Water-based exercise bests standard physical therapy modalities

In patients with chronic low back pain, a therapy program involving therapeutic aquatic exercise outperformed a program of transcutaneous electrical nerve stimulation and infrared ray thermal therapy for reducing pain and disability, researchers found.

Chronic low back pain is a major source of disability around the globe, a burden that increased by 17.5% from 2007-2017, and which costs the U.S. an average of $8,386 per year for each affected patient, Pei-Jie Chen, PhD, of Shanghai University of Sport and Shanghai Shangti Orthopedic Hospital in Shanghai, China, and colleagues explained in JAMA Network Open.

Standard care for chronic low back pain consists of physical therapy modalities designed to relieve pain and reduce disability, including transcutaneous electrical nerve stimulation and infrared ray thermal therapy. However, therapeutic aquatic exercise is increasingly making waves as a popular approach to address the condition.

Chen and colleagues conducted a three-month, single-blind, randomized trial to determine the efficacy of therapeutic aquatic exercise against these physical therapy modalities and to assess the long-term efficacy of the water-based treatment plan.

They found that participants in the therapeutic aquatic exercise group “gained significantly greater and more clinically meaningful improvement in disability compared with improvement in the physical therapy modalities group. We also found that therapeutic aquatic exercise was a more effective treatment than physical therapy modalities on pain intensity, quality of life, sleep quality, kinesiophobia, and fear avoidance for patients with chronic low back pain.”

For their three-month, assessor-blinded trial, Chen and colleagues recruited patients ages 18-65 years with low back pain, with or without lower limb pain, lasting at least three months and with a pain intensity of 3 or higher on a numeric rating scale. Exclusion criteria included mental illness or cognitive impairment, specific lumbago, regular low back pain exercise intervention in the preceding six months, pregnancy or lactation, chlorine allergy, and water-related anxiety or inability to adapt to an aquatic environment.

The trial was conducted from Sept. 10, 2018-March 12, 2019, with a 12-month follow-up period ending on March 17, 20220. A total of 113 participants (52.2% women; median age: 31.0) with chronic low back pain were randomized to receive either therapeutic aquatic exercise (n=56) or the physical therapy modalities (n=57). Both programs lasted 12 weeks and were administered over 60-minute sessions twice weekly, for a total of 24 sessions.

“Participants in the therapeutic aquatic exercise group started the exercise with a 10-minute active warm-up session to enhance neuromuscular activation,” the authors explained. “Then, they performed an aquatic session for 40 minutes and had a 10-minute cool-down session. The target exercise intensity depended on the individual’s self-rated score of approximately 13, indicating 60% to 80% of their maximum heart rate on the Borg Scale Rating of Perceived Exertion, which is a measure sufficiently reliable for quantifying the training load for aquatic exercise. The participants in the physical therapy modalities group received transcutaneous electrical nerve stimulation and infrared ray thermal therapy. Both modalities were focused on pain points, and each had a duration of 30 minutes.”

The study’s primary outcome was disability level as measured using the Roland-Morris Disability Questionnaire (scores from 0-24, higher scores indicate more severe disability). Secondary outcomes included pain intensity, quality of life, sleep quality, recommendation of intervention, and minimal clinically important difference.

Ninety-eight participants (86.7%) completed the 12-month follow-up. Among the findings:

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  • The therapeutic aquatic exercise group “showed greater alleviation of disability, with adjusted mean group differences of −1.77 (95% CI, −3.02 to −0.51; P=0.006) after the 3-month intervention, −2.42 (95% CI, −4.13 to −0.70; P=0.006) at the 6-month follow-up, and −3.61 (95% CI, −5.63 to −1.58; P=0.001) at the 12-month follow-up (P<0.001 for overall group × time interaction).”
  • At 12-month follow-up, patients in the therapeutic aquatic exercise group had greater improvement in the number of participants who met the minimal clinically important difference in pain (at least a 2-point improvement on the numeric scale rating; most severe pain, 30 [53.57%] versus 12 [21.05%]; average pain, 14 [25%] versus 11 [19.30%]; and current pain, 22 [39.29%] versus 10 [17.54%]) and disability (at least a 5-point improvement on the Roland-Morris Disability Questionnaire; 26 [46.43%] versus 4 [7.02%]).
  • One participant in the therapeutic aquatic exercise group and two in the physical therapy modalities group experienced low back pain and other pain related to the interventions.

Chen and colleagues noted that, to their knowledge, this study represents the first time the efficacy of therapeutic aquatic exercise for chronic lower back pain has been compared against the physical therapy modalities included in their control group.

“Some researchers who chose to carry out similar exercises in water and on land discovered that the efficiency of therapeutic aquatic exercise and degree of pain relief associated with therapeutic aquatic exercise were better than those of land exercise,” they wrote. “Even after a single intervention, the frequency of pain in the therapeutic aquatic exercise group was reduced to half of that in the land exercise group. Participants in the therapeutic aquatic exercise group also experienced greater improvement in quality of life and dysfunction than those in the land exercise group. Other researchers provided treatment, such as conventional physical therapy (low back pain pamphlet and lumbar exercise), multimodal physical therapy, or low back pain school, as an intervention in the control group. The dysfunction and quality of life of patients with chronic low back pain significantly improved after the therapeutic aquatic exercise intervention was added to the treatments.”

Study limitations included that most participants were on the lower end of the study’s 18-65 year age range; self-reported pain levels were low, and thus the results may not be generalizable to everyone with chronic low back pain; it is unclear whether the benefits of therapeutic aquatic exercise originated from the benefits of the water environment or from the benefits of any active exercise; combining aquatic exercise with standard physical therapy modalities might be the ideal approach for these patients; blinding participants to the intervention was not possible; and the study did not assess the differences in medical costs and productivity losses between the two treatment options.

  1. A therapy program comprised of therapeutic aquatic exercise was more successful than a program of transcutaneous electrical nerve stimulation and infrared ray thermal therapy for reducing pain and disability among patients with chronic low back pain.

  2. Therapeutic aquatic exercise was also a more effective treatment than physical therapy modalities on pain intensity, quality of life, sleep quality, kinesiophobia, and fear avoidance for patients with chronic low back pain.

John McKenna, Associate Editor, BreakingMED™

This study was supported by grants from the National Natural Science Foundation of China, the Fok Ying-Tong Education Foundation of China, the Science and Technology Commission of Shanghai Municipality, and the Shanghai Key Lab of Human Performance (Shanghai University of Sport), as well as by the Shanghai Frontiers Science Research Base of Exercise and Metabolic Health.

The study authors had no relevant relationships to disclose.

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