Medical rehabilitation : the effects of aquatic physiotherapy in patients with rheumatoid arthritis

Background: Hydrotherapy is frequently indicated in the management of rheumatoid arthritis (RA) patients. Few randomised controlled trials (RCTs) have investigated the effects of hydrotherapy in RA and their findings are inconclusive. Aims: The aim of this thesis was to evaluate the difference in outcomes (including physical function, quality of life, disease activity, psychological wellbeing and cost) between a 6-week course of hydrotherapy compared to land-based therapy for patients with RA. Methods: Forty-three patients (mean age = 60 years; SD = 15.3) diagnosed with RA were randomly assigned into either a hydrotherapy plus home exercise (n = 21) or land based therapy plus home exercise group (n = 22). Hydrotherapy included a weekly 45 minutes session for six weeks in addition to a home-exercise programme. Land-therapy included weekly 45 minutes sessions over six weeks plus home-exercise therapy. Patients were assessed at baseline (Test 1); six weeks (Test 2), three months (Test 3), and six months (Test 4) post-treatment. The Primary outcome measured was functional ability using the Health Assessment Questionnaire-Disability Index (HAQ-DI). Secondary outcomes, including HAQ VAS (pain scale), HAQ-GWB (general wellbeing), HRQoL using the EQ-5D VAS, EQ-5D tariff, EQ-5D profile and Quality Adjusted Life Years (QALYs) were calculated. Disease Activity was measured using RA Disease Activity Index (RADAI) and Disease Activity Score 28 (DAS28). Hospital Anxiety and Depression Scale (HADs) was used to measure psychological wellbeing. Costs to the provider (NHS), society and patient were also collected. Results: Change scores were calculated for all outcome measures between Test 1 and 2; Test 1 and 3; Test 2 and 3 and were used for data analysis. Patients treated with hydrotherapy experienced improvement in functional ability (HAQ-DI; p < 0.001), pain (HAQ VAS; p < 0.001), general wellbeing (HAQ-GWB; p < 0.001), HRQoL (EQ-5D VAS; p = 0.021), psychological wellbeing (HADs; p = 0.023). Moderate correlation was found in all RA patients between the RADAI and DAS28 (r = 0.328, p = 0.032). Moderate correlation was found between depression score (HAD-D) and RADAI (r = 0.578, p < 0.001); there was also moderate significant correlation between anxiety score (HAD-A) and RADAI (r = 0.425, p = 0.005). Predictors of functional disability in patients with RA were RADAI, EQ-5D tariff, GWB, depression score and anxiety score. The characteristics of patients recruited to this study reflected the RA population in Greater Manchester in terms of age, disease duration (DD), gender, body mass index (BMI) and DAS28. Finally, there were no difference between hydrotherapy and land-based treatment in terms of costs to the patient or society, however, when four patients were treated in the pool compared to one patient on land, hydrotherapy was less costly and more effective in improving functional disability. Conclusions: RA patients in the hydrotherapy group showed significant improvement in physical function, psychological well-being, quality of life and reduced health care utilisation compared to those in the land-therapy group. Group hydrotherapy is also less costly compared to one–to-one treatment on land.