If a recent review of relevant international scientific literature is anything to go by, evidence-based research demonstrating the effectiveness of aquatic therapy (exercise or bathing) is thin on the ground and not that encouraging. (See more about this review later in this post.)
Despite an increasing drive for evidence-based therapy - which in the current US climate may be inspired in no small part by a desire to bill for medical insurance coverage - gaining scientific validity for aquatic modalities in clinics or in spas (this is especially sought by medi-spas) is not likely to be easy.
Though 'more and better' clinical research might appear to be the obvious answer to this problem (see next post in this series), very few people seem to dare ask whether that is actually true. Few apparently wonder whether scientific proof is in all cases the key to effective and long-term healing in practice. And, if they wonder aloud, perhaps they risk losing what credibility they might have.
Of course, this is a tricky question since you might have to look closely at what you're dealing with, what problem, what person, and what circumstance. But you might also step back and take a wider perspective, perhaps a philosophical one. I admit that this is a subject that underlies my writing here.
Despite an increasing drive for evidence-based therapy - which in the current US climate may be inspired in no small part by a desire to bill for medical insurance coverage - gaining scientific validity for aquatic modalities in clinics or in spas (this is especially sought by medi-spas) is not likely to be easy.
Though 'more and better' clinical research might appear to be the obvious answer to this problem (see next post in this series), very few people seem to dare ask whether that is actually true. Few apparently wonder whether scientific proof is in all cases the key to effective and long-term healing in practice. And, if they wonder aloud, perhaps they risk losing what credibility they might have.
Of course, this is a tricky question since you might have to look closely at what you're dealing with, what problem, what person, and what circumstance. But you might also step back and take a wider perspective, perhaps a philosophical one. I admit that this is a subject that underlies my writing here.
In a presentation at the ATRI National Aquatic Healthcare Conference, Chicago, Nov. 2009, I set out to demonstrate that it is not always appropriate to assess the therapeutic value of alternative practices by scientific methods. Nor is it reasonable or helpful to devalue or sideline such practices when they do not suit these validation methods, unless of course they cause actual harm*.
Many aspects of health depend on individual factors, such as quality and value of life judgments, and are only partially subject to scientific methods. While evidence-based medicine aims to predict the outcomes of treatments (useful for cost analyses for example), it does not usually address what best suits human circumstance.
Is it possible that, because of the defining stringency of scientific requirements, untapped resources of potentially valuable information are being ignored or overlooked? Could that lead to the suppression or even elimination of practices that are helpful but are not deemed acceptable by scientific standards?
I think there is a need to at least acknowledge this possible limitation and loss. I would also like to suggest that one way to balance any move to limit or devalue the practice of 'unproven' therapies, such as some aquatic therapies, is effectively to collect, gather, and share anecdotal information and simple data.
Opportunities and encouragement in doing this of those involved in practicing aquatic therapy and those who benefit from it, whether in clinical or non-clinical settings (like spas and private practices), could help revive our awareness of the importance and real value of self-directed (albeit not scientific) healing choices.
Despite whatever is efficient in business terms, individuals seem to do better when they choose their therapies and therapists on the basis of a combination of very personal motivations. I think it unlikely that we will ever be able to provide rational explanations or effective controls for this. And yet we keep trying.
Can scientific research realistically be done on all the healing methods that are helping people? Will the results of such research help more of the people, most of the time, when they need it? And, if not, how will we ensure that untested methods that people do find helpful continue to be available to them?
It is arguable that we might get deeper and more lasting value - for some issues at least - by looking more closely at the subjective elements of health care - from an individual's life choices, to the person by whom, and context in which, they are given help. These are aspects that the so-called alternative therapies often value highly.
An outline of the findings of the review article that prompted this post may help illustrate the limitations of current scientific research on aquatic therapy, and provide a point of departure for further discussion. The authors are calling for better research methodology and they might be right. Or are they?
A systematic review of aquatic therapy
Effectiveness of aquatic exercise and balneotherapy: A summary of systematic reviews based on randomized controlled trials of water immersion therapies. Hiroharu Kamioka et al. J. Epidemiol. 2010, 20(1):2-12.Download Review of aquatic therapies (H.Kamioka et al)
The authors of this study searched the existing scientific literature for systematic reviews based on randomized controlled trials (RCTs); they excluded systematic reviews of non-RCTs or observational (anecdotal) studies. In other words, they were only interested in conventional scientific data.
Systematic reviews are now being advocated as a way for healthcare professionals to keep abreast of their fields. In this review study, the AMSTAR checklist (2007) was used to assess the methodological quality of the systematic reviews. Here's an extract about this assessment tool:
Many aspects of health depend on individual factors, such as quality and value of life judgments, and are only partially subject to scientific methods. While evidence-based medicine aims to predict the outcomes of treatments (useful for cost analyses for example), it does not usually address what best suits human circumstance.
Is it possible that, because of the defining stringency of scientific requirements, untapped resources of potentially valuable information are being ignored or overlooked? Could that lead to the suppression or even elimination of practices that are helpful but are not deemed acceptable by scientific standards?
I think there is a need to at least acknowledge this possible limitation and loss. I would also like to suggest that one way to balance any move to limit or devalue the practice of 'unproven' therapies, such as some aquatic therapies, is effectively to collect, gather, and share anecdotal information and simple data.
Opportunities and encouragement in doing this of those involved in practicing aquatic therapy and those who benefit from it, whether in clinical or non-clinical settings (like spas and private practices), could help revive our awareness of the importance and real value of self-directed (albeit not scientific) healing choices.
Despite whatever is efficient in business terms, individuals seem to do better when they choose their therapies and therapists on the basis of a combination of very personal motivations. I think it unlikely that we will ever be able to provide rational explanations or effective controls for this. And yet we keep trying.
Read the next post Keeping a balanced perspective in aquatics: Ai Chi as an example for a scientific viewpoint on why clinical proofs are essential in the face of human 'deductive malfunction'.
Can scientific research realistically be done on all the healing methods that are helping people? Will the results of such research help more of the people, most of the time, when they need it? And, if not, how will we ensure that untested methods that people do find helpful continue to be available to them?
It is arguable that we might get deeper and more lasting value - for some issues at least - by looking more closely at the subjective elements of health care - from an individual's life choices, to the person by whom, and context in which, they are given help. These are aspects that the so-called alternative therapies often value highly.
An outline of the findings of the review article that prompted this post may help illustrate the limitations of current scientific research on aquatic therapy, and provide a point of departure for further discussion. The authors are calling for better research methodology and they might be right. Or are they?
A systematic review of aquatic therapy
Effectiveness of aquatic exercise and balneotherapy: A summary of systematic reviews based on randomized controlled trials of water immersion therapies. Hiroharu Kamioka et al. J. Epidemiol. 2010, 20(1):2-12.Download Review of aquatic therapies (H.Kamioka et al)
The authors of this study searched the existing scientific literature for systematic reviews based on randomized controlled trials (RCTs); they excluded systematic reviews of non-RCTs or observational (anecdotal) studies. In other words, they were only interested in conventional scientific data.
For more on the role of clinical trials and a proposal for those practicing aquatic therapy in non-clinical settings, see What does it take to demonstrate the value of aquatic therapy?
Systematic reviews are now being advocated as a way for healthcare professionals to keep abreast of their fields. In this review study, the AMSTAR checklist (2007) was used to assess the methodological quality of the systematic reviews. Here's an extract about this assessment tool:
'A systematic review addresses a carefully formulated question by analysing all available evidence. It employs an objective search of the literature, applying predetermined inclusion and exclusion criteria to the literature, critically appraising what is found to be relevant. It then extracts and synthesizes from the available evidence base to formulate findings.
However, in spite of the care with which they are conducted, systematic reviews may differ in quality, and yield different answers to the same question. As a result, users of systematic reviews should be critical and look carefully at the methodological quality of the available review.' Download AMSTAR
However, in spite of the care with which they are conducted, systematic reviews may differ in quality, and yield different answers to the same question. As a result, users of systematic reviews should be critical and look carefully at the methodological quality of the available review.' Download AMSTAR
In the systematic review study of aquatic therapy I'm looking at here, out of 111 potentially relevant studies gleaned from international database searches, the researchers found only 7 that fit their criteria - 3 on aquatic exercise, 5 on balneotherapy (bathing), while 1 study included both.
These astonishingly few studies provided no clear evidence of curative effect for bathing; while, for aquatic exercise, they showed small but significant effects on pain, function, quality of life and mental health. None of the potential studies was conducted over more than one year.
The studies deemed acceptable (published from 2006 to 2008) included rheumatoid arthritis, osteoarthritis, fibromyalgia, back pain, and overall health improvement. The excluded studies (published from 1995 to 2008) covered similar conditions, and also included asthma and pregnancy.
Aquatic exercise involved active movement in warm water as distinguished from passive immersion without exercise. Key terms 'hydrotherapy', 'aquatic therapy', 'balneotherapy', and 'spa therapy' were used for the searches. Apparently, specific terms like 'Watsu' or 'Ai Chi' were not used.
In the introduction, the authors noted in broad terms that exercise in warm water is a 'popular treatment for many patients with painful neurologic or musculoskeletal conditions'. While bathing in water without exercise is 'frequently used in alternative medicine as a disease cure'.
They referenced only two studies indicating 'spa therapy is a very popular form of treatment for all types of arthritis in many European countries, as well as in Israel and Japan' and two reports from Japan showing that health education together with spa bathing had positive effects for middle-aged and elderly people.
The researchers identified the following problems when comparing existing published studies:
- distinguishing between aquatic exercise and balneotherapy in RCTs was difficult since they authors felt they are similar practices
(I agree: for example, Watsu-type aquatic bodywork could well be included in either category, since, although the receiver is passive, they are subject to a wide range of supported movements/ exercises.)
- there was quite a high drop-out rate and they suggested that the people being studied might not like undressing and wearing a swimsuit
(This might be more a reflection of the authors' own culture, though certainly not everyone feels comfortable in water and some have conditions that contraindicate it.)
- chemical content and temperature of waters studied differ in various countries and the data are therefore not easily integrated
- long-term effects were not clear, since the study periods ranged from 15 days to a year only
- adverse effects are often not properly evaluated
Among the balneotherapy (bathing) studies in particular, they found great heterogeneity, multiple and varied outcome measurements, poor methodological quality of RCTs, and poor overall quality. This is pertinent for consideration of record-keeping and further studies (see What does it take to demonstrate the value of aquatic therapies?).
Because no clear effect for balneotherapy was found, the authors of this study felt that RCTs based on appropriate research methodology are needed. They also suggested that a common problem with RCTs is that they do not properly evaluate adverse effects, and that future studies should include these data.
The authors proposed that satisfactory methodology should include: intention-to-treat analysis, blinding, and adequate control groups. A good research agenda, they added, would entail: 1. randomized controlled trials for various diseases; 2. cost-benefit analysis; and 3. description of adverse effects.
None of the studies found was in other languages than English, though an international database search was done. No contact was made with institutions, societies or specialists with expertise to identify additional published or unpublished data. Clearly this indicates that we don't have the whole story to hand.
In conclusion: * If you're looking for irrefutable scientific evidence to support your aquatic therapy, (alternative or otherwise) you might struggle. * If you can see beyond the model to the person and the need, you might be able to keep the faith. * If you just know that immersion in warm water is beneficial, jump in and share your thoughts below.
*A note about harm: Adverse effects or complications caused by or resulting from treatment or advice occurs in both conventional and alternative or complementary medical practice. These 'iatrogenic artifacts' can be both obvious and hard to identify. Causes include chance, medical error, negligence, social control and the adverse effects or interactions of prescription drugs. Learn more here.
For an outline of all the posts in this series see Faith and Facts in Aquatics: A digest
Interesting aside: Andrea Salzman's newly launched Aquatic Therapy University offers: Water-Based Intervention for the Musculoskeletal Client: An Aquatic Therapy Primer. This includes Watsu. Among the materials presented is this lecture - 'Make a 3 minute verbal case for providing aquatic therapy services for a patient with a specific musculoskeletal condition. Be able to identify and locate supportive research to bolster case.'
Acknowledgment: Thanks to Keo Opton for alerted me to the review article that prompted this post and to Andrea Salzman for highlighting it in her e-Splash news.
