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Aims. The study aims to compare changes over time among three study groups on the primary outcome, pain, as well as on the
secondary outcomes, other symptoms, activities of daily living function, sport and recreation function, knee-related quality of
life, knee range of motions and the six-minute walk test and to investigate whether aquatic exercises would be superior
compared with land exercise on pain reduction.
Background. Osteoarthritis is a prevalent musculoskeletal disorder. Appropriate exercise may prevent osteoarthritis-associated
disabilities and increase life quality. To date, research that compares the effects of different types of exercise for knee osteoarthritis has been limited.
Design. The study is a randomised trial.
Methods. Eighty-four participants with knee osteoarthritis were recruited from local community centres. Participants were
randomly assigned to the control, aquatic or land-based exercise group. Exercise in both groups ran for 60 minutes, three times
a week for 12 weeks. Data were collected at baseline, week 6 and week 12 during 20062007. The instruments included the
Knee Injury and Osteoarthritis Outcome Score, a standard plastic goniometer and the six-minute walk test. Generalised
estimation equations were used to compare changes over time among groups for key outcomes.
Results. Results showed statistically significant group-by-time interactions in pain, symptoms, sport/recreation and knee-related
quality of life dimensions of Knee Injury and Osteoarthritis Outcome Score, knee range of motions and the six-minute walk test.
However, the aquatic group did not show any significant difference from the land group at both weeks 12 and 6.
Conclusions. Both aquatic and land-based exercise programmes are effective in reducing pain, improving knee range of
motions, six-minute walk test and knee-related quality of life in people with knee osteoarthritis. The aquatic exercise is not
superior to land-based exercise in pain reduction.
Relevance to clinical practice. Similar outcomes could be possible with the two programmes. Health care professionals
may consider suggesting well-designed aquatic or land-based exercise classes for patients with osteoarthritis, based on their
preferences and convenience.
Key words: clinical research, exercise, knee osteoarthritis, nurses, nursing, rehabilitation
Accepted for publication: 24 November 2010
2609
Introduction
Osteoarthritis (OA) is the most prevalent rheumatic disease
and affects older adult populations worldwide (Dawson
et al. 2004), and knees are the most commonly affected
joints. In the USA alone, it has been estimated that
93 million adults in 2005 had symptomatic knee OA
(American Academy of Orthopaedic Surgeons 2008a). Pain,
loss of function and a reduction in quality of life are often
associated with knee OA (Dawson et al. 2004, Williams &
Spector 2006). Globally, knee OA alone is expected to be
the fourth and eighth principle cause of disability in women
and men, respectively (Williams & Spector 2006). This
chronic and disabling condition not only diminishes individual quality of life but also exhausts considerable health
care resources and results in societal costs. The burden of
OA is likely to augment with an ageing population. In
Taiwan, OA is the second most common chronic disease
among older adults. For 2002, the burden of OA in
disability-adjusted life years was 34,150 person years (Office
of Statistics, Republic of China Department of Health
2004).
Studies (Fransen et al. 2001, Smidt et al. 2005) have
shown that exercises seem to improve activities of daily
living (ADL) and reduce pain in patients with knee OA.
Therapeutic exercise is recommended in recent guidelines
as a non-pharmacological treatment for symptomatic knee
OA (Zhang et al. 2005, Misso et al. 2008, Zhang et al.
2008, American Academy of Orthopaedic Surgeons 2008b).
However, the most favourable exercise for specific joint
impairments has not yet been identified (Fransen et al.
2001, Smidt et al. 2005). Knowledge of the effects of
different types of exercise for OA is essential to health care
professionals when making evidence-based recommendations and for patients with OA when making informed
choices.
Background
The Cochrane group (Fransen et al. 2001) systematically
reviewed and combined the study results of 17 OA exercise
studies (a total of 2562 participants). They found that landbased exercise had a small-to-moderate beneficial effect
on pain (SMD = 039; 95% CI = 030047) and on selfreported physical function (Fransen et al. 2001) (SMD 031;
95% CI = 023039) for people with symptomatic OA of
the knee. However, because of great variability in the
contents of these exercise programmes, the reviewers could
not come up with specific recommendations regarding an
optimal dosage or specific types of exercise for knee OA.
2610
Clinical issues
Methods
Design
The study is a randomised trial. After informed consent and a
pretest, participants were randomly assigned to the control,
aquatic or land-based exercise group. A simple randomisation method was used. A research assistant who was not
recruiting participants carried out the allocation sequence by
using a computer-generated random number list. There were
two small groups in each of the exercise programmes with the
starting dates being staggered three months apart. Exercise
classes in both exercise programmes ran for 60 minutes,
three days a week on alternative days for 12 weeks. Data
were collected at baseline, week 6 and week 12 during 2006
2007.
Sample size
Sample size was estimated using G*power software (version
2.0) (Buchner et al. 1997, Faul et al. 2007) for three repeated
measures, within and between interaction among three
groups, a significant level at 005, a small-to-moderate effect
size (f = 020), correlations of 050 and power of 80%. A
sample size of 18 per group would be required for analysing
exercise effects on the primary outcome, the pain dimension
Study interventions
Aquatic exercise programme
A standardised aquatic exercise protocol was developed
based on the Arthritis Foundation Aquatics Program (AFAP)
instructors manual (Arthritis Foundation 2002). The main
components of the programme include a 60-minute flexibility
and aerobic training class, three times a week for 12 weeks.
The exercise training focuses on joint in the trunk, shoulders,
arms and legs and emphasises the muscle groups of the upper
and lower limbs as well as balance and coordination. The
mechanisms for fitness training involve changes in speed,
surface area, direction of movement and turbulence in water
to increase the exercise resistance and to create intensity
variation. A trained exercise instructor taught the group
classes at the public swimming pools of the Taipei City Beitou
Sports Centre, Taipei. Pool temperatures were maintained at
30 C (86 F). The details of the programme were described
in the Wang et al. (2007) study.
Land-based exercise programme
A standardised land-based exercise protocol was developed
based on the People with Arthritis Can Exercise (PACE)
programme instructors manual (Arthritis Foundation 1999).
The main components of the programme include a 60-minute
flexibility and aerobic training class, three times a week for
12 weeks. The exercise training focuses on joints in the trunk,
shoulders, arms and legs and emphasises the muscle groups of
the upper and lower limbs as well as balance and coordination. The exercises for each section are summarised in Table 1.
To assure safe performance of the exercise, the classes include
instruction about basic principles of arthritis exercise, correct
body mechanics and joint protection. Movement against
gravity and variations in speed, level of leg or arm raising, or
moving both extremities simultaneously were used to create
different levels of training intensity. The average number of
repetitions for each exercise begins with 10 and gradually
increases to 15. Classes were taught to a group of participants
by the trained instructor at the indoor basketball court of
Taipei City Beitou Sports Centre, Taipei, ROC.
Participants in both groups monitored their own exercise
intensity using the Borg CR10 scale (Borg 1998). On a scale
of 010, participants maintained their perceived exertion at
levels 3 (moderate) 4 (somewhat strong). The exercise
instructors in both programmes took class attendance
and monitored potential adverse effects of the exercise
2611
Land-based exercises
Focus (duration)
Types of exercise
Warm-up
(5 minutes)
Warm-up
Walk, march and sidestep with
(5 minutes)
variations in movement
directions, arm movements, and
by alternatively lifting the bent
knee or lifting the straight leg like
a toy soldier.
Twenty-four sets of stretching and Upper body training
(10 minutes)
flexibility exercises in neck,
trunk, shoulders and pelvic area,
with 1015 repetitions for each
exercise.
Repeat walk moves, as done in the Lower body training
(10 minutes)
warm-up section, for 5 minutes
and then move in place for an
other 5 minutes, including
alternatively moving heels, feet
and legs in side steps, forwards
and backwards, concurrent with
arm movements.
Flexibility training
(10 minutes)
Aerobic training
(10 minutes)
Cool down
(5 minutes)
Focus (duration)
Flexibility training
Exercise by using the wall for
(10 minutes)
support, including 17 sets of
exercises in hips, knees, ankles
and toes, with 1015 repetitions
of each exercise.
Examples of the 17 sets of the
exercises include forward kick,
side leg lift, hamstring curl,
buttocks squeeze, kick out, leg
lift, small squats, toes in and toes
out, Flamingo, crossovers, leg
circles, side to side weight shift,
front lunge weight shift, push
away, point/flex toes, heel-toe lift,
ankle circles, inversion/ eversion
and toe curls.
Twelve sets of exercises for arms, Aerobic training
elbows, wrists, hands and fingers, (10 minutes)
with 1015 repetitions of each
exercise.
Cool down
(5 minutes)
Types of exercise
Joint check, deep breathing instruction, gentle
muscle stretches, as well as gentle endurance
exercises including walk, march and sidestep, with
variations in moving directions, arm movements.
Joint check = seven manoeuvres including using hands to touch mouth, leg, upper buttocks, back, top of the head, behind the neck and make a
fist to quick assess mobility of neck, back, spine, upper and lower extremities.
2612
Clinical issues
Data collection
Pain is one of the most common complaints and disabling
symptoms in OA populations. Pain reduction is one of the
most important goals of OA management. Therefore pain
dimension of the KOOS was selected as the primary outcome
measure in the study for testing and comparing the efficacies
of the exercise programmes. Other dimensions of OA-specific
health-related quality of life, knee ROMs and timed walk
distance were also important for assessing efficacy of exercise
interventions and were measured as the secondary outcomes
of the study. Questions on demographics and disease
variables were also included in the study questionnaire. Five
blinded outcome assessors who were nursing students, using
standardised instructions, collected data on the 10-page selfreport questionnaire as well as physical measures. To be
consistent, these outcome measurements were carried out in
the following order for each participant: questionnaire, knee
ROM tests and the 6MWT.
KOOS construct validity has been determined in comparison with the Medical Outcomes Study (MOS) 36 shortform Health Survey (SF-36) (Roos et al. 1998, Roos &
Toksvig-Larsen 2003). Cronbachs alpha coefficient for the
KOOS was 088 in current study.
Goniometer
The knee ROMs were measured using a standard plastic
goniometer. The measurement positions and technique followed the Norkinn and White (1985) protocol. Two repeated
measurement trials for active ROMs of knee extension and
flexion were taken consecutively. The mean of two repeated
measurements was used for analysis. Good testretest reliabilities were reported as r = 096099 in the Wang et al.
(2007) study. The baseline data of the two consecutive ROM
measures had correlation coefficients of 078097, which
indicate good testretest reliability (Table 2).
6MWT
The 6MWT was used to measure the distance that participants can walk within six minutes on level ground. Details of
the 6MWT procedure were presented in the Wang et al.
(2007). To avoid potential learning effects, a separate practice session of the 6MWT was conducted a day before the
baseline measures. During the test, all participants walked
independently without using walking aids. Good testretest
reliabilities were reported in previous studies, as the ICCs =
094 and r = 091 for the Montgomery and Gardner (1998)
and Rejeski et al. (2000) studies, respectively. The correlation
coefficient during practice section was 085 for the current
study.
Ethical considerations
Ethics committee approval was obtained from a nursing
college (NTCNIRB number: 94A032). Each participant
Table 2 Testretest reliabilities, errors of measurement and coefficient of variation for knee ROM tests
Variables
ROMs ()
Knee extension
Left
Right
Knee flexion
Left
Right
Person correlation
ME
CV
0855***
0784***
067
075
173
205
0964***
0966***
046
169
04
13
2613
Data analysis
All statistical analyses were carried out using the SPSS
statistical package version 17.0 (SPSS Inc., Chicago, IL,
USA). MannWhitney U tests and chi-square tests were used
to test differences between completers and non-completers in
Excluded (n = 153)
Not meeting inclusion criteria (n = 88)
Refused to participate (n = 65)
Enrollment
Allocation
Lost to follow (n = 1)
[due to having a herpes flare-up
(n = 1)]
Discontinued intervention (n = 0)
Lost to follow-up (n = 2)
[due to travel (n = 1)]
Discontinued intervention (n = 0)
Analysis
Analysed (n = 26)
Excluded from analysis (n = 2)
[due to lost to follow-up]
Allocated to control
group (n = 28)
Lost to follow-up (n = 1)
[due to other obligations
(n = 1)]
Lost to follow-up (n = 2)
[due to other obligations
(n = 1); admit to a hospital
for treating pneumonia
(n = 2)]
Analysed (n = 26)
Excluded from analysis (n = 2)
[due to lost to follow-up]
Analysed (n = 26)
Excluded from analysis
(n = 2) [due to lost to
follow-up]
Figure 1 Flow diagram of the progress of the study (enrolment, intervention allocation, follow-up and data analysis).
2614
Clinical issues
Results
Demographics and baseline equivalence
Eighty-four adults with knee OA were recruited over
six months. Seven participants dropped out of the study,
including two in the aquatic group, two in the land-based
group and two in the control group (Fig. 1). The dropout rate
was about 7%. This left 78 valid cases, with 26 cases in each
of the three groups. There were no differences in demographics, BMI, disease severity or outcome variables between
Variables
Demographics
Age (mean SD)
Sex [f (%)]
Female
Male
Education [f (%)]
Primary school and below
Middle to high school
College and above
Living arrangement [f (%)]
Alone
With family
With friends or room-mates
Current employment status [f (%)]
Employed part time
Homemaker
Retired
Other
Individual monthly income
<10,000
10,00019,999
20,00029,999
30,00039,999
40,00049,999
50,00059,999
Body mass index
Disease variables [mean (SD)]
Years diagnosed with osteoarthritis
Number of joints tendered
Number of joints swollen
Number of comorbid conditions
Total
(n = 78)
Aquatic (n = 26)
Land (n = 26)
Control (n = 26)
v2/F
677 59
667 56
683 64
679 59
0495
0612
67 (859)
11 (141)
22 (846)
4 (154)
23 (885)
3 (115)
22 (846)
4 (154)
0212
0900
32 (410)
25 (321)
21 (269)
12 (462)
6 (231)
8 (308)
10 (385)
10 (385)
6 (231)
10 (385)
9 (346)
7 (269)
1576
0813
11 (141)
64 (821)
3 (38)
2 (77)
23 (885)
1 (38)
5 (192)
21 (808)
0
4 (154)
20 (769)
2 (77)
349
0479
2 (26)
32 (410)
42 (538)
2 (26)
1 (39)
11 (422)
13 (500)
1 (39)
0
11 (400)
14 (560)
1 (40)
1 (38)
10 (385)
15 (577)
0
2205
0900
41 (526)
14 (179)
10 (128)
5 (64)
3 (38)
5 (64)
262 (24)
15 (576)
4 (154)
2 (77)
3 (115)
1 (39)
1 (39)
266 (25)
14 (538)
4 (154)
5 (192)
0
0
3 (115)
254 (24)
12 (462)
6 (231)
3 (115)
2 (77)
2 (77)
1 (38)
266 (208)
0286
0991
2205
0117
0140
1731
0951
0627
0870
0184
0391
0537
68
32
18
10
(64)
(21)
(20)
(10)
71
33
15
10
(63)
(23)
(16)
(10)
70
38
22
08
(74)
(21)
(22)
(09)
SD, standard deviation; f (%), frequency (percentage); v2, value of chi-square; F, value of one-way
62
27
17
11
(54)
(18)
(20)
(11)
ANOVA .
2615
Variables
KOOS (0100)
Pain
Symptoms
ADL
Sport/recreation
QOL
ROM ()
Knee extension
Knee flexion
6MWT
Aquatic (n = 26)
Land (n = 26)
Control (n = 26)
Time
Mean
SD
Mean
SD
Mean
SD
Baseline
Week 6
Week 12
Baseline
Week 6
Week 12
Baseline
Week 6
Week 12
Baseline
Week 6
Week 12
Baseline
Week 6
Week 12
61
70
72
62
66
69
73
75
76
59
64
70
67
70
73
20
19
18
20
20
20
20
18
16
22
22
20
13
13
12
65
72
76
63
67
71
75
79
82
62
65
68
66
71
74
14
15
15
15
16
16
16
15
14
17
16
17
11
11
11
66
67
68
63
61
61
70
70
69
60
59
57
68
67
67
18
19
18
18
17
17
19
19
18
20
20
20
13
14
13
0584
0521
1517
0041
0817
2325
0405
1607
3954*
0096
0577
3220*
0201
0485
2740
0560
0596
0226
0960
0445
0105
0668
0207
0023
0908
0564
0046
0818
0618
0071
Baseline
Week 6
Week 12
Baseline
Week 6
Week 12
Baseline
Week 6
Week 12
37
27
24
1219
1234
1250
3309
3682
3860
13
12
22
37
42
42
765
713
758
37
27
20
1222
1239
1250
3398
3518
3810
12
12
14
57
55
61
727
776
704
34
34
33
1217
1218
1223
3215
3250
3291
12
12
11
51
51
56
858
834
823
0564
3249*
4292*
0073
1266
2124
0353
2053
4436*
0571
0044
0017
0929
0288
0127
0703
0135
0015
*p < 005.
df (2, 75).
The ROM of knee extension was measured by how many degrees of an extended knee close to a straight position (zero degree). A greater degree
represents a worse extension ability, while a zero degree represents the best extension.
KOOS, Knee Injury and Osteoarthritis Outcome Score (KOOS is 0100 points, worst to best); ADL, activity of daily living; QOL, knee-related
quality of life; ROM, range of motion; 6MWT, six-minute walk test.
Clinical issues
Table 5 Generalised linear model on the effect of pain, disease-specific symptoms, ADL, sport/recreation function and QOL measured with
KOOS (n = 78)
Pain
Variables
Group
Aquatic vs. control
Land vs. control
Time
Week 12 vs. baseline
Week 6 vs. baseline
Group time
Aquatic at week 12
vs. control at baseline
Aquatic at week 6 vs.
control at baseline
Land at week 12 vs.
control at baseline
Land at week 6 vs.
control at baseline
Symptoms
SE
ADL
SE
Sport/recreation
SE
SE
QOL
SE
499
109
482
482
0301
0820
118
009
491
491
0811
0986
212
466
486 0662
486 0337
123
119
539
539
0819
0825
109
216
345
345
0752
0531
120
091
135
135
0372
0497
226
221
179
179
0208
0217
143
028
186 0440
186 0880
311
125
209
209
0137
0551
146
097
153
153
0341
0529
484
712** 217
0001
574*
243
263 0356
0074
602** 190
592*
0002
254
254
0024
0019
296
0062
388
962** 296
0001
404
429
0147
536*
263 0125
552
296
217
217
0014
Discussion
Study limitations
The study design had several limitations. First, the study
participants were recruited from local community centres and
2617
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
Figure 2 Changes in pain, disease-specific symptoms, activities of daily living, sport/recreation function, knee-related quality of life, knee range
of motion and walk distance over time at baseline and during exercise (week 6) and post-test (week 12). The data are shown as mean 95%
confidence interval (error bars). (a) Changes in pain over time. (b) Changes in disease-specific symptoms over time. (c) Changes in activities of
daily living over time. (d) Changes in sport/recreation function over time. (e) Changes in knee-related quality of life over time. (f) Changes in
range of motion (ROM) of knee extension over time. (g) Changes in ROM of knee flexion over time. (h) Changes in six-minute walk distance
over time.
Clinical issues
Pain
Variables
SE
Group
Aquatic vs. land
Time
Week 12 vs. baseline
Week 6 vs. baseline
Group time
Aquatic at week 12 vs.
land at baseline
Aquatic at week 6 vs.
land at baseline
389
472
0409
105***
69***
154
154
<0001
<0001
055
218
0801
188
218
0389
Table 7 Generalised linear model on the effect of knee ROM and six-minute walk distance (n = 78)
Knee extension
Variables
Group
Aquatic vs. control
Land vs. control
Time
Week 12 vs. baseline
Week 6 vs. baseline
Group time
Aquatic at week 12 vs.
control at baseline
Aquatic at week 6 vs.
control at baseline
Land at week 12 vs.
control at baseline
Land at week 6 vs.
control at baseline
Knee flexion
SE
6MWT
SE
SE
034
029
038
038
0376
0449
022
052
141
141
0875
0712
941
1831
2149
2149
0662
0394
006
006
022
022
0785
0798
063
007
036
036
0083
0852
758
352
789
789
0337
0655
125***
031
<0001
245***
051
<0001
4756***
1117
<0001
110***
031
<0001
139**
051
0007
3379**
1117
0002
158***
031
<0001
212***
051
<0001
3356**
1117
0003
097**
031
0002
156**
051
0002
842*
1117
0450
2619
Acknowledgements
The authors thank all the participants in this study and the
staff of Taipei City Beitou Sports Center. The study is
supported by the funding of the National Science Council of
Republic of China (NSC, 94-2314-B-227-005).
Contributions
Conclusion
Many previous studies have compared one exercise programme group with one control group and have concluded
that there is a difference, but there is no indication of how the
programme compares with other exercise programmes. Our
study compared two popular community-based exercise
programmes. The study results show that both aquatic and
2620
Conflict of interest
The authors declare that they have no conflict of interests.
Clinical issues
References
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The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of
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For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http://
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2622