What can Functional Assessment Do for Older Adults with Osteoarthritis and Comorbidities When Participating in a Long-Term Aquatic Therapy Program?

Opinion

More than 350 million people have arthritis globally (Global RA Network, 2021). Older adults with Osteoarthritis (OA) symptoms, such as pain, limb dysfunction, and general weakness, showed decreased activities in daily living, disturbed balance when walking, and dual-task limitations [1-3]. The common pain cycle shows that people who become less active demonstrate more pain, thus continuing the cycle. Indeed, inactive persons need a higher stimulus to become active. In an effective exercise program for healthy aging persons, we can promote activity in a satisfying way [4,5]. Aquatic Physiotherapy (AP) exercise is an increasingly popular option, enabling inactive subjects to return to an active lifestyle [6].

Despite the increased popularity of Aquatic therapy, many Physiotherapists (PTs) still have limited knowledge about this therapeutic solution and patient responsiveness [7]. Aquatic load characterization and dose-response for each patient category is still a problem that needs to be addressed for most of the AP conditions and exercises [8,9]. More information is needed before better promotional programs and activity sessions can be developed. This seems to be particularly relevant for elderly people, due to their frailty and limited plasticity [10]. These subjects have chronic diseases, use daily medication, and show a fear of falling; therefore, they move less safely [11-13]. Deeper knowledge of the functional perception profile of these patients will help clinicians arrive at a stronger prognosis for better physiotherapy results [14,15].

Although several studies have shown the efficacy of AP for improved balance and pain reduction in older adults, there is little information on the relationship between function in water and on dry land, particularly in the case of degenerative osteoarthritis diseases [16-18]. Nevertheless, a social community program in public pools appears to be less expensive and is often prescribed by doctors to help with aging. The preference for AP is based on the elderly expectations and satisfaction with the program. Usually, expectations were centered on decreased pain and falls and increased well-being, strength, relaxation, and activities of daily life [17]. Like other studies with OA patients, the patient goals are focused on pain, fall prevention, quality of life, and well-being [19]; and these outcome measures are most often used separately or together.

PTs have studied the efficacy and self-efficacy of AP in the daily life of older adults with OA. Researchers have concluded that an aquatic exercise program decreased pain, stiffness, and improves physical function while increasing self-efficacy in individuals with knee or hip OA [20]. This reinforces the regular prescription of AP by doctors to manage OA problems. A Patient’s recommendations have also been studied and show that older adults usually favor the aquatic exercises because of their own satisfaction [21,22]. Older adults usually consent to their prescribed therapy and activities for the better management of their health care with few misunderstands and provide feedback without hesitation [21]. Several studies confirmed the importance of AP programs for the improvement of self-efficacy in daily life and in functional outcomes in older adults with osteoarthritis [14,20,23]. But how do PTs measure a patient’s therapy process?

Methods

The Function Perception Scale (FPS) based on ICF is an instrument composed of the domains of function taken from the geriatric core set related to the perception of essential functions for dynamic balance, upper limb function, and fall prevention. It consists of 19 items, to be answered from 0 to 4 (0 – no difficulty, 1 – slight difficulty, 2 – moderate difficulty, 3– big difficulty, 4 – cannot execute). This tool can access the potential ability to perform aquatic exercises and predict the individual adaptation to water, leading to a better development in the aquatic physiotherapy program. Furthermore, researchers have also studied and developed tools to predict important factors to help clinicians deal with risks that occur in healthy aging [17,24,25].

Results

Despite the lack of evidence in the literature on a functional measure correlated with health problems and conditions for successful adaptation to the AT program, Graça et al. (2019) studied the FPS and found predictive proprieties for success in aquatic therapy in participants with Hyper Blood Pressure (HBP). Diabetes Mellitus, type 2 (DM2), when taking more than four medications and with a fear of falls. The researchers suggested that this information can be used to avoid constraining incidents during the first aquatic physiotherapy sessions [26]. The outcome of FPS can be used for exercise planning based on patient motor control and for evaluation on follow-up from a recovery based on ICF activities. Finally, the Spearman correlation showed a strong association between Disability of Arm, Shoulder, and Hand Scale (DASH) and FPS (0.708; significant at the 0.01 level). This reinforces the fact that upper limb disability was related to motor control performance. Our sample scores were lower on both scales, showing functional impairment. Health problems like Body Mass Index (BMI), HBP, and the use of more than four medications showed a strong association with FPS and between DASH and FPS. This means that using FPS can predict who will have problems in water adaptation and safety.

Conclusion

The functional benefits can be accessed by FPS in an easy was via self-reporting by patients. Through FPS, patients can look for the predictive factors according to the different kinds of motor control, which influences the planning of the aquatic physiotherapy intervention. Hyper Blood Pressure, DM2, more than 4 medications, and fear of falls showed a strong correlation with FPS and DASH, which can compromise the success of aquatic therapy intervention. Therefore, this tool can alert the physiotherapist to the patient’s fragility for water adaptation; and moreover, adjust the session planning within specific goals.

References

• Rhudy JL, Dubbert PM, Kirchner KA, Williams AE (2007) Efficacy of a program to encourage walking in VA elderly primary care patients: The role of pain. Psychology, Health & Medicine 12(3): 289-298.
• Soto Varela A, Rossi Izquierdo M, Faraldo García A, Vaamonde Sánchez Andrade I, Gayoso Diz P, et al. Balance Disorders in the Elderly. Annals of Otology, Rhinology & Laryngology 125(7): 550-558.
• Coelho T, Fernandes Â, Santos R, Paúl C, Fernandes L (2016) Quality of standing balance in community-dwelling elderly: Age-related differences in single and dual task conditions. Archives of Gerontology & Geriatrics 67: 34-39.
• Alikhajeh Y, Hosseini SRA, Moghaddam A (2012) Effects of Hydrotherapy in Static and Dynamic Balance Among Elderly Men. Procedia - Social and Behavioral Sciences 46: 2220-2224.
• Avelar IS, Soares V, Barbosa RC, Andrade SR, Silva MS, et al. (2018) The influence of a protocol of aquatic exercises in postural control of obese elderly. Revista Andaluza de Medicina del Deporte 11(2): 69-74.
• Kang HS, Ferrans CE, Kim MJ, Kim JI, Lee EO (2007) Aquatic exercise in older Korean women with arthritis: identifying barriers to and facilitators of long-term adherence. Journal of gerontological nursing 33(7): 48-56.
• Bartels EM, Juhl CB, Christensen R, Hagen KB, Danneskiold Samsøe B, et al. (2016) Aquatic exercise for the treatment of knee and hip osteoarthritis. The Cochrane database of systematic reviews 3: CD005523.
• Adsett JA, Mudge AM, Morris N, Kuys S, Paratz JD (2015) Aquatic exercise training and stable heart failure: A systematic review and meta-analysis. International journal of cardiology 186: 22-28.
• Adsett J, Morris N, Kuys S, Hwang R, Mullins R, Khatun M, et al. (2017) Aquatic Exercise Training is Effective in Maintaining Exercise Performance in Trained Heart Failure Patients: A Randomised Crossover Pilot Trial. Heart, lung & circulation 26(6): 572-579.
• Kunduracilar Z, Guvenir Sahin H, Sonmezer E, Sozay S (2018) The effects of two different water exercise trainings on pain, functional status and balance in patients with knee osteoarthritis. Complementary Therapies in Clinical Practice 31: 374-378.
• Stalenhoef PA, Diederiks JPM, Knottnerus JA, Kester ADM, Crebolder HFJM (2002) A risk model for the prediction of recurrent falls in community-dwelling elderly. Journal of Clinical Epidemiology 55(11): 1088-1094.
• Moreland JD, Richardson JA, Goldsmith CH, Clase CM (2004) Muscle Weakness and Falls in Older Adults: A Systematic Review and Meta-Analysis. Journal of the American Geriatrics Society 52(7): 1121-1129.
• Cadore EL, Rodríguez-Mañas L, Sinclair A, Izquierdo M (2013) Effects of different exercise interventions on risk of falls, gait ability, and balance in physically frail older adults: a systematic review. Rejuvenation research 16(2): 105-114.
• Loeser RF, Goldring SR, Scanzello CR, Goldring MB (2012) Osteoarthritis: a disease of the joint as an organ. Arthritis and rheumatism 64(6): 1697-1707.
• Brauer SG, Burns YR, Galley P (2000) A prospective study of laboratory and clinical measures of postural stability to predict community-dwelling fallers. The journals of gerontology Series A, Biological sciences and medical sciences 55(8): 469-476.
• Crenshaw JR, Bernhardt KA, Atkinson EJ, Khosla S, Kaufman KR, et al. (2018) The relationships between compensatory stepping thresholds and measures of gait, standing postural control, strength, and balance confidence in older women. Gait & posture 65: 74-80.
• Devereux K, Robertson D, Briffa NK (2005) Effects of a water-based program on women 65 years and over: a randomised controlled trial. The Australian journal of physiotherapy 51(2): 102-108.
• Munukka M, Waller B, Rantalainen T, Hakkinen A, Nieminen MT, Lammentausta E, et al. (2016) Efficacy of progressive aquatic resistance training for tibiofemoral cartilage in postmenopausal women with mild knee osteoarthritis: a randomised controlled trial. Osteoarthritis and cartilage 24(10): 1708-1717.
• Acree LS, Longfors J, Fjeldstad AS, Fjeldstad C, Schank B, Nickel KJ, et al. (2006) Physical activity is related to quality of life in older adults. Health and quality of life outcomes 4: 37.
• Kars Fertelli T, Mollaoglu M, Sahin O (2018) Aquatic Exercise Program for Individuals With Osteoarthritis: Pain, Stiffness, Physical Function, Self-Efficacy. Rehabil Nurs 44(5): 290-299.
• Monnin D, Perneger TV (2002) Scale to Measure Patient Satisfaction With Physical Therapy. Physical therapy 82(7): 682-691.
• Vanti C, Bonetti F, Ceron D, Piccarreta R, Violante FS, Guccione A, et al. (2013) Cross-cultural adaptation and validation of the Physical Therapy Outpatient Satisfaction Survey in an Italian musculoskeletal population. BMC musculoskeletal disorders 14(1): 125.
• Atroshi I, Gummesson C, Andersson B, Dahlgren E, Johansson A (2000) The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: reliability and validity of the Swedish version evaluated in 176 patients. Acta Orthop Scand 71(6): 613-618.
• Sheppard JP, Stevens R, Gill P, Martin U, Godwin M, et al. (2016) Predicting Out-of-Office Blood Pressure in the Clinic (PROOF-BP): Derivation and Validation of a Tool to Improve the Accuracy of Blood Pressure Measurement in Clinical Practice. Hypertension (Dallas, Tex : 1979) 67(5): 941-950.
• Hultenheim Klintberg I, Gunnarsson AC, Svantesson U, Styf J, Karlsson J (2009) Early loading in physiotherapy treatment after full-thickness rotator cuff repair: a prospective randomized pilot-study with a two-year follow-up. Clinical rehabilitation 23(7) 622-638.
• Graça M, Alvarelhão J, Costa R, Ribeiro A, Daly D, et al. (2019) Perception of functionality Scale based on ICF and related with the DASH Proceedings of the International Congress of Health and Well-being Intervention (ICHWBI 2019); Viseu, Portugal.