Hydrotherapy in the Rehabilitation of Functional Performance and Gait in Knee Osteoarthritis: A Systematic Review of...

Background and Objectives: Knee osteoarthritis (KOA) is a degenerative joint disease that affects quality of life through pain, impaired functional performance, and altered gait patterns. Hydrotherapy is a well-tolerated form of physical rehabilitation, especially suitable for patients with severe pain, as water's properties support movement while reducing joint load. Its effects have been widely studied, primarily focusing on patient-reported outcomes, with limited synthesis of functional performance and gait-related outcomes. Materials and Methods: A systematic search was conducted in PubMed, Web of Science, Cochrane, PEDro, SpringerLink, ScienceDirect, and Google Scholar, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search strategy included a combination of Medical Subject Headings (MeSH) terms and keywords. For example, the PubMed search strategy was as follows: ("knee osteoarthritis" OR "knee OA") AND ("hydrotherapy" OR "aquatic therapy" OR "water-based exercise") AND ("gait" OR "walking" OR "functional performance"). Randomized controlled trials (RCTs) from the last 10 years involving patients with KOA undergoing aquatic therapy were included. Primary outcomes included functional performance assessed by measures such as the 6 min walking test (6MWT), the Timed Up and Go (TUG) test, the five sit-to-stand (5 STS) and stair climb (SC) tests, and by using gait-related parameters (e.g., speed, cadence, and step length) assessed clinically or using technology. Patient-reported outcomes, including the Visual Analog Scale (VAS), Western Ontario and McMaster University's Osteoarthritis Index (WOMAC), and Knee Injury and Osteoarthritis Outcome Score (KOOS), were analyzed as a secondary objective. Results: A total of 479 studies were identified, of which 13 met the eligibility criteria. The results revealed improvements in functional performance, with increases in 6MWT in five studies, the TUG test in four trials, and better performance in the 5-STS and SC tests in five studies. Benefits in gait parameters were noted in four studies. Additionally, one of the articles reported improvements in static and dynamic balance, another showed enhanced proprioception, and a third described more efficient muscle activation during gait following hydrotherapy. Consistent benefits in pain reduction, joint stiffness, and activities of daily living, as reflected by VAS, WOMAC, and KOOS, were also noted immediately and maintained at follow-up. The variability in outcome measures and intervention characteristics limited the possibility of data integration and the calculation of effect sizes. Conclusions: Hydrotherapy as a rehabilitation intervention may be associated with improvements in functional capacity, mobility, and self-reported physical ability in patients with KOA, with some evidence supporting a beneficial effect on gait; however, the certainty of evidence remains low to moderate due to heterogeneity among studies and limited sample sizes. These findings should be interpreted in light of the methodological limitations identified across the included trials.