# Exercise as it relates to Disease/Hydrotherapy or Supreme Ultimate Boxing for Osteoarthritis Management: You Choose

This Wikibooks page is a fact sheet and analysis written by u3083830 focusing on the journal article.

## 1.    Osteoarthritis

Osteoarthritis (OA) is the degeneration of articular cartilage, commonly related to factors such as genetics, obesity, joint damage and age,,. In adults who are older than 40 years, it is the leading cause of pain and disability.
* OA affects 3 million Australians
* It is the third leading cause of life-years lost due to disability,
* Modifiable risk factors include obesity and avoiding injury
* OA results in 39,000 joint replacements in Australia annually

#### Exercise as Treatment

Physical activity is beneficial for individuals who have osteoarthritis, however, land-based exercise programs for this population has poor adherence due to increased levels of pain. There are many other exercise approaches (such as Tai Chi and Hydrotherapy) currently being researched which may provide the benefits of exercise whilst minimising pain.
Tai Chi (translated as ‘Supreme Ultimate Boxing’) is a type of exercise which comprises continuous slow movements including balance, strength and relaxation components. The evidence on Tai Chi in OA is limited and of poor quality,,.
Hydrotherapy is a common prescription for patients who suffer from hip or knee osteoarthritis due to the weight relieving characteristic of that being submersed in water allows. Current evidence on hydrotherapy has mostly been conducted on patients with significant progression in OA, which questions the validity of the results,.
As the article being analysed only compared the effects of Hydrotherapy and Tai Chi on hip and knee OA, this is what the following information will focus on.

## 2. Hydrotherapy or Supreme Ultimate Boxing (Tai Chi)?
#### Where is the research from?

This research was conducted at the St George Hospital, NSW, Australia. The study was supported by a National Arthritis and Musculoskeletal Conditions Improvement (NAMCI) grant.
* The location of the study may impact on the types of participants which are chosen e.g. if all participants are on the hospital joint replacement waiting list, the results may not be applicable to a person at the beginning stages of OA.
* A hospital also may not have the same facilities as a health club and therefore the training conditions provided may not reflect a community setting.
* This study was funded by the NAMCI grant. This funding needs to be noted as it can pressure the authors into publishing results which may be considered favorable by the NAMCI Advisory Group.
* All authors involved are physiotherapists, increasing applicability to other physiotherapists with OA patients.

#### What kind of research was this?

This research was a single blinded Randomised Control Trial (RCT). Below is a table discussing the advantages and disadvantages of this RCT. An RCT is the second highest level of evidence behind a systematic review (summary of many collated individual RCT's). An RCT is considered superior to cohort, case control and case report studies.
| Advantages | Disadvantages |
| Randomisation assumes all groups are equal for all known and unknown characteristics | Results may not correlate in populations not included within the study |
| Eliminates risk of bias in treatment assignment e.g. selection bias | High drop-out rates if the treatment is not producing beneficial results |
| Allows an environment for blinding of assessors which assists in minimising bias by reducing the affects of preconceptions and performance on the outcomes | Expensive to conduct |

#### What did this study include?

The study included participants who were between 59–85 years old with a diagnosis of either hip or knee osteoarthritis which resulted in pain lasting over the previous year. These patients were then randomly allocated to either hydrotherapy, Tai Chi or control groups. The main assessment measures were based on pain and physical function.

#### What were the basic results?

After 12 weeks, both groups demonstrated moderate treatment effect sizes in pain and physical function when compared to control. However, only hydrotherapy demonstrated ‘slight’ improvement in physical performance measures. Furthermore, 49% of the hydrotherapy and 34% of the Tai Chi participants were considered 'treatment responders' as per the Osteoarthritis Research Society International (OARSI) responder criteria.

#### Conclusions and Critiques

There are several aspects which need to be considered before drawing conclusions from this research.
* Poor treatment adherence was evident in this study, especially in the Tai Chi group, with 39% of participants attending less than half of the available classes. This has the potential to skew the results in favour of hydrotherapy (which had a non-attendance rate of only 19%).
* This study only included exclusively white ethnicity, potentially making the conclusions less applicable to other ethnic backgrounds.
* Many of the participants had reported osteoarthritis for > 6 years which is correlated to decreased responsiveness to exercise. This may lead to an underestimation of the effect of either intervention in individuals with mild to moderate structural disease.
* Less than half of the participants in either group met the OARSI responder criteria - the agreed upon effect size of an OA treatment for it to be classed as effective.
It is important to note that the appropriateness of the methods in this study and the research techniques utilised decreased the chance of bias and increased the overall quality of the research. Therefore, even though further research is required, we can trust the credibility of the authors conclusions.

## 3.    Practical advice

The main conclusion from this research is that if you are suffering from OA, the best treatment you can undertake is what works best for you whether that be either of the interventions above or not. The authors demonstrated that hydrotherapy or Tai Chi can provide benefits to some individuals living with hip or knee osteoarthritis. However, it would be wise to continue to look out for research in future which meets the OARSI responder criteria and has a greater spread across ethnicity groups, better adherence and a wider inclusion of various OA progressions.

#### Food for thought...

Perhaps keep an eye out for an interesting concept which the authors theorised by combining the two into a water based Tai Chi. Would this be the best of both worlds? Further research will tell.

#### Further information/resources

For further information about this article, please contact:
* Marlene Fransen, PO Box M201 Missenden Road, Camperdown, New South Wales, Australia 2050. E-mail: mfransen@thegeorgeinstitute.org
Other resources include:
* http://www.arthritisaustralia.com.au/ - An organisation which provides support and information to Australians living with arthritis
* http://www.aihw.gov.au/osteoarthritis/ - For further information and statistics on Osteoarthritis
* http://www.taichiaustralia.com.au/ - For access to Tai Chi Classes in Australia (currently only in Melbourne, South Australia and Tasmainia)
* http://www.guysandstthomas.nhs.uk/resources/patient-information/therapies/physiotherapy/hydrotherapy-knee-oa-exercise-sheet.pdf - Link to an example hydro therapy program for knee OA.

## References

* 1 2 3 4 5 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 Care & Research. 2007;57(3):407-14.
* 1 2 3 4 5 March, L. M., & Bagga, H. (2004). Epidemiology of osteoarthritis in Australia. Medical Journal of Australia, 180(5), S6.
* 1 2 Munro, J. F., Nicholl, J. P., Brazier, J. E., Davey, R., & Cochrane, T. (2004). Cost effectiveness of a community based exercise programme in over 65 year olds: cluster randomised trial. Journal of epidemiology and community health, 58(12), 1004-1010.
* ↑ Buckwalter, J. A., & Mankin, H. J. (1997). Articular cartilage: degeneration and osteoarthritis, repair, regeneration, and transplantation. Instructional course lectures, 47, 487-504.
* 1 2 3 Fransen M, Crosbie J, Edmonds J. Physical therapy is effective for patients with osteoarthritis of the knee: a randomized controlled clinical trial. The Journal of rheumatology. 2001;28(1):156-64.
* ↑ Hartman, C. A., Manos, T. M., Winter, C., Hartman, D. M., Li, B., & Smith, J. C. (2000). Effects of T'ai Chi training on function and quality of life indicators in older adults with osteoarthritis. Journal of the American Geriatrics Society, 48(12), 1553-1559.
* ↑ Song, R., Lee, E.-O., Lam, P., & Bae, S.-C. (2003). Effects of tai chi exercise on pain, balance, muscle strength, and perceived difficulties in physical functioning in older women with osteoarthritis: a randomized clinical trial. The Journal of rheumatology, 30(9), 2039-2044.
* ↑ Foley, A., Halbert, J., Hewitt, T., & Crotty, M. (2003). 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. Annals of the rheumatic diseases, 62(12), 1162-1167.
* ↑ Petticrew M, Roberts H. Evidence, hierarchies, and typologies: horses for courses. Journal of epidemiology and community health. 2003;57(7):527-9.
* 1 2 Stang A. Randomized controlled trials—an indispensible (sic) part of clinical research. Deutsches Ärzteblatt International. 2011;108(39):661.
* ↑ Levin KA. Study design VII. Randomised controlled trials. Evidence-based dentistry. 2007;8(1):22 5. Petticrew M, Roberts H. Evidence, hierarchies, and typologies: horses for courses. Journal of epidemiology and community health. 2003;57(7):527-9
* ↑ Karanicolas, P. J. (2010). Practical tips for surgical research: blinding: who, what, when, why, how?. Canadian Journal of Surgery, 53(5), 345.
* 1 2 Pham, T., van der Heijde, D., Altman, R., Anderson, J., Bellamy, N., Hochberg, M., . . . Dougados, M. (2004). OMERACT-OARSI initiative: Osteoarthritis Research Society International set of responder criteria for osteoarthritis clinical trials revisited. Osteoarthritis and Cartilage, 12(5), 389-399.