ࡱ> q 3bjbjt+t+ fQAA]llll8,4($ $ : N + LNNNNNN$}qFr; " ; ; rll$ : e; b l8$ : Lllll; Lv b 1E L: 0v 3. Results 3.1 Introduction When the studies searched for were retrieved, and data collection from the included studies was done, comparisons of the studies could start. These comparisons helped to conduct the analysis and the summary of the data collected, in order to answer the main question of this review. In the light of the main question and the data collected, the comparisons important to make and presumably possible to answer, were: Comparing short term vs long term treatment. Comparing high frequency vs low frequency treatment. Comparing the effects of land based exercise therapy vs aquatic therapy. Comparing aquatic therapy vs immersion alone. Comparing short term effect vs long term effects. Comparing aquatic therapy effects on OA vs RA vs AS. This chapter consists of; an introduction part presenting the studies retrieved, with a description of the participants, interventions and outcome measures used; a methodological part describing the quality of the included studies; and a final part where the results are presented. 3.1.1 Description of studies found In total 25 studies were retrieved at Niwi (Nederlands Instituut voor Weetenschaapelijke Informatiediensten) after the literature search. During the data collection, 13 of the 25 studies retrieved, proved not to fulfil one or more of the eligibility criteria and were excluded from this review. These studies are listed here with the justification for their exclusion. Alexander 2001 (13) Missing relevant outcome measures.Danneskiold-Samse 1987 (14) Not a controlled trial.Elkayam 1991 (15)Not an active treatment.Gowans 1999(16)Aquatic therapy is not the intervention in focusHill 1997 (17) Not an active treatment.Lineker 2000 (18)Not a controlled trial.Melton-Rogers 1996 (19)Not a controlled trial.Meyer 1994 (20)Not a controlled trial.Patrick 2000 (21) Missing relevant outcome measures.Sukenik 1999 (22)Not an active treatment.Templeton 1996 (23)Not a controlled trial.Tishler 1995 (24)Not an active treatment.Wigler 1995 (25)Not an active treatment. The 12 remaining studies meeting the eligibility criteria are displayed and described more thoroughly in table 3.1. In addition, two studies, Van Tubergen (2001) and Wyatt (2001), could not be retrieved as the issues from the journals they were published in were not yet available at the libraries that kept these journals. 10 of the included studies are randomised controlled trials and two studies, are controlled clinical trials (2,10). Year of publishing ranged from 1978 (2) to 2000 (11). All included studiess are published in English language. Table 3.1 displays the data characteristics of the included studies, describing the design, participants, interventions, outcomes and authors conclusions. Relevant data not mentioned in this table, was not mentioned in the studies. Table 3.1: Characteristics of included studies: StudyDesignParticipantsInterventionOutcomesAuthors ConclusionNguyen (1997) RCT, Gr1.AT, Gr2. ControlN = 188 (OA)3 weeks. daily -Pain (VAS) improved significantly at end of treatment and maintained at 6 month follow up for AT-group. Quality of life, (AIMS2) improved significantly in AT-group. -3 weeks of AT has prolonged beneficial, symptomatic effects in OA. Hall et al (1996) RCT, Gr1.AT, Gr2. Immersion , Gr3. Land ex., Gr4. Relaxation N =139 (RA), age = 58 disease duration 11 yrs. 30 min. sessions, 2 times a week, for 4 weeks.-Joint tenderness (RAI) improved significantly in all patients pre to post test. Gr.1 improved most. Maintained in gr.3 at follow up. All subjects significantly improved physical capacity and mood and tension (AIMS2) at post test and at follow up. The AT group showed greatest reduction. Although all treatment forms had some effect AT produced the greatest improvements. This study provides some justification for the continued use of AT. Ahern (1995) RCT- 2 phases: 4-day & 6 weeks Gr1. AT Gr2. Control N =72 (RA or OA) age = 67, Disease duration: 9,4 yrs. Phase1: 30 min / day for 4 days. Phase 2: 2x / week for 6 weeks-Pain/stiffness (VAS) , improved significantly over time, with greater improvement for RA than for OA -Function (Time to climb 4 steps, and to walk 25 m): non- significant improvements. The results suggest that AT has beneficial effects in patients with RA and OA through improvements in self-efficacy. Hansen (1993) RCT, Gr1.ET, Gr2. Gr-ex. in ph.prct., gr3. Gr-ex, Gr4.Gr-ex+ AT, Gr5 .ControlN = 65 (RA ARA criteria), age = 52 Daily exercises, min.3 x/ week, max.90 min/ day or 330 min/week , over 2 years. No statistically significant effects of the training on any of the measured variables (morning stiffness, joint pain, number of swollen joints, aerobic fitness, or muscle strength). Although most patients are in favour of training, the results of this study does not support that training lessons per se affect the disease activity or the progression of the disease.Green (1993) RCT, gr1. Home -ex, Gr2. Home-ex + ATN = 47 (OA of the hip) age = 66 -2 times a week-No scores mentioned for pain, ADL or quality of life.Home exercise is beneficial, AT is of no added value. Suomi (2000) RCT Gr1.AT Gr2. Control N = 24 (lower limb arthritis, RA or OA), age = 57, disease duration; 20 years. 45 min sessions, 3 x/week, for 6 weeks. Lateral and total sway areas with eyes open was significantly improved in hydrotherapy group. AT increased postural stability in women with lower extremity arthritis Minor (1989) RCT, Gr1. Aerobic walk walk,Gr2.AT, Gr3.ROM ex. N = 96 (RA or OA), age = 59, Duration disease: 12,7 yrs.60 min 3x/ week for 12 weeks.Pain (AIMS) improved significantly in gr.1 and gr.3. Social activity did not improve. Depression and anxiety improved significantly in gr.1 and 2. At 9 months follow up the AT-group showed significant improvement in physical self-concept, pain and morning stiffness. The findings document the feasibility and efficacy of conditioning exercise for people who have rheumatoid arthritis or osteoarthritis Table 3.1: Characteristics of included studies StudyDesignParticipantsInterventionOutcomesAuthors ConclusionSmith (1998) RCT Gr1.AT Gr2. ROM ex. N = 24 (RA), age = 58 Duration of disease: 20 yearsGr1.60 min 3x /week for 10 wks.Gr2. ROM ex.. 2-3 times a dayFunctional status, measured with HAQ score, showed no significant differences between the groups. Significant improvement over time in exercise tolerance in both groups. -Participation in either intervention may result in reduction in joint activity and improvement in exercise tolerance. The ROM ex group scored significantly higher in selfreported walking ability and total HAQ score.Sylvester (1989) RCT Gr1.AT Gr2. SWD and ET.N = 14 (OA of the hip), age = 66, Duration of diagnosis; 2-8 years. 30 min sessions, 2 times a week, for 6 weeks.Pain ( VAS), decreased significantly in both groups across time. ADL (Owestry Low Back Pain Disability Questionnaire), improved significantly for AT-group over time. Gait (pedabarograph), showed a nonsignificant increase in vertical force and stance time for both groups. The AT group improved in functional ability and reported a higher score on the Life Satisfaction Scale. Pain improved in both groups at post testing.  Stenstrom (1991) CT Gr1.AT Gr2. ET.N = 60 (functional class II RA), age = 54, disease duration; 13 yrs. -40 min ses-sions, 1x/ week over 4 yearsJoint tenderness (RAI), no significant differences between the groups. Pain (VAS during 7 functional tests), showed no significant differences between the groups. The AT group improved significantly in grip strength and activity level. Maintained at 2 year follow up. Intensive exercising does not lead to any undesirable consequences. Helliwell (1996) RCT, Gr 1. In patient AT, Gr 2. Outpatient AT + home- ex, Gr3. Home-exN = 44 (AS) Gr1. 3 weeks AT 3x /week + 1 h group-ex. 5x /week.Gr2. 6 weeks AT 2x /week + home ex. 2x /day. Gr3. 6 weeks.Pain (VAS) improved across time at post test for both AT-groups. No improvements were maintained at follow up.The AT regimes produced significantly better short-term improvement in cervical rotation than the exercise only regime, and both in-patient and AT-patients reported more subjective improvement. Baldwin (1978)CT , Crossover design: Gr1. AT, no therapy, home ex. Gr2. Home ex. , no therapy, AT N = 12 (JRA), age = 11 AT: 30 min 1x/ week for 20 weeks. No therapy:9 wks. Home ex.: 30 min / day 20 weeks.Joint tenderness, evaluated on palpation, extreme motion and weight bearing, showed gr.1 improved after hydrotherapy (gr.2 had no improvement after home exercises). The ideal form of physiotherapy for children with JRA should incorporate AT and individual home exercises. All children suffering from JRA should be taught to swim, as this is one field of sport in which they can compete with their peers. Abbreviations: ADL = Activities of daily living; AIMS 2 = Arthritis Impact Measure Scale 2; ARA = American Rheumatism Association; AS = Ankylosing Spondylitis; AT= Aquatic therapy; CT = Controlled trial; Group-ex.= Group exercises; Gr = Groups; HAQ = Health Assessment Questionnaire; JRA = Juvenile Rheumatoid Arthritis; N = number of participants; OA = Osteoarthritis; PH.PRCT = Physical practice; RA = Rheumatoid Arthritis; RAI = Ritchies Articular Index; RCT = Randomized controlled trial; ROM = Range of motion; SWD= Short wave diathermy. 3.1.2 Description of participants Patient population sizes ranges from 12 participants (2) to 188 participants (8). Mean age of the participants ranges from 11 years (2) to 67 years (1). In total, the 12 studies investigates the effect of aquatic therapy on 785 patients. The distribution among the three diagnoses are displayed in figure 3.1.  Figure 3.1: Showing the distribution among the three diagnoses. One study (n=44) deals with ankylosing spondylitis (6). Three studies (n=249) deals only with OA (8,3,12) Five studies (n=300) deals only with RA, (2,4,5,9,10) Three studies (n=192) deals with RA and OA (1,7,11) Description of intervention Four studies, uses no intervention for control groups (1,5,8,11). Other control interventions includes home exercises, aerobic training, range of motion exercises, short wave diathermy, exercise therapy, group training, seated immersion and progressive relaxation in water. Duration of intervention ranges from three weeks (8) to four years (10). Description of outcome measures The chosen outcome measures of interest are pain, ADL-functioning and Health-Related Quality of Life (HRQL). Table 3.2 displays the measurement tools used in the studies found and how many studies they are used in. It also displays which outcome they measured. Table 3.2: Showing outcomes, measurement tools and the number of studies each measurement tool was used. (for description of the measurement tools see table 1.2, 1.3). OUTCOMESMEASUREMENT TOOLSNO. OF STUDIES PainVAS7Descriptive pain scale1Overall change score1Analgesic requirement1Time of relief of articular gelling1Ritchies Articular Index2McGill Pain Questionnaire1Beliefs in Pain Control Questionnaire1Palpation1FunctionAbility to rise from chair1Timed walk up and down a fixed staircase rig2Time and no. Of steps taken to walk a fixed distance 2Stanford Health Assessment Questionnaire (HAQ) 3Owestry Low Back Pain Disability Questionnaire 1Pedabarograph1Kistler Force Platform configuration1Frenchay Activity Index (FAI)1Healh Related Quality of LifeZung self rating depression scale1Middlesex Hospital Questionnaire (MHQ)1Illness Behaviour Questionnaire (IBQ)1Arthritis Self-eficacy Questionnaire1Philadelphia Questionnaire (PQ)1Arthritis Impact measurement scale (AIMS2)3 3.2 Methodological quality of included studies Few of the retrieved studies concerning aquatic therapy score very high on the PEDro scale. The score ranges from score 2 to 6, out of a maximum score of 10 points. The PEDro scores obtained by the 12 included studies are displayed in table 3.3. For further information concerning the PEDro scale see appendix III. Table 3.3: The methodological quality of the studies as measured by the PEDro scale is presented in the table. The studies are listed according to their score on the PEDro scale. 1234567891011SUMNguyen1997Y10100011116/10Hall1996Y11100010116/10Suomi2000Y10100010115/10Green 1993Y11100000115/10Ahern 1995Y11100000115/10Hansen 1993Y10100010115/10Sylvester 1990Y10000000114/10Minor1989Y10100000114/10Smith 1998Y11000000114/10Helliwell1996Y10000000113/10Stenstrom1991N00100010103/10Baldwin1978Y00100000102/10 3.3 Effects of Aquatic therapy on pain 3.3.1 Introduction Of the 12 studies included in this review, three of them do not address pain as an outcome measure (3,9,11). The study by Green (1993) mention several pain measurement tools, but gives no scores for them. Suomi (2000) addresses only postural sway measures, while Smith (1998) focuses on disease activity and exercise tolerance without mentioning pain as an outcome measure. These three studies are therefore not mentioned further in this section regarding the effects of aquatic therapy on pain. The most frequent measurement tool for measuring pain was a 10 mm Visual Analogue Scale, which was used in seven studies. Other tools that were used to measure pain are described in 1.4.1. 3.3.2 Comparing short term vs long term treatment on pain Three studies are considered as investigating long term aquatic therapy treatment ( 2,5,10). All of these studies deal with rheumatoid arthritis. These are the studies of Stenstrom (1991), Hansen (1993) and Baldwin (1978). The duration of their studies was four years, two years and 20 weeks, respectively. Baldwins study deal strictly with children with juvenile rheumatoid arthritis, and can not be compared to any of the other studies, as they all deal with well grown-up adults. However, Baldwin reports a significant across time reduction in joint tenderness after 20 weeks of aquatic therapy, with no improvements for the control group. Both Stenstrom and Hansen report no significant effects of their long term aquatic therapy interventions on pain. None of the included studies deal with long term interventions for osteoarthritis or ankylosing spondylitis. Hall (1996), Helliwell (1996) and Nguyen (1997) study three weeks of aquatic therapy. Helliwells study deals with patients with ankylosing spondylitis. He compares two different aquatic therapy interventions with a home exercise program. Both groups receiving aquatic therapy reduced pain significantly from baseline values to post-testing while the control group had no improvements. Hall reports a significant reduction in joint tenderness and pain in all groups, as measured by Ritchies Articular Index and McGill Pain Questionnaire. He mentions that all four different treatment forms have beneficial effects on joint tenderness, but that the aquatic therapy group improved the most. Nguyen found significant across time and between group improvements in pain at post testing for the aquatic therapy group in the study. The remaining studies investigate effects of aquatic therapy interventions of different durations, from six weeks (1,12) to twelve weeks (7). The two studies with six weeks interventions, gave similar results with regard to pain. Ahern (1995) and Sylvester (1989) report significant improvements over time for the six weeks aquatic therapy groups on a VAS-scale for pain. Minor (1989) finds in her twelve week intervention, that pain, measured by AIMS, decreased in control groups at post testing, but no improvements for the aquatic therapy group. Comparing high frequency vs low frequency treatment on pain Two of the three long term studies (2,10) were the studies with the lowest treatment frequency, with one aquatic therapy session per week. As mentioned in section 3.1.1, Stenstrom (1991) finds no significant improvements on pain in the studies dealing with RA-patients. Baldwin (1978) reports significant improvements in joint tenderness from baseline to post-testing in children with juvenile rheumatoid arthritis. Hall (1996), Helliwell (1996) and Minor (1989) had the highest frequency of treatments, with three sessions per week. Hall reports significant improvements across time at post-testing in joint tenderness and pain for a group of people with RA. Minor finds significant improvements in pain at post-testing for people with OA who participated in an aerobic exercise program ( land-based or aquatic). She states that people with arthritis can exercise to improve fitness without experiencing exacerbation of their symptoms. Helliwell reports significant improvement in pain for two groups of AS-individuals participating in different aquatic therapy groups from baseline to post-testing. Comparing the effects of land based exercise therapy vs aquatic therapy on pain Seven studies compares aquatic therapy with land based exercise therapy (2,4,5,6,7,10,12). The exercise therapy intervention differs among the studies, both in terminology and nature of activity: Sylvester (1989); exercise therapy in combination with short wave diathermy. Hall (1996); land exercises. Baldwin (1978) and Helliwell (1996); home exercises. Minor (1989); Aerobic walk or range-of-motion exercises. Stenstrom (1991); exercise therapy. Hansen (1993); self training, group training in physical practice or group training. Four studies compare aquatic therapy with exercise therapy for people with RA. Of these, Baldwin reports significant reductions in joint tenderness for the aquatic therapy group compared to a home exercise group. Hall states that the greatest measurable improvements can be found in land exercise and aquatic therapy groups, compared to passive land and water based interventions. Stenstrom and Hansen report no differences in pain or joint tenderness between the aquatic groups and the land exercise groups. Sylvester and Minor compares aquatic therapy with land based exercises for people with OA. Minor finds significant improvements in pain measured by AIMS for land exercise control groups at post-testing. Sylvester finds no differences between the groups, but both the land exercise group and the aquatic group improved significantly at post-testing. Helliwell reports significant improvements in pain for individuals with AS participating in an inpatient and outpatient aquatic therapy group at post-testing, compared to a home exercise control group. Comparing aquatic therapy vs immersion alone on pain This comparison is only done by Hall (1996), who measures pain with the Beliefs in Pain Questionnaire (BPCQ) McGill Pain Questionnaire (MPQ) and joint tenderness with Ritchies Articular Index (RAI). She states that both the aquatic therapy group and the immersion group improved significantly over time at post-testing , but that there were no differences between the groups. Comparing short term vs long term effects on pain Five studies includes post-intervention follow-up assessments (1,2,4,6,7). Helliwell (1996) measures pain and stiffness in people with ankylosing spondylitis, using a combined VAS-scale. He states that the significant differences in VAS-scores between groups seen immediately after treatement, were not found at follow up after two, four and six months. Baldwin (1978) reports no maintained improvements for pain or tenderness for people with RA at nine weeks follow up. Hall (1996) measures pain in people with RA using the BPCQ and MPQ, and joint tenderness with the RAI. She states that all patients demonstrated a significant reduction in their evaluative/affective pain at post-testing, but this was not maintained at a three month post assessment. No significant changes in sensory pain occured at any time during this study. Ahern (1995) and Minor (1989) give follow up data for people with OA and RA. Ahern states that four weeks after a four consecutive day aquatic therapy intervention, most variables had returned to pre-treatment values. Another group which continued with aquatic therapy after the initial four days, maintained the initial improvements made throughout a six week period. Minor states that patients in a twelve-week aquatic therapy group, had significantly improved their pain one year after baseline measures were taken. Nguyen (1997) reports maintenance of improvement at 6 months follow up for AT group. Comparing aquatic therapy effects on OA vs RA vs AS on pain In the study of Minor (1989), the OA patients shows better improvement in pain compared to the RA group, measured with the AIMS at measures 12 weeks after baseline. 3.4 Effects of Aquatic therapy on ADL function 3.4.1 Introduction Of the twelve trials included in this study, eight measures ADL function (1,3,4,5,7,9,10,12). Smith (1998), Hansen (1993) and Ahern (1995) are all using the Health Assessment Questionnaire (HAQ). Hall (1996), Minor (1989) and Green (1993) are all using the AIMS. Other measurement tools used are; Ability to rise from a chair and time taken to walk up and down a fixed staircase (3), time and no. of steps taken to walk a fixed distance (3,10), Owestry low back pain disability questionnaire (12). Out of those eight authors, Hall, Sylvester, Minor, and Stenstrom reports a positive effect of aquatic therapy on ADL functioning. Hansen, Ahern and Smith report no significant difference between baseline data and end of treatment. Green does not report any results about ADL even though some conclusions are mentioned. Sylvester and Green studies is on a group of OA patients. Stenstrom, Smith, Hansen and Hall study on groups of RA patients. Ahern and Minor study on a mixed group of OA and RA patients. 3.4.2 Comparing short term vs long term treatment on ADL-functioning The study of Stenstrom (1991) is lasting over a four years treatment period, with treatment one time a week. The aquatic therapy group of people with RA under study reaches a significantly higher level of physical activity than an exercise therapy group over the same period of time. The other functional tests that the author focuses on (buttoning, lifting, leaning forward and rising), show no significant differences between the two groups. The other long term treatment is performed by Hansen (1993), with a two year long study on people with RA with treatment three times a week, of max. 90 min. a day. He sees no statistically significant effect of the training on any of the measurement variable, but reports at the same time that all patients experienced a general improvement of disease activity and ADL. The five other authors (1,3,4,7,9,12) include treatment periods from four to twelve weeks. Hall (1996), studies on a group of people with RA which lasts four weeks with treatment two times a week. She concludes that all patients significantly improved their physical capacity by 4,8 % after treatment, indifferently from control group or intervention group. Ahern (1995) (twice a week for six weeks on OA and RA patients) and Smith (1998) (three times a week for ten weeks on people with RA), show no significant difference in their results even though Ahern states that the intervention group experienced an increase in self efficacy for function. Ahern involves people with a mean age of 67 years, while Smith involves patients with a duration of disease of 20 years. 3.4.3 Comparing high frequency vs low frequency treatment on ADL-functioning The session frequency oscillates between the eight authors studying ADL, from one to three times a week, and from 30 to 40 minutes sessions (except Hansen: max 90 min. per day). The study of Stenstrom (1991) lasting over four years used treatments one time a week. Stenstrom reports a significantly higher level of physical activity in aquatic group compared to the exercise therapy group. Smith (1998) and Hansen (1993) are the two authors investigating a three times a week intervetion. Smith reports no significant difference between groups for any of the eight categories of the HAQ. Hansen, with the same questionnaire concludes to no statistical significant effect of the training on any of the measured variables, as well between groups. 3.4.4 Comparing the effects of land based exercise therapy vs aquatic therapy on ADL-functioning Of the eight studies evaluating ADL (1,3,4,5,7,9,10,12), four compare aquatic therapy with a control group following an land based exercise therapy program: Minor (1989) uses people with OA and RA on two groups: one ROM exercise therapy control group, and one aerobic walk. Smith (1998) uses people with RA on a ROM exercise therapy control group. Stenstrom (1991) uses people with RA on exercise therapy, and Hall (1996) uses RA on land exercise. Stenstrom states that the level of the physical activity is higher in the aquatic therapy group than in the control group but mentions as well there were no significant differences between groups in any of the single functional tests. Hall and Minor (who as well report positive outcome on ADL), state that the improvement is not better in the aquatic therapy group than in the control groups (land exercise and aerobic walk). Smith indicates a statistically significant improvement in only 2 components of the questionnaire for the ROM group (total score and walking) and in none of the components of the aquatic therapy group. 3.4.5 Comparing aquatic therapy vs immersion alone on ADL-functioning Only Hall (1996), investigating people with RA with the AIMS questionnaire shows a comparison between a group following aquatic therapy and an immersion alone group. She states that both groups at the end of the treatment or at three months follow-up showed significant improvement on physical capacity (for walking, hand and finger function and arm function). 3.4.6 Comparing short term vs long term effects on ADL-functioning Only three (4,10,7) out of eight (1,3,4,5,7,9,10,12) authors studying on ADL includes a follow up evaluation: Hall (1996) includes a three months follow up, Stenstrom (1991) includes a two years follow up, and Minor (1989) includes a follow up nine months after. Only Hall and Minor report a follow-up effect of aquatic therapy maintained in ADL function. Hall reports a 4,8 % improvement post-treatment which increases even more after a three months period, while Minor states that aerobic pool participants maintained post intervention changes nine months after end of treatment except for duration of morning stiffness and depression, with some participants which continued training after end of treatment (at least one hour a week for the nine following months). Stenstrom, observes that the aquatic therapy group was also significantly more active at two year follow up than they were at baseline while this was not the case for the control group. 3.4.7 Comparing aquatic therapy effects on OA vs RA vs AS on ADL-functioning It is to be noted that the study done by Helliwell (1996), is the only one on AS individuals and it does not include an ADL function test. No results can therefore be showed on ADL improvement for AS individuals in this review. Only Ahern (1995) and Minor (1989) include the two other diagnoses (OA and RA) in their study, but none of them compares the two conditions on ADL functioning directly. 3.5 Effects of aquatic therapy on HRQL 3.5.1 Introduction In the studies found for this review, there were five studies measuring HRQL (4,5,7,8,12 ) Nguyen Hall (1996), Minor (1989), Sylvester (1989) and Hansen (1993). As measurement tools for HRQL, Sylvester used a Philadelphia Questionnaire, Hansen used a questionnaire called patient questionnaire about physical activities and the effect of the two year training program. Nguyen, Hall and Minor all used the AIMS or the revised AIMS2 scale. The three studies using the AIMS scale had different ways of displaying the results. Nguyen used total score for all the items, while Hall and Minor specified the score for each item. Comparing short term vs long term treatment on HRQL Nguyen (1997), Hall (1996), Minor (1989) and Sylvester (1989) all report improvements for the aquatic group. Nguyen Hall and Minor report a significant improvement, while Sylvester reports improvement, but not significant Of all the studies showing improvement, the longest treatment period was twelve weeks (7) and the shortest period was 3 weeks (8). The study of Hansen (1993), which did not show any improvements in any of the groups, had treatments lasting over 2 years. Comparing high frequency vs low frequency treatment on HRQL Hall (1996) and Sylvester (1989) were the two studies with lowest treatment frequency, having treatments two times a week. Hall shows significant improvements of all the groups and Sylvester obtained improvements on the aquatic group, but not significant. The study with the highest frequency Nguyen (1997), having daily treatments, also shows significant improvements for aquatic group. The two groups with treatments 3 times a week, show significant improvements for all groups (7) and no significant improvements at all (5). 3.5.4 Comparing the effects of land based exercise therapy vs aquatic therapy on HRQL Four out of five aquatic therapy groups achieved some improvements, significant or not (see section 3.6.2) However, both Hall (1996) and Minor (1989) reports that the control groups also improved (significantly). The land exercise group in the study of Hall significantly improved on physical capacity, mood and tension, but the aquatic group had greater improvement. Minor shows significant improvement on pain, physical activity, depression and anxiety for both aquatic group and aerobic walk group. The ROM exercise group only improved on pain. 3.5.5 Comparing aquatic therapy vs immersion alone on HRQL Only Hall (1996) compares aquatic therapy with immersion alone. This study reports that both aquatic therapy and immersion significantly improved in physical capacity (significant) and mood and tension (not significant). The aquatic group demonstrated the greatest improvement. Hall suggests that this result show an enhancement effect in the interaction between exercise and the water. 3.5.6 Comparing short term vs long term effects on HRQL All authors performing follow up testing (4,,7,8) reports maintenance or improvement on HRQL for all aquatic groups and some of the control groups. Hall (1996), Nguyen (1997) and Minors (1989) studies were the only to perform follow up testing. Hall had a three months follow up, which reveals significant improvement in mood and tension in all groups (greatest in the aquatic group). Nguyen shows significant improvement for aquatic group on quality of life at, four weeks and 24 weeks follow up. No improvement for the control group. Minor had a twelve months follow up. This reveals significant improvement on physical activity, anxiety and depression for aquatic group and aerobic group. ROM exercise group shows no improvements at follow up. 3.5.7 Comparing aquatic therapy effects on OA vs RA vs AS on HRQL Out of the twelve included studies, only one investigates AS (6), but this study did not measure HRQL and is therefore not included in this comparison. OA was the condition of the populations in the studies of Sylvester (1989) and Nguyen (1997), and RA the condition in the study of Hall (1996) and Hansen (1993). Minor (1989) included both OA and RA in the study. All studies, except the study of Hansen show improvements on HRQL. Minor compared the effect (AIMS score), between the aerobic groups (aerobic walk and aquatic group) and the ROM group, on OA vs RA, pre-to post treatment. The total mean score in the aerobic groups, OA and RA, were almost similar twelve weeks after baseline testing. There are however variations in the score on the different items on the AIMS questionnaire. On the item pain (part of HRQL in AIMS), the people with OA improved more than the people with RA, who worsened pre-to post treatment. On depression and anxiety the people with RA improved more than the people with OA . Both the OA and the RA groups in the aerobic intervention group improved more compared to the ROM exercises group. . 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