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Systematic review

The effect of hydrotherapy for persons with musculoskeletal disorders

Based on the findings from the two controlled trials included in this systematic review, it is unclear whether hydrotherapy influences sick absences among women with fibromyalgia or chronic widespread pain.

Based on the findings from the two controlled trials included in this systematic review, it is unclear whether hydrotherapy influences sick absences among women with fibromyalgia or chronic widespread pain.


Key message

Musculoskeletal disorders are common in the Norwegian population. These disorders are reported as the main contributor to sick leave and work absence. The Norwegian Rheumatism Association commissioned the Norwegian Knowledge Centre 1) to summarise the effects of hydrotherapy (training in warm water) on sick absence and return- to- work among persons with musculoskeletal disorders, and 2) to provide a list of systematic reviews that summarised the effects of hydrotherapy on pain, function and quality of life.

A systematic review was conducted that included two studies. Both studies investigated the effects of hydrotherapy in combination with another type of training and cognitive behavior therapy or an education program that promoted coping strategies on self-reported sick absence during the last week among women with fibromyalgia.

The two studies showed that:

  • It is unclear if hydrotherapy in combination with an educational programme  for women with fibromyalgia or chronic widespread pain, give less self-reported days off work due to fibromyalgia symptoms compared to education programme only.  The documentation was of very low quality.
  • It is unclear if hydrotherapy in combination with land-based training, cognitive therapy and a patient information leaflet  to women with fibromyalgia, give less self-reported days off work due to fibromyalgia symptoms, compared to patient information leaflet only. The documentation was of very low quality.

None of the included studies evaluated the effects of hydrotherapy among other groups of musculoskeletal disorders than fibromyalgia and chronic widespread pain.

We identified 62 systematic reviews that summarised the effects of hydrotherapy on pain, function and quality of life. These systematic reviews are categorised and attached in a list.

Summary

Background

Musculoskeletal disorders are frequent in the Norwegian population. The most common musculoskeletal disorders are rheumatoid arthritis, ankylosing spondylitis, osteoarthritis, osteoporosis, fibromyalgia, back-, neck-, shoulder- and hip disorders. Musculoskeletal disorders are reported as the main contributor to sick leave and disability retirement. There are great individual variations to what extent the different musculoskeletal disorders influence pain, quality of life, everyday life and work life. These disorders are reported as main contributors to sick leave and work absence. Often musculoskeletal disorders leads to permanent disability.

Hydrotherapy (training in warm water) is one of many rehabilitation interventions offered to persons with musculoskeletal disorders in Norway, especially to persons with rheumatoid arthritis, fibromyalgia, and pelvic girdle pain in pregnancy. Due to the heterogeneity of the musculoskeletal group, one might expect different effects of hydrotherapy depending on condition. The Norwegian Rheumatism Association commissioned the Norwegian Knowledge Centre to summarise the effects of hydrotherapy on sick leave and return- to- work among persons with musculoskeletal disorders.

 

Objective

The aim of this systematic review was to answer the following questions:

  1. What is the effect of hydrotherapy (in this review: training in warm water)  compared to no training, waiting list or another type of training on sick absence and return-to-work among persons with musculoskeletal disorders?
  2. Are there systematic reviews summarising the effects of hydrotherapy on pain, function, and/or quality of life among persons with musculoskeletal disorders?

 

Method

We searched the following databases for relevant studies: MEDLINE, AMED, Embase, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, Health Technology Assessment (HTA) Database, Database of Abstracts of Reviews of Effects (DARE), OTSeeker, PEDro, CINAHL, PubMed  og Web of Science. The search strategy was developed in collaboration with a librarian.  

We included trials that met the following criteria:

(a) a study population suffering from musculoskeletal disorders for more than 3 months;

(b) evaluating the effects of hydrotherapy alone or in combination with other interventions;

(c) comparing to no hydrotherapy, waiting list or another type of training (but not training in warm water); 

(d) with outcomes on self-reported or register-based sick absence, days away from work due to a musculoskeletal disorders, and return-to work (aim 1) and pain, function and quality of life (aim 2); and  

(e) randomised controlled trials and clinical controlled trials were eligible for inclusion to answer question 1 and systematic reviews were identified to answer question 2.

We searched for controlled trials to answer question one. Two reviewers screened the literature, critically assessed the risk of bias of the studies, and extracted data independently. We applied the instrument Grading of Recommendations Assessment, Development and Evaluation (GRADE) to assess the extent to which we have confidence in the effect estimates.  

We searched for systematic reviews to answer the second question. Relevant systematic reviews were identified. The results from these systematic reviews were not summarised and the reviews were not critically appraised. They were categorised in a list of abstracts only.

Results

The search for controlled trials yielded 1763 hits, of which two trials were included. Both of the studies evaluated the effects of hydrotherapy among women with fibromyalgia or chronic widespread pain, measured with the Fibromyalgia Impact Questionnaire (FIQ). FIQ reported a total score based on 10 subscales. Only one of these subscales met our inclusion criteria. The relevant subscale collected data on self-reported days off work due to fibromyalgia symptoms.

A randomised controlled trial showed that hydrotherapy including an educational programme for women with fibromyalgia or chronic widespread pain had small or no effects on self-reported percentage days off work due to fibromyalgia symptoms compared to an educational programme only (MD: -9,32 % (95 % CI -23,94 % to 5,30 %). A non-randomised controlled trial showed that women with fibromyalgia participating in deep water running as part of a multimodal  programme reported less days off work due to fibromyalgia symptoms, than women who only received a patient information leaflet (MD: -0,69 (95 % CI -1,03 to -0,35) (normalized score range 0-10) .

We also identified 62 systematic reviews summarising the effects of hydrotherapy on pain, function, and quality of life on for persons with musculoskeletal disorders. The reviews were categorised according to type of disorder and listed in the appendix.

 

Discussion

Both of the two included studies investigated the effects of hydrotherapy among women with fibromyalgia or chronic widespread pain limiting the possibility of generalisation to other musculoskeletal disorders. Due to the different study design of the two included studies, no meta-analysis was possible and therefore, the studies had to be GRADE evaluated separately. The outcome was measured with FIQ, an instrument that does not differentiate housework from paid work.  In addition, only one out of ten subscales referred to sick absence. The studies reported different effect estimates on sick absence. Therefore, based on different calculation method the results on sick absence were not comparable. Due to these limitations, the quality of documentation was evaluated to very low. This influenced our confidence in the effect estimates and the true effect might be very different from the effect estimate.

Conclusion

Based on the findings from the two controlled trials included in this systematic review, it is unclear whether hydrotherapy influences sick absences among women with fibromyalgia or chronic widespread pain. 

  • More randomised controlled trials are needed that assess the effects of hydrotherapy on sick absence and return-to-work  including other participants than women with fibromyalgia or chronic widespread pain.

62 systematic reviews that summarised the effects of hydrotherapy for persons with musculoskeletal disorders on pain, function and quality of life were identified. These reviews answered question two.

    About this publication

  • Year: 2015
  • Authors Myrhaug HT, Strøm V, Hafstad E, Kirkehei I, Reinar LM.
  • ISSN (digital): 1890-1298
  • ISBN (digital): 978-82-8121-960-1