Zainab Naeem[i], Salwa Atta Mohyudin[ii], Yamna Mazher[iii] , Mir Shakeel Ahmad[iv], Rameeza Hassan[v] , Muhammad Salman Bashi[vi]

DOI: 10.36283/pjr.zu.11.2/006


Background and aim: This study was conducted to find the effects of hydrotherapy and land-based exercises on pain, grip strength and functional status in hand osteoarthritis patients.

Methodology: Eighty participants were randomized into two study groups i.e. hydrotherapy based exercise group or land based exercise group. Both groups were treated for 3 sessions per week for eight weeks and assessed after two months follow up. Numeric Pain Rating Scale (NPRS), Hand held dynamometer and Functional Index for Hand Osteoarthritis (FIHOA) were used to measure pain, grip strength and functional status of hand before and after treatment sessions for eight weeks and again assessed at two months of follow up.

Results: Multivariate analysis of variance indicates a statistically significant group-by-time interaction (p=.00). Pain intensity was significantly reduced in both groups whereas Grip strength and functional outcomes were significantly improved in patients of group B (hydrotherapy based exercises) as compared to group A (land based exercises) (P=.02 and .00).

Conclusion: Hydrotherapy based exercises prove to be more efficient in terms of improving functional outcomes of patients of hand osteoarthritis.

Keywords: Functional outcomes, grip strength, hand, hydrotherapy, land based exercises, osteoarthritis.


Hand osteoarthritis, is the most frequently occurring joint disease1, commonly affecting first carpometacarpal joint, interphalangeal joints, proximal & distal interphalangeal joints (DIP and PIP)2,3,4. Impairments of hand osteoarthritis are pain, decreased hand strength and flexibility, and inhibition of activity and limitation of participation in functional tasks5,6,7. Deformities, lack of activity, and great loss of function may compromise the role of hand as well as self-identity8. Both pharmacological and non-pharmacological interventions are required to achieve ideal management of osteoarthritis of hand9,10,11 as reported by The European League against Rheumatism (EULAR), as these interventions should be personalized with the patient’s needs and anticipations and also considering their pain level, disabilities and restricted life quality12. Exercises which are mainly performed under water are known as hydrotherapy 13. Furthermost the temperature required to heat the water is thirty-two to thirty-six degrees Celsius. Meanwhile the chief objective of physical therapy for patients with osteoarthritis is to reduce aches and enhancing the activity level14,15,16, but the only experiments included in this Cochrane review are involving the patients suffering from osteoarthritis of knee joint or hip joint, or suffering from both. It is believed that exercises performed under hot water likely decrease muscle aches, reducing the joint stiffness and induce feelings of relaxation in patients of arthritis17, 18. As initial therapy it is more beneficial in patients with arthritis as compare to the same level of training without water19. Currently, hydrotherapy is becoming one of the acceptable methods with excessive admiration in rehabilitation20. The advantages, which are linked with hydrotherapy, are because of some characteristics of water including water resilience property buoyancy reduces gravity forces and also providing resistance to improve muscle strength15, 21,22.  A Randomized Clinical trial which was conducted by Luciana E Silva et al. to find out the effects of hydrotherapy based exercises compared with land based exercises on knee osteoarthritis. The results showed in pain reduction and enhancement of function of knee in both groups. But the greater effects have been observed in the group performed hydrotherapy based exercises23. Although, few researches are conducted on hydrotherapy involving different regions of body most commonly on knee joint but a little research on hand osteoarthritis had done considering hydrotherapy as a treatment. The objective of this study was to determine the effects of hydrotherapy based exercises compared with land based exercises in osteoarthritis of hand.


This was a double blinded Randomized Clinical Trial conducted in Aziz Bhatti Shaheed Hospital, Gujrat, Pakistan in a duration of six months. 86 patients were assessed for inclusion criteria. 80 patients were recruited. The inclusion criteria was based according to American College of Rheumatology (ACR) which was pain of hand, stiffness or aching including 3 or 4 of the features mentioned here: tissue enlargement of two or more of ten selected joints, tissue hypertrophy of 2 or more Distal Interphalangeal joints, fewer than 3 swollen Metacarpo-phalangeal joints and deformity of at least 1 out of 10 selected joints. Participants were excluded if they exhibited other diseases including rheumatoid arthritis, co morbidities i.e., hypertension, diabetes etc., traumatic injuries of hand, surgery of hand past 6 weeks, steroid injections past 2 weeks, cognitive or mental dysfunction or if they had any skin disease. The participants were allocated randomly into either a water-based or land based exercise group by using lottery method. The participants were assigned the group according to even or odd number drawn by the patient from the box. The participants with even number were allocated to land-based exercise group and the participants with odd number were allocated to water-based exercise group. Participants were blind to the groups they were allocated and assessor was also blind to the assigned intervention. Sample size of 68 was calculated by using G-power Analysis Software, Version ( with 0.80 power of study, with 0.5 margin of error and 95% confidence interval. To manage anticipated dropouts total recruited participants were 80 before the completion of the study and in each group, forty patients were allocated.

Outcome Measures

Primary Outcome Measures

Numeric pain rating scale (NPRS) and hand-held dynamometers were used as primary outcome measures for pain and grip strength of hand respectively. Numeric Pain Rating Scale (NPRS) was used for pain measurement, which is a single dimensional 11point scale (0-10) which measures pain intensity, with test–retest reliability of r = 0.96 and validity correlations of 0.86 to 0.95. Grip strength of affected hand was measured with the help of hand-held dynamometer, patient was in sitting position and forearm was in extended position while taking the measurements.

Secondary Outcome Measure

Functional Index for Hand Osteoarthritis (FIHOA) was used as secondary outcome tool for functional status of hand (24). It was used to evaluate the functional impairments of hand with osteoarthritis, scoring from 0 (no functional impairment) to 30 points (maximal impairment). Mean Standardized Response (MSR) value for FIHOA was 0.58.

The measurements were taken before the application of treatment which was baseline measurements by the assessor who was blind to the group of the patient being allotted. After eight weeks, same assessor took second measurements known as post treatment measurements and follow up measurements were taken after two months. Patients were also blinded to the treatment being given to them.


Land Based Exercises: Participants of land based exercise group (Group A) performed exercises, which included in the protocol, were Tabletop, Small fist. Large fist, Okay sign, Finger spread, Thumb reach, Key pinch, Gripping and Fingertip pinch without water as patient was in seated position. Patients were asked to perform the aforementioned exercises under the supervision of therapist and last three above mentioned exercises were performed with the help of ball. The patients were instructed to take 3 sessions per week, with 10 repetitions of each exercise for 1-2 weeks, 12 repetitions in 3-4 weeks and 15 repetitions in 5-8 weeks.

Hydrotherapy Based Exercises: Participants included in Hydrotherapy based exercises (Group B) performed all exercises under the supervision of physiotherapist while patient was in seated position. Total nine exercises were performed including Tabletop, Small fist. Large fist, Okay sign, Finger spread, Thumb reach, Key pinch, Gripping and Fingertip pinch. Patient was asked to place his hand in a container filled with water at room temperature and performed all the exercises under water. Similarly last three respective exercises were performed while holding the ball in hand. The patients were instructed to take 3 sessions per week, with 10 repetitions of each exercise for 1-2 weeks, 12 repetitions in 3-4 weeks and 15 repetitions in 5-8 weeks. Baseline treatment was given to both groups.

Ethical concerns

This trial was registered in WHO Registry of IRCT having reference number IRCT20200511047403N1. The trial was also approved from the Institutional Ethical Review Board.

Statistical Analysis

The statistical Package for Social Sciences – version 25 was used for statistical analysis. Statistical significance was set at P=0.05 and it was performed on the basis of intention to treat analysis. For Descriptive Statistics Frequency tables and bar charts were used. Parametric test was used to compare two population at different various intervals. Independent sample t-test was applied to measure difference between two groups. Mixed Modal ANOVA was applied to measure the differences collectively between the groups. Repeated measure ANOVA was applied to measure difference within each group.


40 patients of group A: Land based exercises group (n=40) (age, 49.65±6.09 years; BMI, 27.82±3.31; males: 15, females: 25) group B: Hydrotherapy group (n=40) (age, 50.12±4.90 years; BMI, 27.86±3.16; males: 16, females: 24). No significant differences were found among both groups for demographics i.e. age, gender, BMI, duration of symptoms and measured variables (NPRS, Grip strength, FIHOA) at pre-treatment level. (Table 1).

Multivariate tests for outcome measures indicate a statistically significant group-by-time interaction (F=4.46, p=.00). The univariate group-by-interaction was statistically significant group-by-time interaction. (F=2.23, P=.11). The results of post hoc test  revealed that at Post treatment level and at follow up level the mean values of the NPRS reduced significantly in patients of both groups (P=.001). Mean values of grip strength were significantly reduced at follow up level in Group B who received hydrotherapy (P=.001) compared to group A (.022) whereas FIHOA was significantly increased in group B (0.00) compared to Group A (P=0.02) (Table 2). A paired t test revealed that there was a significant increase in mean values of MDF in all groups (p<.01).


The study was conducted to find out the effects of hydrotherapy-based exercises and land-based exercises on pain, grip strength and FIHOA in patients of osteoarthritis of hand. The results of this study showed significantly reduction in pain intensity in both groups, grip strength was improved in hydrotherapy-based group at two months follow up while more significant improvement had been seen in FIHOA at post treatment and after two months follow up assessment in hydrotherapy-based exercise group.

A latest study conducted in Iran on hand osteoarthritis to find out the effects of kinesio taping with exercise on pain, ROM, strength of hand and functional capabilities of hand in comparison with only exercise. The result of this study revealed that the group with kinesio taping and exercise showed significant improvement as reduction in pain intensity, increased ROM and hand strength, and enhancement of functional status of hand compared with only exercise group in patients suffering with hand osteoarthritis (25). The results of under discussion study showed significantly reduction in pain intensity, increased grip strength in both hydrotherapy and land-based exercise group while more significant improvement had been seen in FIHOA at post treatment and after two months follow up assessment in hydrotherapy-based exercise group.

In other study, conducted on the different kinds of osteoarthritis patients predominantly with affected knee, hip, hand and foot involvement. The applied intervention was balneotherapy including the combination of peloid (mud) therapy and hydrotherapy (aquatic exercises or mineral water dipping). It was an out-patient and single centered study and results showed the significant decrease in pain and improvement in other outcome measures in all types of osteoarthritis except hip osteoarthritis (26). In contrast, the present study the targeted population was adult to older patients between the ages of forty to sixty years were involved. Further studies with extended follow up are recommended to evaluate the long-term effects of hydrotherapy.


Hydrotherapy based exercises prove to be more efficient in terms of improving functional outcomes of patients of hand osteoarthritis.


  • Stoffer-Marx MA, Klinger M, Luschin S, Meriaux-Kratochvila S, Zettel-Tomenendal M, Nell-Duxneuner V, et al. Functional consultation and exercises improve grip strength in osteoarthritis of the hand – a randomised controlled trial. Arthritis Res Ther. 2018;20(1):253. Epub 2018/11/11
  • Sankah BE, Stokes M, Adams J. Exercises for hand osteoarthritis: a systematic review of clinical practice guidelines and consensus recommendations. Physical Therapy Reviews. 2019 Jul 4;24(3-4):66-81.
  • Gloersen M, Steen Pettersen P, Kvien TK, Haugen IK. Validation of the Intermittent and Constant Osteoarthritis Pain Questionnaire in Patients with Hand Osteoarthritis: Results from the Nor-Hand Study. J Rheumatol. 2019;46(6):645-51. Epub 2019/03/17.
  • Stephen May MA. Views of general practitioners toward physiotherapy management of osteoarthritis—a qualitative study. Physiotherapy theory and practice. 2018 Apr 16.
  • Mooventhan A, Nivethitha L. Scientific evidence-based effects of hydrotherapy on various systems of the body. North American journal of medical sciences. 2014 May;6(5):199.
  • Corvillo I, Armijo F, Álvarez-Badillo A, Armijo O, Varela E, Maraver F. Efficacy of aquatic therapy for neck pain: a systematic review. International journal of biometeorology. 2019 Jun 17:1-1.
  • Bartels EM, Juhl CB, Christensen R, Hagen KB, Danneskiold-Samsoe B, Dagfinrud H, et al. Aquatic exercise for the treatment of knee and hip osteoarthritis. Cochrane Database Syst Rev. 2016;3:CD005523. Epub 2016/03/24.
  • Sawant RS, Shinde SB. Effect of hydrotherapy based exercises for chronic nonspecific low back pain. Indian Journal of Physiotherapy and Occupational Therapy – An International Journal. 2019;13(1):133.
  • Cantarero-Villanueva I, Fernández-Lao C, Fernández-de-Las-Peñas C, Lopez-Barajas IB, Del-Moral-Ávila R, de la-Llave-Rincón AI, Arroyo-Morales M. Effectiveness of water physical therapy on pain, pressure pain sensitivity, and myofascial trigger points in breast cancer survivors: a randomized, controlled clinical trial. Pain Medicine. 2012 Nov 1;13(11):1509-19.
  • Dias JM, Cisneros L, Dias R, Fritsch C, Gomes W, Pereira L, et al. Hydrotherapy improves pain and function in older women with knee osteoarthritis: a randomized controlled trial. Braz J Phys Ther. 2017;21(6):449-56. Epub 2017/07/25.
  • Hennig T, Haehre L, Hornburg VT, Mowinckel P, Norli ES, Kjeken I. Effect of home-based hand exercises in women with hand osteoarthritis: a randomised controlled trial. Ann Rheum Dis. 2015;74(8):1501-8. Epub 2014/03/29.
  • Moe RH, Garratt A, Slatkowsky-Christensen B, Maheu E, Mowinckel P, Kvien TK, Kjeken I, Hagen KB, Uhlig T. Concurrent evaluation of data quality, reliability and validity of the Australian/Canadian Osteoarthritis Hand Index and the Functional Index for Hand Osteoarthritis. Rheumatology. 2010 Dec 1;49(12):2327-36.
  • Munoz GA, Millan SJ. Comparing the Camry dynamometer to the Jamar dynamometer for use in healthy Colombian adults/Comparacion del dinamometro Camry con el dinamometro Jamar para su uso en adultos colombianos saludables/Comparacao dos dinamometros Camry e Jamar para seu uso em adultos colombianos saudaveis. Revista Salud Bosque. 2019 Jul 1;9(2):18-27.
  • Majid Farhadian MZM, MSc Student; Alireza Shamsoddini, PhD. Effect of Kinesio Taping on Pain, Range of Motion, Hand Strength, and Functional Abilities in Patients with Hand Osteoarthritis: A Pilot Randomized Clinical Trial. 13 March 2019.
  • Tenti S, Giordano N, Mondanelli N, Giannotti S, Maheu E, Fioravanti A. A retrospective observational study of glucosamine sulfate in addition to conventional therapy in hand osteoarthritis patients compared to conventional treatment alone. Aging Clin Exp Res. 2020;32(6):1161-72. Epub 2019/08/21.
  • Fioravanti A, Tenti S, Giannitti C, Fortunati NA, Galeazzi M. Short- and long-term effects of mud-bath treatment on hand osteoarthritis: a randomized clinical trial. Int J Biometeorol. 2014;58(1):79-86. Epub 2013/01/15.
  • SKMKİGTA, Karagülle HYMZ. Outpatient balneological treatment of osteoarthritis in older persons A retrospective study. 24 January 2018.
  • Zhu Z, Cui L, Yin M, Yu Y, Zhou X, Wang H, et al. Hydrotherapy vs. conventional land-based exercise for improving walking and balance after stroke: a randomized controlled trial. Clin Rehabil. 2016;30(6):587-93. Epub 2015/07/02.
  • Chowdhury RS, Islam MD, Akter K, Sarkar MA, Roy T, Rahman ST. Therapeutic Aspects of Hydrotherapy: A Review. Bangladesh Journal of Medicine. 2021 Jun 5;32(2):138-41.
  • Khruakhorn S, Chiwarakranon S. Effects of hydrotherapy and land-based exercise on mobility and quality of life in patients with knee osteoarthritis: a randomized control trial. Journal of Physical Therapy Science. 2021;33(4):375-83.
  • Tarnava A. Supersaturated Hydrogen-Rich Water Hydrotherapy for Recovery of Acute Injury to the Proximal Phalanges on the 5th Toe: A Case Report. The Journal of Science and Medicine. 2021 Jan 12;3(1).
  • Ihza AA. Literature Review: The Effectiveness of Kinesiotaping and Hydrotherapy in Improving The Quality of Life of The Elderly With Osteoarthritis. Gaster. 2021 Aug 30;19(2):195-204.
  • Rivers A. Land-based Exercise versus Hydrotherapy in Osteoarthritis.
  • Garbi FP, Rocha Júnior PR, Pontes ND, Oliveira AD, Barduzzi GD, Boas PJ. Aquatic physiotherapy in the functional capacity of elderly with knee osteoarthritis. Fisioterapia em Movimento. 2021 Sep 15;34.
  • Mira NO, Cardona IC, Osorno LV, Diaz DR, Ceballos LM. Evaluating the effect of a water exercise routine on the postural stability of the elderly/Evaluación del efecto de una rutina de ejercicios acuá ticos sobre la estabilidad postural de adultos mayores. Colombia Medica. 2021 Jul 1;52(3):1-1.



[i] Lecturer Islam Medical & Dental College Physical Therapy Department Sialkot,

[ii] Lecturer Lahore College of Physical Therapy LM&DC Lahore

[iii] Senior Lecturer Lahore College of Physical Therapy, LM&DC Lahore

[iv] Clinical Supervisor Physical Therapy  Ghurki Trust Teaching Hospital, Lahore

[v] Clinical Supervisor Physical Therapy Royal Specialist Hospital, Islamabad

[vi] Head of Department Physical therapy Riphah International University, Lahore