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Three Part Question

In [adults with rheumatoid arthritis] does [more than six sessions of hydrotherapy, instead of just six, have a greater effect] on [reducing pain and increasing function]

Clinical Scenario

A 56 year old female with a diagnosis of rheumatoid arthritis has benefited from a course of 6 hydrotherapy sessions. She asks if she should have some more. You wonder if there is any evidence to support the number of sessions provided.

Search Strategy

MEDLINE 1966-01/05, CINAHL 1982-01/05, AMED 1985-01/05, EMBASE 1996-01/05, via Dialog Datastar. In addition the Cochrane database and PEDro database were also searched.
[rheumatoid adj arthritis] AND [hydrotherapy OR balneotherapy OR aquatherapy OR exercise in water OR remedial therapy OR balneology]. LIMIT to human AND English language.

Search Outcome

105 articles were retrieved of which 3 were relevant to the 3 part question.
A Cochrane review on Balneotherapy for Rheumatoid Arthritis was found but not appropriate for our 3 part question. One of the papers cited in the review (Hall et al 1996) has been critically appraised and included in our evidence.
The articles came from Physiotherapy Canada, Journal of Rheumatology and Arthritis Care Research.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Sanford- Smith et al, 1998, Canada	24 subjects 30-80 years old with RA	Randomized controlled trial	Treadmill stress test	Increased time on treadmill and peak work load	No sample size estimates were made, wide age range of both patient groups even though these were comparable at baseline. Not conclusive as to whether hydro is more beneficial than range of movement exercise class, additional study in this area is needed
			HAQ (Health Assessment Questionaire)	Improved HAQ score in all 8 categories
			AJC(Active Joint Count)	Decreased number of joints active, no particular pattern of improvement of weight bearing versus nonweight bearing joints
			ESR	Decreased values post aquaaerobics
			Grip strength	Increase in grip strength
Hall J et al. June 1996, Britain	139 patients with Rheumatoid Arthritis	RCT	Grip strength, wrist range of movement, duration of morning stiffness, CRP levels	No significant improvement in any subjects	10 outcome measures were used and so this makes the results section including the tables appear complex.
			Ritchie Index	Significant reduction in joint tenderness in number of tender joints
Bilberg A et al, 2005, sweden	46 patients with chronic Rheumatoid Arthritis	Randomized Controlled Trial	Aerobic Capacity	No significant improvement	Small sample size More women than men Too many outcome measures
			Physical component of the SF- 36	Patients perception of physical function improved significantly.This could be due to time spent with physiotherapist

Comment(s)

From the 3 articles appraised, all patients who received hydrotherapy improved in physical or emotional measurements. However the three articles differ in the length of hydrotherapy given from twice weekly over4 weeks to twice weekly over 12 weeks, therefore no clarification can be obtained as to the optimum number of hydrotherapy sessions needed before a patient can achieve clinical improvement.

Clinical Bottom Line

There is no current evidence available to counter the current use of six sessions of hydrotherapy.

References

1. Sanford-Smith S, Mackay-Lyons M, Nunes-Clement S. Therapeutic benefit of aquaerobics for individuals with Rheumatoid Arthritis. Physiotherapy Canada Winter 1998 p40-46.
2. Hall J, Skevington S, Maddison P and Chapman K. A Randomized and Controlled Trial of Hydrotherapy in Rheumatoid Arthritis. American College of Rhematology June 1996 p206-215.
3. Bilberg A, Ahlmen M, Mannerkorpi K. Moderately intensive exercise in a temperate pool for patients for patients with RA: A RCT. Rheumatology 2005 p502-508.