Early Aquatic Physical Therapy Improves Function and Does Not Increase Risk of Wound-Related Adverse Events for Adults After Orthopedic Surgery: A Systematic Review and Meta-Analysis

Published:August 08, 2012DOI:https://doi.org/10.1016/j.apmr.2012.07.020



      To investigate whether early postoperative aquatic physical therapy is a low-risk and effective form of physical therapy to improve functional outcomes after orthopedic surgery.

      Data Sources

      Databases MEDLINE, CINAHL, AMED, Embase, and PEDro were searched from the earliest date available until October 2011. Additional trials were identified by searching reference lists and citation tracking.

      Study Selection

      Controlled trials evaluating the effects of aquatic physical therapy on adverse events for adults <3 months after orthopedic surgery. Two reviewers independently applied inclusion and exclusion criteria, and any disagreements were discussed until consensus could be reached. Searching identified 5069 potentially relevant articles, of which 8 controlled trials with 287 participants met inclusion criteria.

      Data Extraction

      A predefined data extraction form was completed in detail for each included study by 1 reviewer and checked for accuracy by another. Methodologic quality of included trials was assessed independently by 2 reviewers using the PEDro scale.

      Data Synthesis

      Pooled analyses were performed using random effects model with inverse variance methods to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs) (continuous outcomes) and risk difference and 95% CIs (dichotomous outcomes). When compared with land-based physical therapy, early aquatic physical therapy does not increase the risk of wound-related adverse events (risk difference=.01, 95% CI −.05 to .07) and results in improved performance of activities of daily living (SMD=.33, 95% CI=.07–.58, I 2=0%). There were no significant differences in edema (SMD=−.27, 95% CI=−.81 to .27, I 2=58%) or pain (SMD=−.06, 95% CI=−.50 to .38, I 2=32%).


      After orthopedic surgery aquatic physical therapy improves function and does not increase the risk of wound-related adverse events and is as effective as land-based therapy in terms of pain, edema, strength, and range of motion in the early postoperative period.


      List of abbreviations:

      ACL ( anterior cruciate ligament), ADL ( activities of daily living), CI ( confidence interval), QOL ( quality of life), RD ( risk difference), ROM ( range of motion), SMD ( standardized mean difference), THR ( total hip replacement), TKR ( total knee replacement)
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