# Exercise as it relates to Disease/Is Hydrotherapy the new therapy for Parkinson's Disease?

This is an analysis of the journal article Daniele Volpe, Maria Giulia Giantin, Roberto Maestri, Giuseppe Frazzitta, 2014 "Comparing the effects of hydrotherapy and land-based therapy on balance in patients with Parkinson’s disease: a randomized controlled pilot study" Clinical Rehabilitation Vol 28,Issue 12, pp. 1210 - 1217 First published date: June-03-2014 DOI: 10.1177/0269215514536060

## What is the background to this research?

Parkinson’s Disease (PD) is a chronic and progressive degeneration of the neurological pathways that become more prevalent in an aging population. PD affects about 1 in 100 people over the age of 65 and rises to 3 in 100 at 85 years old, making it a relevant neurological condition with the aging population in Australia.
PD patients experience poor balance and frequent falls as the disease progresses, meaning there is a risk for further complications such as fractures and social isolation due to fear. The benefits of pharmacology advancements still don’t help PD patients regain the loss of balance that they suffer, but only slows the progression of PD. Some research has shown benefits in PD patients balance and walking with physiotherapy and the newest advancement has been dancing. But with hydrotherapy being a preferred treatment with other neurological conditions such as Cerebral Palsy, are there benefits for PD?

## Where is the research from?

Daniele Volpe has been involved in Parkinson’s research for many years, with previous research identifying major breakthroughs, including the benefits of dancing for improving balance in patients with Parkinson’s.
The research was completed in Italy at a hospital with participants being eligible to enter the 2-month study. Of the 40 eligible patients, 2 did not meet the criteria and another 4 chose not to participate. To complete the study the clinicians were all part of journal article publishers, had no grants for the experimental study and no conflict of interest, as reported by them.

## What kind of research was this?

The study was a randomized single-blind controlled trial. This is an important technique as it is able to assess the benefits across a group of people with the condition who can be linked to other patients outside the study. If there are any side effects or risks of the treatment, it will also allow therapists to educate patients about these prior to using it.

## What did the research involve?

| | Hydrotherapy | Land-based exercises |
| How long is the class | 60 | 60 |
| No. times a week | 5 | 5 |
| For how long | 2 months | 2 months |
| Movement | The same exercises as Land based exercises just in water | Exercises as according to Dutch physiotherapy guidelines |
Participants were randomly placed into two groups through a computer algorithm and organized by someone not involved in the process. This has the benefits of being a blind allocation so results are not skewed by bias. Diagnosis of PD was checked with a neurological specialist and selection criteria were clearly outlined for relevant physicians to see if research is relevant.
The primary outcome measure is sway area, which is shown to correlate strongly with increased falls and isn’t affected by tripping in elderly people aged 60-96. It is also easily reproducible with the same conditions and isn’t an outcome improvement subjected to bias. There are a number of secondary outcomes of subjective reports or tests susceptible to clinician error or bias. The participant size was a small 34 patients, making the study an experimental based research of whether there is any possible benefit of hydrotherapy in PD, rather than a gold standard technique that hydrotherapy should be included in the therapy program for PD patients. The follow-up was only a week later, so long-term benefits are unknown.

## What were the basic results?

| | Pre Hydrotherapy | Post Hydrotherapy | Difference | Pre Land Exercises | Post Land Exercises | Difference |
| COPSwayOE | 74.9 ± 55.2 | 124.6 ± 58.9 | 49.7 ± 67.1 | 117.0 ± 61.6 | 142.5 ± 106.4 | 25.4 ± 63.8 |
| COPSwayCE | 45.6± 42.1 | 91.0 ± 56.9 | 45.4 ±64.9 | 77.4 ± 67.1 | 84.3 ± 91.2 | 6.9 ± 45.3 |
| TUG (s) | 13.1 ± 3.8 | 11.0 ± 2.0 | -2.0 ± 2.3 | 12.8 ± 3.0 | 11.6 ± 2.9 | -1.1 ± 1.1 |
| FES | 11.9 ± 6.5 | 6.0 ± 4.2 | -5.9 ± 4.8 | 11.8 ± 6.2 | 9.8 ± 5.6 | - 1.9 ± 1.4 |
TUG: Timed up and Go, FES: falls efficacy scale.
The small sample size has resulted in a large variation with the standard deviation being close to the actual score for some of the key primary outcomes. However, the authors have used their results to conclude that hydrotherapy was safe and viable as well as having better balance scores than the land-based exercises.
Volpe has effectively highlighted the limitations of the study and therefore the conclusions that he makes due to the limited results. Emphasising that the study shows Hydrotherapy has the same impact, if not a greater impact, than land-based therapy classes.

## What conclusions can we take from this research?

This study has shown that Hydrotherapy in the PD population is safe with short-term improvements similar to if not better than land-based exercises. To achieve such results patients are required to do 5 sessions a week of 60 minutes.
These findings are similar to other small study groups looking at the benefits of aqua therapy in the PD group. These groups also showed improvements in Unified Parkinson’s Disease Rating Scale (UPDRS) and Berg Balance Scale.
Since the article was published there have been numerous small studies including a systematic review that showed Hydrotherapy having the same impact or greater impact than land-based exercises . None of the studies reported any medical or safety concerns in the hydrotherapy group. This supports Volpe's research in this article.

## Practical advice

If in an environment conducting land-based exercise classes for PD patients where there is access to a pool, hydrotherapy is a safe and feasible alternative with good social aspects, without a loss of balance improvements sought after with Physiotherapy.

## References

* 1 2 Sveinbjornsdottir, S. (2016), The clinical symptoms of Parkinson's disease. J. Neurochem., 139: 318–324. doi:10.1111/jnc.13691
* 1 2 3 4 5 6 7 8 9 Daniele Volpe, Maria Giulia Giantin, Roberto Maestri, Giuseppe Frazzitta, (2014) “Comparing the effects of hydrotherapy and land-based therapy on balance in patients with Parkinson’s disease: a randomized controlled pilot study” Clinical Rehabilitation Vol 28, Issue 12, pp. 1210 – 1217, DOI: 10.1177/0269215514536060
* 1 2 Jamile Vivas PhD, PTa.Pablo Arias PhDb. Javier Cudeiro PhD, MD (2011) “Aquatic Therapy Versus Conventional Land-Based Therapy for Parkinson's Disease: An Open-Label Pilot Study” Volume 92, Issue 8, August 2011, Pages 1202-1210 https://doi.org/10.1016/j.apmr.2011.03.017
* 1 2 Daniele Volpe, Matteo Signorini, Anna Marchetto, Timothy Lynch, Meg E Morris (2013) A comparison of Irish set dancing and exercises for people with Parkinson’s disease: A phase II feasibility study BMC Geriatrics, 2013, Volume 13, Number 1, Page 1
* 1 2 Guyatt, G. H., Oxman, A. D., Vist, G. E., Kunz, R., Falck-Ytter, Y., Alonso-Coello, P., & Schünemann, H. J. (2008). GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ : British Medical Journal, 336(7650), 924–926. http://doi.org/10.1136/bmj.39489.470347.AD
* ↑ Overstall, P. W., Exton-Smith, A. N., Imms, F. J., & Johnson, A. L. (1977). Falls in the elderly related to postural imbalance. British Medical Journal, 1(6056), 261–264
* ↑ Pompeu, J. E., Gimenes, R. O., Pereira, R. P., Rocha, S. L., & Santos, M. A. (2013). Effects of aquatic physical therapy on balance and gait of patients with Parkinson's disease. J Health Sci Inst, 31(2), 201-4
* ↑ Aan Fleur Terrens, Sze-Ee Soh & Prue Elizabeth Morgan (2017) “The efficacy and feasibility of aquatic physiotherapy for people with Parkinson’s disease: a systematic review” Disability and Rehabilitation Vol. 0 , Iss. 0,0
* ↑ Louise M.CarrollMSc, DanieleVolpeMD, Meg E.MorrisPhD, JeanSaundersPhD, Amanda M.CliffordPhD (2017), Aquatic Exercise Therapy for People With Parkinson Disease: A Randomized Controlled Trial Archives of Physical Medicine and Rehabilitation, Volume 98, Issue 4, April 2017, Pages 631-638, https://doi.org/10.1016/j.apmr.2016.12.006