Conservative Care Recommendations and the Benefits of Aquatic Exercise for Patients with Osteoarthritis

Background

Our joint interest in aquatic therapy began during a lecture given during the Biomechanics class in our first year of physical therapy (PT) school. This curiosity led us to pursue multiple projects related to aquatic therapy which have included: a business project together during the Managing Contemporary Practice class (HydroHealth), each of us creating a critically appraised topic (CAT) and evidence table during our Evidence Based Practice II class, and ultimately creating our final capstone project around aquatic therapy as well. We worked side by side throughout the past school year, completing every component together, and ultimately creating this final project presentation on this page.

LA’s Background

My passion for aquatic therapy blossomed during an aquatic therapy business project that Lindsay and I did in our second year. From there, I was able to go on a clinical rotation and  receive further training that allowed me to treat patients using a Hydroworx underwater treadmill. I saw how far individuals with osteoarthritis (OA) would travel just to get in the water to exercise, and I saw first hand the benefits aquatic therapy could provide. However, during my time as a PT student, I have also learned that many individuals do not know about aquatic therapy and its benefits (specifically the OA population). Therefore, gaining more knowledge about current OA recommendations and how aquatic therapy ties into them will make me a better, more evidence based therapist when treating individuals with lower extremity OA. 

Lindsay’s Background

My passion for aquatic therapy stems from being a former competitive swimmer, which had fostered my deep love for water. I can appreciate the many benefits that aquatic therapy poses and am looking forward to pursuing the ability to administer this mode of therapy to those who are appropriate in my final clinical rotation and beyond. Additionally, I am highly interested in the realm of orthopedics and am currently pursuing a residency in this specialty. The musculoskeletal system captivates me and with a large percentage of our population having OA, having a better understanding and the clinical tools to address this pathology would be highly beneficial. Therefore, through combining both orthopedics and aquatic therapy, I hope to have a better understanding of best recommendations for my patients with OA and have valuable materials to present to them in the clinic to manage their symptoms.

Statement of Need

OA is one of the leading causes of disability worldwide and with our aging population, treating those with this pathology has become common in the PT clinic.¹ Although PT’s can help address the associated functional limitations and many symptoms related to OA, long term self-management is crucial. There is ample literature conducted on OA as well as on the use of aquatic therapy as a treatment method, but there appears to be a lack of patient friendly educational material and guidelines on current evidence based conservative care recommendations. This capstone project aims to bridge the gap between the current literature and what patients can understand for enhanced outcomes. Creating a handout on the current evidence-based recommendations on OA conservative care as well as a library of beneficial aquatic exercises for those with OA will provide patients with the tools to make informed decisions regarding their care and promote long term maintenance of the progress made during PT treatment sessions. 

Furthermore, we felt that our curriculum lacked sufficient information regarding aquatic therapy as well as the more specific and up to date recommendations for OA interventions. This drove us to dive deeper into the literature and fill these knowledge gaps so that we could  improve our exercise prescription and patient education regarding OA care. Therefore, the clinician reference guide and the powerpoint presentation were created to fit this need and supplement the information learned throughout the DPT curriculum. These materials could be used for future clinical in services as well as provided as additional resources during the Advanced Orthopedics or Musculoskeletal II classes. 

Overview and Purpose

Our capstone project intends to meet the needs addressed above through evidence-based educational products made available to PT’s, patients, and PT students, so they can be used to ultimately improve patient care outcomes.

As PT’s we must emphasize and promote patient education and engagement through improvements in health literacy and self-management. Additionally, adequate patient education can lead to improved health outcomes in an age of escalating health care costs and overwhelming future cost projections.² The overall presumption has been that low health literacy means that communication by clinicians is typically poorly understood which can lead to poor self-health management or responsibility and incomplete health care utilization.²

Health Literacy

The final products were created and adjusted to appropriately meet the needs of our intended audiences using the information provided in the educational modules on Sakai. Our patient education handout and aquatic home exercise library were tailored to our patient population. Therefore, it was extremely important that we were able to portray this research in a way that patients with various educational levels and health backgrounds would be able to comprehend. The patient materials were geared to be at the below basic level of literacy since 59% of older adults have a basic or below basic level of literacy, which is estimated to be around the 5th grade reading level.³ Furthermore, NC has a higher proportion of residents that are at a basic or below basic level compared to the national average, so our intended population falls into this lower category.  Although the sample was small, the use of a focus group composed of older adults with OA allowed us to assess our success in creating a patient education handout at the appropriate health literacy level.

While our other two deliverables were geared towards clinicians and students, health literacy was still accounted for as some of the material would be unfamiliar to some.  We aimed to provide adequate detail for a more comprehensive understanding, provided charts and illustrations, and utilized feedback from our mentors to make the materials more clinician-friendly.

Products

For Patients: 

• The Patient Education Handout for OA outlines the up to date evidence-based recommendations for OA conservative care options. 

For Clinicians:

• The PT Reference Sheet for OA Management provides the details for exercise prescription for those with OA as well as additional evidence on the conservative care recommendations for OA. We hoped that this information could supplement the information provided in the Patient Education Handout via a patient-clinician discussion, as the material was more dense than what is appropriate for the targeted health literacy level.
• The Aquatic Intervention for Patients with LE OA PowerPoint provides the evidence regarding the use of aquatic therapy intervention for those with OA as a conservative method, as surgical prehabilitation, as well as post-operative rehabilitation. 

For Both:

• The HEP Library for LE OA provides clinicians with OA friendly exercises that target many of the major impairments associated with the pathology so that they can more easily prescribe these exercises in a home exercise program. The handout was designed to be comprehended by patients so that they could follow the instructions and perform these exercises independently.

Evaluation 

Tools

We created two feedback tools, one for each target audience group. The first evaluation tool was given to patients with OA in order to seek advice on how to improve the patient education handout in an effort to optimize health literacy and patient education. The second evaluation tool was given to PT’s and PT students to provide feedback on the remaining products and give advice on how to improve delivery of evidence based material in order for our end products to have the best possible clinical utility. 

Google Survey Link for patient education handout: https://forms.gle/GFTLV695xc2JgSMW8 

Google Survey Link for remaining products: https://docs.google.com/forms/d/e/1FAIpQLSez13GpR6HQMGdURJ81FP3V01Pf8Ltu_mbwgwEqzAneS857yg/viewform?usp=sf_link

Feedback

Despite a small sample size of 10, 90% of respondents to the patient education handout evaluation tool felt the handout was easy to follow and 80% felt the information was written clearly and concisely. 100% of respondents felt the handout was visually appealing, they understood the role a PT could play in OA management, and they learned new strategies for OA management. Lastly, 80% of respondents felt other patients would be able to understand the information delivered within the patient education handout. The short response portion of the evaluation tool provided specific feedback on areas that needed to be improved upon, and these suggestions were implemented in future revisions.

Despite a small sample size of only 2, 100% of respondents to the PT/SPT evaluation tool felt our products had sufficient clinical utility, appropriate aesthetics, and were easy to understand/read. 

After receiving feedback, we edited and modified our products three times in order to comply with recommendations and advice given through our evaluation tools and suggestions made by our capstone committee and advisor. 

Reflections

LA’s Self Reflection

This experience has truly been one of the most rewarding during my time in UNC’s DPT program. I have always sought out to “add more tools to my tool belt” throughout my time at UNC, and with the help of my wonderful classmate Lindsay and our trusted capstone advisors/committee, I have been able to do just that. I surpassed meeting my personal learning objectives by leaps and bounds and am now completely confident in my knowledge of lower extremity OA. After completing this project, I believe I have broadened my knowledge, deepened my resources, familiarized myself with CPG’s, and am adequately equipped to provide quality, evidence based care to individuals with OA. 

Lindsay’s Self Reflection

My personal learning objectives were to enhance my ability to integrate evidence-based practice into my plans of care and to deepen my understanding of the evidence-based recommendations on conservative care options for those with OA so that I can better inform my patients. I hoped to create valuable patient education materials to promote commitment to exercise specifically tailored to those with OA to promote symptom management and healthy habits. Also I aimed to improve my understanding on the benefits and parameters of utilizing aquatic therapy to optimally prepare myself for my clinical rotation.

After completing this project, I believe that I have met these goals as I feel that I am much more equipped to prescribe appropriate interventions and educate patients on evidence based conservative care recommendations for those with OA. The amount of research that I sifted through and the many evidence tables and outlines created to appraise the articles found has made me much more efficient in the research process. Overall, this project has been incredibly rewarding, and I would not have wanted to tackle it with anyone other than LA. 

Acknowledgements 

To Dr. Mike Gross, PT, PhD, FAPTA, thank you for consistent guidance, helping us shape our many broad ideas into this project, and providing great feedback throughout this whole process.

To Dr. Emily Paul, PT, DPT, ATC, thank you for sparking our interest in aquatic therapy a few years ago and providing great feedback on all our deliverables.

To Dr. Nicole Zimmerman, PT, DPT, OCS, thank you for providing valuable constructive criticism along the way and introducing us to other incredible mentors.

To Dr. Joeline Kane Hernandez, PT, DPT, thank you for providing valuable feedback on our aquatic home exercise library for those with OA and providing clinically useful tips on how to adjust the exercises positions.

To Class of 2022 for reviewing our materials and making these past few years an absolute blast. We can’t wait for future alumni reunions and to hear about all the amazing things you all will be doing as practicing clinicians! 

To our OA Focus Group, thank you for reviewing our patient education handout and providing honest feedback and critiques so that we could improve the deliverable to better serve our future patients.

References 

1. Key priorities for implementation | Osteoarthritis: care and management | Guidance | NICE. Accessed October 10, 2021. https://www.nice.org.uk/guidance/cg177/chapter/Key-priorities-for-implementation
2. Paterick TE, Patel N, Tajik AJ, Chandrasekaran K. Improving health outcomes through patient education and partnerships with patients. Proc (Bayl Univ Med Cent). 2017;30(1):112-113. doi:10.1080/08998280.2017.11929552
3. Health Literacy | Center on Aging Care Sheets. Accessed April 20, 2022. https://www.uofazcenteronaging.com/care-sheet/providers/health-literacy

References from Patient Education Handout and Clinician Reference Sheet:

1. Key priorities for implementation | Osteoarthritis: care and management | Guidance | NICE. Accessed October 10, 2021. https://www.nice.org.uk/guidance/cg177/chapter/Key-priorities-for-implementation 
2. Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, Callahan L, Copenhaver C, Dodge C, Felson D, Gellar K, Harvey WF, Hawker G, Herzig E, Kwoh CK, Nelson AE, Samuels J, Scanzello C, White D, Wise B, Altman RD, DiRenzo D, Fontanarosa J, Giradi G, Ishimori M, Misra D, Shah AA, Shmagel AK, Thoma LM, Turgunbaev M, Turner AS, Reston J. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res (Hoboken). 2020 Feb;72(2):149-162. doi: 10.1002/acr.24131. Epub 2020 Jan 6. Erratum in: Arthritis Care Res (Hoboken). 2021 May;73(5):764. PMID: 31908149.
3.  Patient education: Arthritis and exercise (Beyond the Basics) – UpToDate. Accessed February 18, 2022. https://www.uptodate.com/contents/arthritis-and-exercise-beyond-the-basics 
4. Turner MN, Hernandez DO, Cade W, Emerson CP, Reynolds JM, Best TM. The role of resistance training dosing on pain and physical function in individuals with knee osteoarthritis: A systematic review. Sports Health. 2020;12(2):200-206. doi:10.1177/1941738119887183 
5. Haff G, Triplett T. Essentials of Strength Training and Conditioning. 4th ed. National Strength and Conditioning Association; 2016. 
6. Escalante Y, Saavedra JM, García-Hermoso A, Silva AJ, Barbosa TM. Physical exercise and reduction of pain in adults with lower limb osteoarthritis: a systematic review. J Back Musculoskelet Rehabil. 2010;23(4):175-86. doi: 10.3233/BMR-2010-0267. PMID: 21079296.  
7. Alnahdi AH, Zeni JA, Snyder-Mackler L. Muscle impairments in patients with knee osteoarthritis. Sports Health. 2012 Jul;4(4):284-92.
8. Pozzi F, Snyder-Mackler L, Zeni J. Physical exercise after knee arthroplasty: a systematic review of controlled trials. Eur J Phys Rehabil Med. 2013;49(6):877-892.
9. Weng MC, Lee CL, Chen CH, et al. Effects of different stretching techniques on the outcomes of isokinetic exercise in patients with knee osteoarthritis. Kaohsiung J Med Sci. 2009;25(6):306-315. doi:10.1016/S1607-551X(09)70521-2
10. Stretching and Flexibility Guidelines Update. Accessed November 30, 2021. https://www.acsm.org/all-blog-posts/certification-blog/acsm-certified-blog/2021/03/18/stretching-and-flexibility-guidelines-update
11. Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SMA, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ, Espinosa R, Haugen IK, Lin J, Mandl LA, Moilanen E, Nakamura N, Snyder-Mackler L, Trojian T, Underwood M, McAlindon TE. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019 Nov;27(11):1578-1589. doi: 10.1016/j.joca.2019.06.011. Epub 2019 Jul 3. PMID: 31278997. 
12. Key priorities for implementation | Osteoarthritis: care and management | Guidance | NICE. Accessed October 10, 2021. https://www.nice.org.uk/guidance/cg177/chapter/Key-priorities-for-implementation  
13. Summary of Findings –  Tai chi. American College of Rheumatology/Arthritis Foundation. Published online April 5, 2011. 
14. Song R, Lee E-O, Lam P, Bae S-C. Effects of a Sun-style Tai Chi exercise on arthritic symptoms, motivation and the performance of health behaviors in women with osteoarthritis. Taehan Kanho Hakhoe Chi. 2007;37(2):249-256. doi:10.4040/jkan.2007.37.2.249  
15. Riskowski J, Dufour AB, Hannan MT. Arthritis, foot pain and shoe wear: current musculoskeletal research on feet. Curr Opin Rheumatol. 2011;23(2):148-155. doi:10.1097/BOR.0b013e3283422cf5 
16. Kamioka H, Tsutani K, Okuizumi H, et al. Effectiveness of aquatic exercise and balneotherapy: a summary of systematic reviews based on randomized controlled trials of water immersion therapies. J Epidemiol. 2010;20(1):2-12. doi:10.2188/jea.je20090030
17. King MR, Haussler KK, Kawcack CE et al. Mechanisms of aquatic therapy and its potential use in managing equine osteoarthritis. Equine Veterinary Education. 2013: 204-209.  
18. Brosseau L, Yonge KA, Robinson V, et al. Thermotherapy for treatment of osteoarthritis. Cochrane Database Syst Rev. 2003;2003(4):CD004522. doi:10.1002/14651858.CD004522 
19. Cheung C, Wyman JF, Resnick B, Savik K. Yoga for managing knee osteoarthritis in older women: a pilot randomized controlled trial. BMC Complement Altern Med. 2014;14:160. Published 2014 May 18. doi:10.1186/1472-6882-14-160 
20. Haaz S, Bartlett SJ. Yoga for arthritis: a scoping review. Rheum Dis Clin North Am. 2011;37(1):33-46. doi:10.1016/j.rdc.2010.11.001 
21. Cognitive behavioral therapy. September 8, 2016. Accessed March 8, 2022. https://www.ncbi.nlm.nih.gov/books/NBK279297/  
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23. Donec V, Kubilius R. The effectiveness of Kinesio Taping® for pain management in knee osteoarthritis: a randomized, double-blind, controlled clinical trial. Ther Adv Musculoskelet Dis. 2019;11:1759720X19869135. Published 2019 Aug 29. doi:10.1177/1759720X19869135
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References from the Aquatic Home Exercise Program Library:

1. Lim JY, Tchai E, Jang SN. Effectiveness of aquatic exercise for obese patients with knee osteoarthritis: a randomized controlled trial. PM R. 2010;2(8):723-793. doi:10.1016/j.pmrj.2010.04.004
2. Fransen M, Nairn L, Winstanley J, Lam P, Edmonds J. Physical activity for osteoarthritis management: a randomized controlled clinical trial evaluating hydrotherapy or Tai Chi classes. Arthritis Rheum. 2007;57(3):407-414. doi:10.1002/art.22621
3. Silva LE, Valim V, Pessanha AP, et al. Hydrotherapy versus conventional land-based exercise for the management of patients with osteoarthritis of the knee: a randomized clinical trial. Phys Ther. 2008;88(1):12-21. doi:10.2522/ptj.20060040
4. Assar S, Gandomi F, Mozafari M, Sohaili F. 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;12:27. Published 2020 Apr 29. doi:10.1186/s13102-020-00175-y
5. Wyatt FB, Milam S, Manske RC, Deere R. The effects of aquatic and traditional exercise programs on persons with knee osteoarthritis. J Strength Cond Res. 2001;15(3):337-340. 
6. Escalante Y, Saavedra JM, García-Hermoso A, Silva AJ, Barbosa TM. Physical exercise and reduction of pain in adults with lower limb osteoarthritis: a systematic review. J Back Musculoskelet Rehabil. 2010;23(4):175-86. doi: 10.3233/BMR-2010-0267. PMID: 21079296.  
7. Alnahdi AH, Zeni JA, Snyder-Mackler L. Muscle impairments in patients with knee osteoarthritis. Sports Health. 2012 Jul;4(4):284-92.
8. Pozzi F, Snyder-Mackler L, Zeni J. Physical exercise after knee arthroplasty: a systematic review of controlled trials. Eur J Phys Rehabil Med. 2013;49(6):877-892. 
9. Pisters MF, Veenhof C, van Dijk GM, Heymans MW, Twisk JWR, Dekker J. The course of limitations in activities over 5 years in patients with knee and hip osteoarthritis with moderate functional limitations: risk factors for future functional decline. Osteoarthr Cartil. 2012;20(6):503-510. doi:10.1016/j.joca.2012.02.002 
10. OA Prevalence and Burden – Osteoarthritis Action Alliance. Accessed February 11, 2022. https://oaaction.unc.edu/oa-module/oa-prevalence-and-burden/ 

References from the Aquatic Therapy for OA PowerPoint:

1. Man GS, Mologhianu G. Osteoarthritis pathogenesis – a complex process that involves the entire joint. J Med Life. 2014;7(1):37-41.
2. Bannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra SMA, Kraus VB, Lohmander LS, Abbott JH, Bhandari M, Blanco FJ, Espinosa R, Haugen IK, Lin J, Mandl LA, Moilanen E, Nakamura N, Snyder-Mackler L, Trojian T, Underwood M, McAlindon TE. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019 Nov;27(11):1578-1589. doi: 10.1016/j.joca.2019.06.011. Epub 2019 Jul 3. PMID: 31278997.
3. Key priorities for implementation | Osteoarthritis: care and management | Guidance | NICE. Accessed October 10, 2021. https://www.nice.org.uk/guidance/cg177/chapter/Key-priorities-for-implementation 
4. D’Lima DD, Colwell Jr CW, Morris BA, Hardwick ME, Kozin F. The effect of preoperative exercise on total knee replacement outcomes. Clin Orthop Relat Res 1996;326:174–82.
5. Escalante Y, Saavedra JM, García-Hermoso A, Silva AJ, Barbosa TM. Physical exercise and reduction of pain in adults with lower limb osteoarthritis: a systematic review. J Back Musculoskelet Rehabil. 2010;23(4):175-86. doi: 10.3233/BMR-2010-0267. PMID: 21079296.  
6. Alnahdi AH, Zeni JA, Snyder-Mackler L. Muscle impairments in patients with knee osteoarthritis. Sports Health. 2012 Jul;4(4):284-92.
7. Pozzi F, Snyder-Mackler L, Zeni J. Physical exercise after knee arthroplasty: a systematic review of controlled trials. Eur J Phys Rehabil Med. 2013;49(6):877-892. 
8. Arthritis Foundation. Arthritis by the Numbers. In: Atlanta, GA: Arthritis Foundation; 2019: https://www.arthritis.org/Documents/Sections/About-Arthritis/arthritis-facts-stats-figures.pdf. Accessed Feb. 11, 2022.
9. Franco MR, Morelhão PK, de Carvalho A, Pinto RZ. Aquatic Exercise for the Treatment of Hip and Knee Osteoarthritis. Phys Ther. 2017 Jul 1;97(7):693-697. doi: 10.1093/ptj/pzx043. PMID: 28444338.
10. Pisters MF, Veenhof C, van Dijk GM, Heymans MW, Twisk JWR, Dekker J. The course of limitations in activities over 5 years in patients with knee and hip osteoarthritis with moderate functional limitations: risk factors for future functional decline. Osteoarthr Cartil. 2012;20(6):503-510. doi:10.1016/j.joca.2012.02.002 
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12. OA Prevalence and Burden – Osteoarthritis Action Alliance. Accessed February 11, 2022. https://oaaction.unc.edu/oa-module/oa-prevalence-and-burden/ 
13. Provider Education Toolkit – Osteoarthritis Action Alliance. Accessed February 11, 2022. https://oaaction.unc.edu/resource-library/modules/  
14. Kolasinski SL, Neogi T, Hochberg MC et al. J. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res (Hoboken). 2020 Feb;72(2):149-162. doi: 10.1002/acr.24131. Epub 2020 Jan 6. Erratum in: Arthritis Care Res (Hoboken). 2021 May;73(5):764. PMID: 31908149.
15. Summary of Findings –  Tai chi. American College of Rheumatology/Arthritis Foundation. Published online April 5, 2011.
16. Kamioka H, Tsutani K, Okuizumi H, et al. Effectiveness of aquatic exercise and balneotherapy: a summary of systematic reviews based on randomized controlled trials of water immersion therapies. J Epidemiol. 2010;20(1):2-12. doi:10.2188/jea.je20090030
17. Coruzzi, P., Ravanetti, C., Musiari, L., Biggi, A., Vescovi, P. P., & Novarini, A. (1988). Circulating opioid peptides during water immersion in normal man. Clinical science, 74(2), 133-136.
18. King MR, Haussler KK, Kawcack CE et al. Mechanisms of aquatic therapy and its potential use in managing equine osteoarthritis. Equine Veterinary Education. 2013: 204-209. 
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22. Hale LA, Waters D, Herbison P. A randomized controlled trial to investigate the effects of water-based exercise to improve falls risk and physical function in older adults with lower-extremity osteoarthritis. Arch Phys Med Rehabil. 2012;93(1):27-34. doi:10.1016/j.apmr.2011.08.004
23. Barker AL, Talevski J, Morello RT, Brand CA, Rahmann AE, Urquhart DM. Effectiveness of aquatic exercise for musculoskeletal conditions: a meta-analysis. Arch Phys Med Rehabil. 2014;95(9):1776-1786. doi:10.1016/j.apmr.2014.04.005
24. Wang TJ, Lee SC, Liang SY, Tung HH, Wu SF, Lin YP. Comparing the efficacy of aquatic exercises and land-based exercises for patients with knee osteoarthritis. J Clin Nurs. 2011;20(17-18):2609-2622. doi:10.1111/j.1365-2702.2010.03675.x
25. Lim JY, Tchai E, Jang SN. Effectiveness of aquatic exercise for obese patients with knee osteoarthritis: a randomized controlled trial. PM R. 2010;2(8):723-793. doi:10.1016/j.pmrj.2010.04.004 
26. Silva LE, Valim V, Pessanha AP, et al. Hydrotherapy versus conventional land-based exercise for the management of patients with osteoarthritis of the knee: a randomized clinical trial. Phys Ther. 2008;88(1):12-21. doi:10.2522/ptj.20060040
27. Assar S, Gandomi F, Mozafari M, Sohaili F. 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;12:27. Published 2020 Apr 29. doi:10.1186/s13102-020-00175-y 
28. Fransen M, Nairn L, Winstanley J, Lam P, Edmonds J. Physical activity for osteoarthritis management: a randomized controlled clinical trial evaluating hydrotherapy or Tai Chi classes. Arthritis Rheum. 2007;57(3):407-414. doi:10.1002/art.22621 
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31. Wyatt FB, Milam S, Manske RC, Deere R. The effects of aquatic and traditional exercise programs on persons with knee osteoarthritis. J Strength Cond Res. 2001;15(3):337-340
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43. Kim, S., Hsu, FC., Groban, L. et al. A pilot study of aquatic prehabilitation in adults with knee osteoarthritis undergoing total knee arthroplasty – short term outcome. BMC Musculoskelet Disord 22, 388 (2021). https://doi.org/10.1186/s12891-021-04253-1
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