Research Article: The benefits of hydrotherapy to patients with spinal cord injuries

Date Published: May 16, 2018

Publisher: AOSIS

Author(s): Terry J. Ellapen, Henriëtte V. Hammill, Mariëtte Swanepoel, Gert L. Strydom.


Many patients with spinal cord injury (PWSCI) lead sedentary lifestyles, experiencing poor quality of life and medical challenges. PWSCI don’t like to participate in land-based-exercises because it’s tedious to perform the same exercises, decreasing their rehabilitative compliance and negatively impacting their well-being. An alternative exercise environment and exercises may alleviate boredom, enhancing compliance.

Discuss the benefits of hydrotherapy to PWSCI concerning underwater gait-kinematics, thermoregulatory and cardiovascular responses and spasticity.

A literature surveillance was conducted between 1998 and 2017, through the Crossref meta-database and Google Scholar, according to the PRISMA procedures. Key search words were water-therapy, aquatic-therapy, hydrotherapy, spinal cord injury, rehabilitation, human, kinematics, underwater gait, cardiorespiratory, thermoregulation and spasticity. The quality of each paper was evaluated using a modified Downs and Black Appraisal Scale. The participants were records pertaining to PWSCI and hydrotherapy. The outcomes of interest were: hydrotherapy interventions, the impact of hydrotherapy on gait-kinematics, thermoregulation during water submersion and cardiorespiratory function of PWSCI. Omitted records included: non-English publications from before 1998 or unrelated to hydrotherapy and PWSCI. The record screening admissibility was performed as follows: the title screen, the abstract screen and the full text screen.

Literature search identified 1080 records. Upon application of the exclusion criteria, 92 titles, 29 abstracts and 17 full text records were eligible. Only 15 records were selected to be included in this clinical commentary. Evidence shows a paucity of randomised control trials (RCT) conducted in this field.

Hydrotherapy improves PWSCI underwater gait-kinematics, cardiorespiratory and thermoregulatory responses and reduces spasticity.

Partial Text

Hydrotherapy, also known as aquatic or water therapy, has long been perceived as an effective, yet underutilised, therapeutic modality (Kesiktas et al. 2004). The benefits of hydrotherapy include enhanced aerobic capacity, improved muscle strength and endurance, increased joint range of motion (anti-spasticity), as well as decreased muscle fatigue and joint pain, enhanced cardiorespiratory functioning and a reduced cardiometabolic risk profile (Kesiktas et al. 2004). The majority of patients with spinal cord injury (PWSCI) lead sedentary lives, associated with a poor cardiometabolic profile (diabetes mellitus, increased insulin resistance, decreased insulin sensitivity, increased adiposity, obesity and body mass index as well as poor cardiorespiratory function) (Nooijen et al. 2016). Attempts to combat the poor cardiometabolic risk profile of PWSCI usually involve upper limb land-based exercises (Tweedy et al. 2016). La Fountaine et al. (2015) reported that these upper limb exercises are not as effective as lower limb exercises with regard to expending energy. A primary goal of exercising is to increase PWSCI’s energy expenditure, thereby improving their poor cardiometabolic risk profile (La Fountaine et al. 2015). In order to increase energy expenditure, the rehabilitation programme’s frequency, intensity and duration are increased, so that in turn it often leads to more upper limb injuries (Ellapen et al. 2017). Ellapen et al. (2017) reported that habitual use of the same upper body exercises leads to overuse orthopaedic injuries and boredom, resulting in poor rehabilitative exercise adherence. Strydom et al. (2009) reported that variation in habitual exercise and rehabilitative regimes increases patient adherence and subsequently is able to positively impact the realisation of the programme objectives. Hydrotherapy provides the following alternative options to land-based exercises: (1) a different rehabilitative environment, (2) the prescription of different upper limb and core exercises and (3) the opportunities for group and/or individual rehabilitation sessions with the exercise therapist (thereby increasing social interaction) (Kesiktas et al. 2004).

The authors followed the standard practices for systematic reviews: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

The literature review identified 1080 records by the use of the key search words (water therapy, aquatic therapy, hydrotherapy, spinal cord injury, rehabilitation and human). The application of additional key words (kinematics underwater gait, cardiorespiratory, thermoregulation and spasticity) resulted in 92 records. All the titles of each record were screened (n = 92); however, only 29 abstracts were screened. Thirty-seven animal records, 26 duplicate records, 10 records pertaining to non-PWSCI and 2 non-English records were excluded. The remaining 17 full text records were reviewed. Two full text records comprised of one animal record and the other that pertained to the adoption of hydrotherapy as an ergogenic aid. The remaining 15 records comprised of 4 systematic reviews pertaining to PWSCI (but 2 specific to hydrotherapy), 7 non-randomised control trials, 2 randomised control and 2 case studies (Table 2). Table 1 assesses the quality of each record according to the modified Downs and Black Appraisal Scale (in an attempt to eliminate risk of biasness). A descriptive overview of the characteristics and findings of the studies is found in Table 2. A total of 142 participants were reported (but 83 PWSCI), with sample sizes varying from 1 to 30 and participant age varying from 5 to 70 years. Five studies provided kinanthropometric characteristics, whereas 5 studies considered the number of years injured, and 10 studies described the aquatic exercise intervention. The overall quality of the studies was rated as fair (62.0%) (Table 1).

The discussion will focus on the empirical findings of the impact of hydrotherapy on the gait kinematics of PWSCI as well as their thermoregulatory, spasticity and cardiorespiratory responses.

Hydrotherapy aids in reducing PWSCI muscle spasticity and cardiometabolic risk profiles, while favourably enhancing underwater gait kinematics and cardiorespiratory capacity. However, more RCT should be undertaken to increase the present body of knowledge.




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