Hydrotherapy and Land-Based Exercise: Differential Impacts on Pain, Knee Biomechanics and Quadriceps Activation in Osteoarthritis

Abstract

Purpose

Stiffness during walking is a frequent problem among individuals with knee osteoarthritis, primarily resulting from pain. Currently, there is no agreement on the optimal exercise approach to relieve gait-related symptoms in these patients. This study examines the impact of hydrotherapy and land-based exercises on factors contributing to stiff gait during the early stance phase, including pain, knee kinematics, and the co-activity of flexor and extensor muscles in women with knee osteoarthritis.

Methods

A single-blind randomized controlled trial was conducted with 36 women diagnosed with knee OA of grade 2 or higher. Participants were randomly assigned to three groups: control, hydrotherapy, and land-based exercise. Pain levels were assessed using the Knee Injury and OA Outcome Score (KOOS), while kinematic and electromyographic (EMG) analyses were performed during walking. The interventions consisted of 18 sessions over 8 weeks, focusing on strengthening exercises. Data were analyzed using two-factor mixed-method ANOVA, with significance set at P < 0.05.

Results

Both exercise modalities significantly reduced pain (P = 0.006) and improved knee range of motion (ROM) (P = 0.001) during early stance of gait. The hydrotherapy group demonstrated a greater reduction in pain compared to the land-based exercise group, indicated by a higher effect size. Kinematic analysis also revealed a significant increase in knee flexion during the early stance phase for both groups, with hydrotherapy showing a larger effect size for this improvement. EMG results indicated that hydrotherapy significantly enhanced rectus femoris activity (P < 0.001), while both interventions reduced biceps femoris and semimembranosus activity.

Conclusions

The results indicate that hydrotherapy outperforms land-based exercises in reducing pain and improving knee kinematics and muscle activity in women with knee osteoarthritis. The unique properties of water, such as buoyancy and resistance, likely play a significant role in these advantages by reducing the load on the joints, strengthening muscles, and enhancing functional mobility. In general, hydrotherapy proves to be a highly effective approach for treating knee osteoarthritis, resulting in significant improvements in factors influencing stiff gait during the early stance phase, especially when compared to land-based exercise programs. These findings advocate for the inclusion of hydrotherapy in rehabilitation strategies for women suffering from knee osteoarthritis.

Keywords

Osteoarthritis / Hydrotherapy / Kinematics / Electromyography / Medical and Health Sciences / Clinical Sciences / Human Movement and Sports Science

References

[1] ArmandS, DecoulonG, Bonnefoy-MazureA. Gait analysis in children with cerebral palsy. EFORT open reviews, 2016, 112448-460.

[2] AssarS, GandomiF, MozafariM, SohailiF. The effect of total resistance exercise vs. aquatic training on self-reported knee instability, pain, and stiffness in women with knee osteoarthritis: A randomized controlled trial. BMC Sports Sci Med Rehabil, 2020, 12: 1-3.

[3] AstephenJL, DeluzioKJ, CaldwellGE, DunbarMJ, Hubley-KozeyCL. Gait and neuromuscular pattern changes are associated with differences in knee osteoarthritis severity levels. J Biomech, 2008, 414868-876.

[4] BartelsEM, JuhlCB, ChristensenR, HagenKB, Danneskiold-SamsøeB, DagfinrudH, LundH. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev, 2016.

[5] ChildsJD, SpartoPJ, FitzgeraldGK, BizziniM, IrrgangJJ. Alterations in lower extremity movement and muscle activation patterns in individuals with knee osteoarthritis. Clin Biomech, 2004, 19144-49.

[6] DavisHC, Luc-HarkeyBA, SeeleyMK, BlackburnJT, PietrosimoneB. Sagittal plane walking biomechanics in individuals with knee osteoarthritis after quadriceps strengthening. Osteoarthritis Cartilage, 2019, 275771-780.

[7] FisherNM, WhiteS, YackHJ, SmolinskiRJ, PendergastDR. Muscle function and gait in patients with knee osteoarthritis before and after muscle rehabilitation. Disabil Rehabil, 1997, 19247-55.

[8] FoleyA, HalbertJ, HewittT, CrottyM. Does hydrotherapy improve strength and physical function in patients with osteoarthritis—a randomised controlled trial comparing a gym-based and a hydrotherapy-based strengthening programme. Ann Rheum Dis, 2003, 62121162-1167.

[9] FransenM, CrosbieJ, EdmondsJ. Physical therapy is effective for patients with osteoarthritis of the knee: A randomized controlled clinical trial. J Rheumatol, 2001, 281156-164

[10] HeidenTL, LloydDG, AcklandTR. Knee joint kinematics, kinetics, and muscle co-contraction in knee osteoarthritis patient gait. Clin Biomech, 2009, 2410833-841.

[11] HinmanRS, HeywoodSE, DayAR. Aquatic physical therapy for hip and knee osteoarthritis: results of a single-blind randomized controlled trial. Phys Ther, 2007, 87132-43.

[12] HopkinsWG, MarshallSW, BatterhamAM, HaninJ. Progressive statistics for studies in sports medicine and exercise science. Med Sci Sports Exerc, 2009, 4113-13.

[13] HortobágyiT, WesterkampL, BeamS, MoodyJ, GarryJ, HolbertD, DeVitaP. Altered hamstring-quadriceps muscle balance in patients with knee osteoarthritis. Clin Biomech, 2005, 20197-104.

[14] Hubley-KozeyC, DeluzioK, LandryS, McNuttJ, StanishW. Neuromuscular alterations during walking in persons with moderate knee osteoarthritis. J Electromyogr Kinesiol, 2006, 164365-378.

[15] HummerET, MurphyEN, SuprakDN, BrillaLR, San JuanJG. Movement direction impacts knee joint kinematics during elliptical exercise at varying incline angles. Knee, 2021.

[16] LewekMD, RudolphKS, Snyder-MacklerL. Control of frontal plane knee laxity during gait in patients with medial compartment knee osteoarthritis. Osteoarthritis Cartilage, 2004, 129745-751.

[17] LiikavainioT, BraggeT, HakkarainenM, KarjalainenPA, ArokoskiJP. Gait and muscle activation changes in men with knee osteoarthritis. Knee, 2010, 17169-76.

[18] McQuadeKJ, De OliveiraAS. Effects of progressive resistance strength training on knee biomechanics during single-leg step-up in persons with mild knee osteoarthritis. Clin Biomech, 2011, 267741-748.

[19] MunukkaM, WallerB, HäkkinenA, NieminenMT, LammentaustaE, KujalaUM, PalonevaJ, KautiainenH, KivirantaI, HeinonenA. Effects of progressive aquatic resistance training on symptoms and quality of life in women with knee osteoarthritis: a secondary analysis. Scand J Med Sci Sports, 2020, 3061064-72.

[20] ÖzüdoğruA, GelecekN. Effects of closed and open kinetic chain exercises on pain, muscle strength, function, and quality of life in patients with knee osteoarthritis. Rev Assoc Med Bras, 2023, 697. e20230164

[21] PöyhönenT, SipiläS, KeskinenKL, HautalaA, SavolainenJ, MälkiäE. Effects of aquatic resistance training on neuromuscular performance in healthy women. Med Sci Sports Exerc, 2002, 34122103-2109.

[22] Roos, EM, Lohmander S. Knee injury and Osteoarthritis Outcome Score (KOOS): validation and comparison to the WOMAC in patients with knee osteoarthritis. Health Qual Life Outcomes. 2003;1:17.

[23] ShalhoubM, AnayaM, DeekS, ZabenAH, AbdallaMA, JaberMM, KoniAA, ZyoudSH. The impact of pain on quality of life in patients with osteoarthritis: a cross-sectional study from Palestine. BMC Musculoskelet Disord, 2022, 231248.

[24] SilvaLE, ValimV, PessanhaAPC, OliveiraLM, MyamotoS, JonesA. Hydrotherapy versus conventional land-based exercise for the management of patients with osteoarthritis of the knee: a randomized clinical trial. Phys Ther, 2008, 88112-21.

[25] WyattFB, MilamS, ManskeRC, DeereR. The effects of aquatic and traditional exercise programs on persons with knee osteoarthritis. J Strength Cond Res, 2001, 153337-40

[26] YangSS, SeoTB, KimYP. Effect of aqua walking exercise on knee joint angles, muscular strength, and visual analogue scale for patients with limited range of motion of the knee. J Exerc Rehabil, 2021, 174265.

[27] ZeniJAJr, HigginsonJS. Dynamic knee joint stiffness in subjects with a progressive increase in severity of knee osteoarthritis. Clinic Biomech, 2009, 244366-71.

RIGHTS & PERMISSIONS

Beijing Sport University