p = 0.029) were improved, but there was no significant difference in motor function (WMD = -0.328, 95% CI: -1.781 to 1.125, Z = 0.44, p = 0.658). Conclusion: Compared with conventional rehabilitation therapy, aquatic exercise can effectively improve balance, walking ability, and quality of life in patients with Parkinson's disease. However, it had no obvious effect on improving motor function. This study was limited by the number and quality of the included studies, and more high-quality studies are needed to verify this. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022365103.

Aquatic therapy following arthroscopic rotator cuff repair enables faster improvement of Constant score than land-based therapy or self-rehabilitation therapy

PURPOSE

To compare the clinical and functional outcomes of arthroscopic rotator cuff repair over a period of 2 years using three postoperative rehabilitation modalities: aquatic therapy, land-based therapy, and self-rehabilitation therapy. The null hypothesis was that aquatic therapy would provide no difference in Constant score compared to land-based therapy and self-rehabilitation therapy.

METHODS

A prospective study was performed on subjects scheduled for arthroscopic rotator cuff repair between 2012 and 2017 that complied with the following criteria: (i) small to medium sized symptomatic supraspinatus and/or infraspinatus tendon tears, (ii) low to moderate tendon retraction according to Patte, and (iii) fatty infiltration stage ≤2. Patients were allocated to perform either aquatic therapy, land-based therapy, or self-rehabilitation therapy for 2-4 months. Independent observers blinded to the study design collected Constant score, SSV, and patient satisfaction at 2 months, 3 months, 6 months, 1 year and 2 years.

STUDY DESIGN

Level III, cohort study RESULTS: At 2 months follow-up, patients performing aquatic therapy had significantly higher Constant scores (p < 0.001) and SSV (p < 0.001) compared to those performing land-based therapy or self-rehabilitation therapy. At 3 months follow-up, patients performing aquatic therapy had significantly higher Constant scores (p < 0.001), and SSV (p < 0.001), both of which exceeded the respective minimal clinically important differences (MCIDs) of 10.4 and 12. Patients performing aquatic therapy continued to have significantly higher Constant scores and SSV at 6 months, 1 year, and 2 years.

CONCLUSION

Aquatic therapy has a very limited positive effect on clinical outcomes at 3 months after surgery, but yields no relevant improvements on function or satisfaction at 1 to 2 years follow-up.

Brazilian practice guidelines for stroke rehabilitation: Part II

The Brazilian Practice Guidelines for Stroke Rehabilitation - Part II, developed by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology (Academia Brasileira de Neurologia, in Portuguese), focuses on specific rehabilitation techniques to aid recovery from impairment and disability after stroke. As in Part I, Part II is also based on recently available evidence from randomized controlled trials, systematic reviews, meta-analyses, and other guidelines. Part II covers disorders of communication, dysphagia, postural control and balance, ataxias, spasticity, upper limb rehabilitation, gait, cognition, unilateral spatial neglect, sensory impairments, home rehabilitation, medication adherence, palliative care, cerebrovascular events related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the future of stroke rehabilitation, and stroke websites to support patients and caregivers. Our goal is to provide health professionals with more recent knowledge and recommendations for better rehabilitation care after stroke.

Aquatic Therapy versus Standard Rehabilitation after Surgical Rotator Cuff Repair: A Randomized Prospective Study

Introduction: Post-operative rehabilitation following rotator cuff tear repair (RCR) is important to promote tendon healing, restore strength, and recover normal function. Aquatic therapy in hot water allows body relaxation, which promotes patient conditioning for efficient rehabilitation. The aim of this study was to assess whether aquatic therapy is more efficient than standard (land-based) rehabilitation in terms of range of motion (ROM), function, and pain after arthroscopic RCR. Methods: We prospectively randomized 86 patients scheduled for arthroscopic RCR to either aquatic therapy (n = 44) or standard rehabilitation (n = 42) using block sizes of four or six. Patients were evaluated clinically at 1.5, 3, 6, and 24 months and using ultrasound (US) at 6 months. Two-way mixed ANOVA tests were performed to evaluate the effects of rehabilitation type (between-subjects factor) on ROM and patient reported outcome measures (PROMs) over time (within-subjects factor). Post-hoc inter-group comparisons at each time point were also conducted using Wilcoxon rank sum tests or unpaired Student t-tests and adjusted for multiple comparisons using the Bonferroni correction. Results: The two groups did not differ significantly in terms of demographic data or pre-operative characteristics, except for the Single Assessment Numeric Evaluation (SANE) score, which was lower in the aquatic therapy group (37.9 ± 23.6 vs. 55.6 ± 24.9, p = 0.019). The mixed model revealed the absence of interaction effect between the type of rehabilitation and time on PROMs and ROM except on the SANE score (p < 0.001), which was biased by the existing pre-operative difference mentioned above. Furthermore, none of the post-operative outcomes were statistically different between the two groups at 1.5, 3, 6, and 24 months. In addition, no significant difference could be noted regarding tendon healing rate (p = 0.443), complication (p = 0.349), workstop duration (0.585), or patient satisfaction (p = 0.663). Conclusion: Compared to the standard rehabilitation, the aquatic therapy did not yield superior clinical and functional outcomes after arthroscopic RCR when started immediately after the surgery.

Optimal Assistance Timing to Induce Voluntary Dorsiflexion Movements: A Preliminary Study in Healthy Participants

Swing-phase dorsiflexion assistance with robotic ankle–foot orthosis could improve toe clearance and limb shortening such that compensatory movements are suppressed. However, facilitating voluntary effort under assistance remains a challenge. In our previous study, we examined assistance effects of swing-phase dorsiflexion with different delay times after toe-off on a dorsiflexion-restricted gait with a high-dorsiflexion assistive system. Results showed that later dorsiflexion assistance could lead to an increase in the tibialis anterior’s surface electromyography but could also deteriorate compensatory movement. Thus, we concluded that there is a suitable assistance timing to simultaneously achieve voluntary effort and optimal gait. In the present research, we derived a method to identify a suitable dorsiflexion assistance delay time via a multiple linear regression analysis on ankle data of stroke patients with a pathological gait with insufficient dorsiflexion. With the identification method, an experiment was conducted on six healthy participants with restricted dorsiflexion. Results showed that the identified assistance timing improved the amplitude of the tibialis anterior’s surface electromyography while also suppressing limb shortening during circumduction and hip hiking. Although a practical study of stroke survivors is required, observations from this research indicate the potential to successfully induce voluntary efforts with the identified dorsiflexion assistance timing.

Effects of Health Qigong Exercise on Lower Limb Motor Function in Parkinson's Disease

Purpose

This study explored the effects of Health Qigong exercise on lower limb motor function in patients with Parkinson's disease (PD).

Patients and Methods

A total of 40 patients with PD were recruited and randomly allocated into the experimental group and the control group. The experimental group completed an intervention of Health Qigong exercise over 12 weeks, while the control group did not perform any regular physical activity. Data relating to gait, lower-limb joint range of motion, Timed Up and Go, as well as scores for motor function scale from the Unified Parkinson's Comprehensive Rating Scale III (UPCRS III) before and after the intervention were collected for Repeated Measure ANOVA.

Results

Compared to the control group, Health Qigong exercise improved the constant- and high-speed stride length and gait velocity of patients, but not constant- and high-speed stride frequency. Left and right hip flexion and extension range were improved as well as left and right knee flexion range. Finally, Timed Up and Go time became significantly slower and UPCRS III score significantly decreased.

Conclusion

Health Qigong exercise can improve walking ability and lower limb joint range of motion in patients with PD, lessen motor difficulties, and improve the quality of life. This non-pharmacological exercise intervention may be a useful adjustment treatment for PD.

Non-invasive, non-pharmacological/bio-technological interventions towards neurorestoration upshot after ischemic stroke, in adults-systematic, synthetic, literature review

Considering its marked life-threatening and (not seldom: severe and/or permanent) disabling, potential, plus the overall medico-psycho-socio-economic tough burden it represents for the affected persons, their families and the community, the cerebrovascular accident (CVA)-including with the, by far more frequent, ischemic type-is subject to considerable scientific research efforts that aim (if possible) at eliminating the stroke induced lesions, and consist, as well, in ambitious-but still poorly transferable into medical practice-goals such as brain neuroregeneration and/or repair, within related corollary/upshot of neurorestoration. We have conducted, in this respect, a systematic and synthetic literature review, following the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)" concept. Accordingly, we have interrogated five internationally renowned medical data bases: Elsevier, NCBI/PubMed, NCBI/PMC, PEDro, and ISI Web of Knowledge/Science (the last one to check whether the initially identified articles are published in ISI indexed journals), based on a large (details in the body text) number of most appropriate, to our knowledge, key word combinations/"syntaxes"-used contextually-and subsequently fulfilling the related, on five steps, filtering/selection methodology. We have thereby selected 114 fully eligible (of which contributive: 83-see further) papers; at the same time, additionally, we have enhanced our documentation-basically, but not exclusively, for the introductive part of this work (see further)-with bibliographic resources, overall connected to our subject, identified in the literature within a non-standardized search. It appears that the opportunity window for morph-functional recovery after stroke is larger than previously thought, actually being considered that brain neurorestoration/repair could occur, and therefore be expected, in later stages than in earlier ones, although, in this context, the number of cases possibly benefitting (for instance after physical and/or cognitive rehabilitation-including with magnetic or direct current transcranial stimulation) is quite small and with more or less conflicting, related outcomes, in the literature. Moreover, applying especially high intense, solicitating, rehabilitation interventions, in early stages post (including ischemic) stroke could even worsen the functional evolution. Accordingly, for clarifications and validation of more unitary points of view, continuing and boosting research efforts in this complex, interdisciplinary domain, is necessary. Until finding (if ever) effective modalities to cure the lesions of the central nervous system (CNS)-including post ischemic stroke-it is reasonable and recommendable-based on rigorous methodologies-the avail of combined ways: physiatric, pharmacologic, possibly also bio-technologic. On a different note, but however connected to our subject: periodic related systematic, synthetic literature reviews reappraisals are warranted and welcome.

Evaluation of quality of life in individuals with chronic stroke who underwent aquatic exercises: A case series

BACKGROUND

Aquatic exercises are among the treatments available to improve the quality of life after stroke.

OBJECTIVES

To investigate changes in the quality of life after 8-week of aquatic exercises in post-stroke individuals.

METHODS

A case series study was designed, including four male participants. Exclusive aquatic exercise was performed for 8-week, 50 minutes per session, 2×/week. Their quality of life was evaluated before and after the intervention using the Stroke Impact Scale (SIS).

RESULTS

Participant 1 improved in the mobility domain, achieving a Clinically Important Difference (CID). Participant 2 improved in the strength and mobility domain, achieving CID; his stroke recovery was 6%, and it reached 50% post-intervention. Participant 3 improved in the mobility domain, achieving a CID and a Minimal Detectable Change (MDC); his stroke recovery increased from 45 to 60% post-intervention. Participant 4 improved the strength, mobility, and activities of daily living domains, achieving a CID and a MDC, but his stroke recovery remained unchanged at 80%.

CONCLUSIONS

All participants achieved a CID in the mobility domain; thus, the aquatic exercise intervention was considered meaningful. Moreover, the SIS is able to evaluate aspects of the recovery process regarding health-related quality of life after stroke, as demonstrated by the results of the overall recovery after aquatic exercises.

Monitoring Dysfunction after Stroke Sequelae in Patients undergoing Hydro-/ Thermo-/ Kinesio-Therapy

Stroke is an important health problem generating a set of musculoskeletal and cognitive consequences that significantly affect the patient’s clinical-functional status and quality of life, as well as the effectiveness of the recovery treatment. Hydro-/ thermo-/ kinesio-therapy with water from Lake Techirghiol, known for its special properties, is also used for patients with neurological disorders and consists in immersing the patient in the therapeutic pool with specific exercises under the strict supervision of specialized medical staff. The aim of this study is to analyze the effects of Lake Techirghiol water on the functional deficit in patients with post-stroke sequelae. In this sense, 200 patients who were hospitalized in the Balneal Rehabilitation Sanatorium of Techirghiol, Constanta County, Romania during 2018-2020 were included in the study and they were divided into two groups: patients from group 1 performed on a daily basis, for 12 days, hydro-/ thermo-/ kinesiotherapy and other physical-kinetic procedures, and the patients from group 2 performed on a daily basis, for 12 days, only physical-kinetic procedures, without hydro-/ thermo-/ kinesio-therapy. Patients’ assessment was made based on the Functional Independence Measure scale and a better evolution was observed in the patients who performed hydro-/ thermo-/ kinesio-therapy as compared to those who did not perform this procedure, in the sense of a diminution of the functional deficit by making self-service activities easier and by improving gait disorders and transfers. We consider appropriate that we extend the period of patients’ treatment and follow-up in our next research so as to highlight, if relevant, any notable changes in terms of increasing functional independence also in the case of patients undergoing land-based kinesiotherapy.

Hydrotherapy Intervention for Patients Following Total Knee Arthroplasty: A Systematic Review

Background Hydrotherapy or aquatic exercise has long been known as a source of postoperative rehabilitation proposed in routine clinical practice. However, the effect on clinical outcome as well as the optimal timing of hydrotherapy in patients undergoing total knee arthroplasty (TKA) remain unclear. The purpose of this review was to assess the influence of aquatic physiotherapy on clinical outcomes and evaluate the role of the timing of aquatic-therapy for clinical outcomes after undergoing TKA.

Methods An extensive literature search was performed in Embase, PubMed, and the Cochrane Library for randomized controlled trials (RCTs) that evaluated the impact of hydrotherapy on patients after TKA. The methodological quality of the trials was evaluated based on the Cochrane Risk of Bias Tool.

Results All available studies on postoperative hydrotherapy after TKA were included. The primary endpoint was to evaluate the effect of hydrotherapy on clinical outcomes. The secondary outcome was to explore the role of the timing of aquatic therapy for clinical outcomes following TKA.

Conclusion Although definitive conclusions could not be reached due to insufficient data, most studies indicated that participants benefited from aquatic-therapy in muscle strength, rather than gait speed, after TKA. Currently available data demonstrated that early postoperative hydrotherapy possessed a greater potential to improve clinical outcomes in main clinical scores and quality-adjusted life years (QALYs).