LAUSR

Dear Editor, We would like to acknowledge the much-needed and comprehensive work by Iliescu et al.,1 who performed a systematic review on the effectiveness of aquatic therapy on mobility, balance, and functional independence in adult people with stroke. This is the most recent review to compare aquatic therapy with land-based interventions in stroke rehabilitation. The authors used robust and recommended methods to search and select studies, assess study quality, and analyze the data by performing several meta-analyses. A total sample of 19 randomized or non-randomized prospectively controlled trials of fair to good methodical quality have been included. A key result is that aquatic therapy demonstrated statistically significant improvements over land therapy in most balance and mobility outcomes, such as the Berg Balance Scale and the Timed Up and Go Test. The authors concluded that aquatic therapy may be more useful than traditional land-based therapies for improving balance and mobility after stroke, but that the evidence for improving functional independence is conflicting. We would like to comment on this review with respect to some methodological concerns and our long-term clinical experiences with aquatic therapy as a rehabilitation intervention for people with a stroke. First, we think that the results of the meta-analyses are flawed and may have only little clinical relevance, since a huge variety of different water-based interventions with different exercise conditions and “doses” have been summarized and compared to “land-based therapy,” consisting of very different exercise modalities. For example, the eight studies included in the meta-analysis on the outcome “balance” (Berg Balance Scale; significant mean treatment effect of 2.3 points (95% confidence interval (CI) = 1.2 to 3.3)) included general aquatic therapy (three studies), underwater treadmill training (two studies), dual task training, Halliwick aquatic therapy in combination with Ai Chi, and underwater walking (one study each), indicating high heterogeneity. For example, intervention participants in the study by Chu et al.2 performed 60 minutes/day on three days/week for eight weeks of intensive water-based exercised in chest-level water, aimed to improve cardiovascular fitness. The control group performed exercises focused on improving upper extremity functions of the same amount. In another study included in the meta-analysis,3 participants performed Halliwickbased exercises and underwater walking in addition to land therapy for a total of 35 to 45 minutes/day on Comment on: “Evaluating the effectiveness of aquatic therapy on mobility, balance, and level of functional independence in stroke rehabilitation: a systematic review and meta-analysis”