Cardiorespiratory responses to aquatic treadmill walking in patients with rheumatoid arthritis
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PRI 9.2_crc v4 6/30/03 1:12 PM Page 59
Physiotherapy Research International, 9(2) 59–73, 2004 © Whurr Publishers Ltd 59
Cardiorespiratory responses to
aquatic treadmill walking in patients
with rheumatoid arthritis
JANE HALL and JIM GRANT Physiotherapy Department, Royal United Hospital,
Bath, UK
DAVID BLAKE Royal National Hospital for Rheumatic Diseases, Bath, UK
GORDON TAYLOR Research and Development Support Unit, University of Bath, UK
GERARD GARBUTT School of Health Sciences, University of East London, UK
ABSTRACT Background and Purpose. Hydrotherapy is popular with patients with
rheumatoid arthritis (RA). Its efficacy as an aerobic conditioning aid is equivocal. Patients
with RA have reduced muscle strength and may be unable to achieve a walking speed
commensurate with an aerobic training effect because the resistance to movement increases
with speed in water. The physiological effects of immersion may alter the heart rate–oxygen
consumption relationship (HR–V̊O2 ) with the effect of rendering land-based exercise
prescriptions inaccurate. The primary purpose of the present study was to compare the
relationships between heart rate (HR), and ratings of perceived exertion (RPE), with speed
during land and water treadmill walking in patients with RA. Method. The study design
used a two-factor within-subjects model. Fifteen females with RA (47±8 SD years)
completed three consecutive bouts of walking for five minutes at 2.5, 3.5 and 4.5 km/h–1 on
land and water treadmills. Expired gas, collected via open-circuit spirometry, HR and RPE
were measured. Results. HR and RPE increased on land and in water as speed increased.
Below 3.5 km/h–1 V̊O2 was significantly lower in water than on land (pPRI 9.2_crc v4 6/30/03 1:12 PM Page 60
60 Hall et al.
INTRODUCTION showed that the cardiorespiratory stimulus
was below that recommended by the ACSM
Rheumatoid arthritis (RA) is a chronic for improvements in aerobic capacity
inflammatory disease of the synovial joints, because they were unable to walk fast
characterized by swollen, painful joints, enough against the resistance of the water.
disturbed joint motion and muscle atrophy This finding was attributed to insufficient
that results in physical deconditioning leg strength and implies that the cardiorespi-
(Ekdahl and Broman, 1992). Improving ratory challenge is limited by peripheral
aerobic capacity (VO2max) through the use of fatigue as a result of the resistance to move-
hydrotherapy is popular but the evidence ment in water as speed increases (Hall et al.,
base is lacking because of the methodolog- 1996). At slow speeds in water, when resis-
ical defects of the few studies available tance is minimal, buoyancy dominates and
(Daneskiold-Samsoe, 1987; Minor et al., may result in reduced energy expenditure
1989; Melton-Rogers et al., 1996; Sandford- compared with similar speeds on land. As
Smith, 1998; Verhagen et al., 2000). speed increases so does the resistance which
Furthermore the evidence is equivocal, with may result in the preferential utilization of
Rintala et al. (1996), showing no changes in glycolytic, rather than aerobic pathways.
VO 2max after a 12-week hydrotherapy There is therefore an interaction between
programme. This is likely to be related to buoyancy (at slow speed) and resistance (at
the use of rate of perceived exertion (RPE) fast speed) that could affect the metabolic
as the method of exercise prescription, in pathways used and the ability of
that exercise in water produces a greater hydrotherapy to improve aerobic fitness.
perception of effort for a given V̊O 2 Patients with RA have reduced muscle
(Svedenhag and Seger, 1992; Hall et al., strength and may be unable to generate the
1998). Therefore, it is possible that the use walking speeds in water that are required to
of land-based measures to monitor exercise stimulate a cardiorespiratory response of the
intensity may have underestimated the magnitude recommended by the ACSM for
aerobic demand. Melton-Rogers et al. improved aerobic fitness (ACSM, 1991).
(1996) showed that the intensity of deep Therefore, the first aim of the present study
water running in eight patients with RA was to determine if the cardiorespiratory
provided sufficient stimulus for improve- system could be stimulated in line with
ment of aerobic capacity as recommended ACSM recommendations for improvement
by the American College of Sports Medi- in aerobic capacity during treadmill walking
cine (ACSM, 1991). However, it is unlikely in water, as this type of functional activity is
that the majority of patients with RA would considered to mimic terrestrial gait most
be capable of performing deep water running closely. The second aim of this study was
given that subjects are suspended in deep compare the relationship between oxygen
water and make no foot contact with the pool consumption (V̊O2) to heart rate (HR) and
bottom. Furthermore, Moening et al. (1993) ratings of perceived exertion (RPE) given
showed it has been shown that the biome- the importance of these linear relationships
chanical demands of deep water running are in the monitoring of exercise intensity on
dissimilar from land running. Therefore, land. These relationships may differ in water
translation of any functional effects to dry because of the hypervolaemia and enhanced
land may be limited. A study on normal cardiac output associated with head-out
females who walked on a water treadmill water immersion (Christie et al., 1990;PRI 9.2_crc v4 6/30/03 1:12 PM Page 61
Treadmill walking in RA patients 61
Gabrielsen et al., 2000). Furthermore, the National Hospital for Rheumatic Diseases,
literature on walking and running activities in Bath, and were invited to participate in the
water shows that the relationship is altered study by letter.
depending on the water temperature, water The sample size was calculated using
depth, exercise intensity, type of exercise and data from a previous study on normal
subject skill (Frangolias and Rhodes, 1996; females (Hall et al., 1998). By use of the
Melton-Rogers et al., 1996; Hall et al., 2001). differences in V̊O2 between water and land
Therefore, the null hypothesis that the treadmill walking as the dependent variable,
V̊O2–HR and V̊O2–RPE relationships were power of 80% and alpha of 0.05 showed that
similar in water to land was tested. a sample size of 15 patients was necessary.
Ethical approval
METHOD
Ethical approval for the study was granted
Study design by the local regional ethical committee.
The study used a two-factor within-subjects Protocol
design.
At an initial visit, and following their
Subjects informed, written consent, patients’ past and
current medical history was documented by
Fifteen female patients, aged 30–60 years means of a health screening questionnaire
with functional Class I or Class II RA, and an interview adapted from the
according to the criteria of the American Hydrotherapy Association of Chartered
College of Rheumatology (Hochberg et al., Physiotherapists Standards for Good Prac-
1992), and with a disease duration of five tice (Great Britain). Information on the level
years or less were recruited from Royal of habitual physical activity was recorded
National Hospital for Rheumatic Diseases, using the Allied Dunbar National Fitness
Bath. Patients with early disease were Survey (Allied Dunbar National Fitness
chosen to ensure completion of all the tasks Survey, 1992). Details about disease dura-
required. Patients were excluded if they tion and status, duration of early morning
walked with an aid, had undergone lower stiffness, medication, height, weight, HR,
limb surgery within the past three months, blood pressure (BP) and joint tenderness
had undergone hip, knee or ankle arthro- were recorded using the Ritchie Articular
plasty or were experiencing a flare-up of Index (Thompson et al., 1981). Disease
their RA. Additionally, patients with known status and pain were evaluated by use of the
cardiovascular disease were excluded. Health Assessment Questionnaire (Fries et
Female patients were selected on the basis al., 1980) and visual analogue scale (VAS)
of greater female to male incidence of RA. (Scott and Huskisson, 1976).
Furthermore, data in the literature on the Following these procedures patients
detraining effects associated with RA are underwent a familiarization period in the
generated primarily from female patients water (Aquaciser 100R, Ferno UK) and on
(Minor et al., 1988; Hakkinen et al., 1995). the land treadmills (Trimline 4000T). A
Patients meeting the entry criteria were pilot study ascertained that patients required
identified from the database at the Royal 30 minutes’ instruction and practice on thePRI 9.2_crc v4 6/30/03 1:12 PM Page 62
62 Hall et al.
water treadmill to feel comfortable and be medication regimen, especially in respect of
consistent in their technique. Practising land time of ingestion on the days testing took
treadmill walking required 10 minutes. The place. Speed and gradient calibration checks
first visit therefore lasted approximately 2.5 on both treadmills were made at monthly
hours. Given the novelty of walking with a intervals. The air temperature of the labora-
mouthpiece in situ it was considered impor- tory averaged 26˚C (±2.1˚C) and the
tant for patients to experience this before humidity was 50% (±4.8%).
data collection periods, and patients
returned to the Aquaciser laboratory for a Measurements
further 30-minute visit to become comfort-
able with the open-circuit spirometry set-up Expired gas was collected for the f inal
during land and water treadmill walking. minute of each exercise bout via open-circuit
Patients were also instructed in the use of spirometry by use of a Hans–Rudolph valve,
the Borg scale. mouthpiece and Douglas bag system, and
A pilot study indicated that patients were following the technique described by Cooke
able to walk on the water treadmill at speeds (1996). Gas samples were analysed using an
up to a maximum of 4.5 km/h–1. Above this infrared CO 2 analyser (PK Morgan 901,
speed patients were forced to run or hold on Gillingham, UK) and a paramagnetic O 2
to the handrails. Therefore three speeds of analyser (OA 250 Servomex). The respira-
walking were selected: 2.5, 3.5 and 4.5 tory exchange ratio (RER) was calculated
km/h –1, representing slow, moderate and from V̊OC 2 /V̊O 2 . Ventilation (V̊ E ) was
fast. During the water treadmill test patients recorded using a dry gas volume meter
were instructed to walk ‘as normally as (Havard Apparatus, UK). Gas volumes were
possible’ without holding on to the corrected to standard conditions of tempera-
handrails. To prevent sculling-type motions ture, pressure and dry (STPD) and standard
of the hands, patients were asked to adopt a calculations were used to calculate V̊O2, V̊E
loose-fisted position with the forearm in and V̊CO2 (Powers and Howley, 2001). Stride
mid-prone and the elbow flexed to 90˚. frequency was recorded for 60 s in the fourth
After a two-minute warm-up period patients minute of each exercise bout by counting the
completed three consecutive bouts of five number of strides. In the final 10 s HR was
minutes’ duration at progressively measured by use of a short range telemetry
increasing speeds (2.5, 3.5 and 4.5 km/h–1). device (Polar Favor™ HR monitors) and RPE
Use of the water treadmill enabled the water using the Borg 6–20 scale, which has been
depth to be made individual to the level of shown to be a reliable and valid instrument to
the xiphoid process, and the water was measure perceived exertion (Noble and
maintained at thermoneutral (34.5 ˚C) as Robertson, 1996). Two scales were
recommended by the Hydrotherapy Associ- completed after the method adopted by
ation of Chartered Physiotherapists. The Svedenhag and Seger (1992): one for the legs
land and water tests were performed in (RPEL) and one for breathing (RPEB), repre-
random order at the same time of day and senting peripheral muscle and respiratory–
separated by at least 72 hours. Patients were metabolic signals, respectively. Standardized
two hours post-prandial and refrained from verbal and written instructions for
smoking and caffeine intake from two hours completing the RPE scales were given to
before the test began. Patients were subjects during the familiarization period and
reminded to continue with their usual before each walking test. BP was recordedPRI 9.2_crc v4 6/30/03 1:12 PM Page 63
Treadmill walking in RA patients 63
using a manual sphygmomanometer on the p value was observed. Pre- and post-test data
following occasions: (e.g. oral temperature and BP) were analysed
using paired Student’s t-tests. Differences
• Standing on land before exercise. between relationships were tested by use of a
• Standing immersed on the water tread- paired Student’s t-test after a simple linear
mill immediately before exercise. regression model estimated the dependent
• Immediately exercise finished. variable, for a given level of the independent
• Five and ten minutes after the end of for each patient, and tests for normality of the
exercise whilst standing on land. response variable were satisfactory. All
values are expressed as mean ± standard
Because it was not possible to make deviation (SD). Data was analysed using
measurements of core body temperature, SPSS for Windows, Version 10.
sub-lingual temperature was recorded
before and after the exercise session. After RESULTS
the water treadmill test only it increased
significantly by 0.37 ˚C (pPRI 9.2_crc v4 6/30/03 1:12 PM Page 64
64 Hall et al.
were on disease-modifying antirheumatic were observed between the land and water
drugs and anti-inflammatory agents, the treadmills (Table 2).
dose of which remained unchanged during HR increased significantly on land and in
the study. water as the treadmill speed increased
As the treadmill speed increased V̊O2 , V̊E (pPRI 9.2_crc v4 6/30/03 1:12 PM Page 65
Treadmill walking in RA patients 65
30
25
20
V̊E (L/min–1)
15
10
Land Water
5
0.4 0.5 0.6 0.7 0.8 0.9
V̊O2 (L/min )
–1
FIGURE 2: V̊E–V̊O2 relationship during land and water treadmill walking. V̊E did not differ significantly in water
and on land for a given V̊O2. However, the range is extended in water there is a greater percentage increase in V̊E
relative to V̊O2, especially at 4.5 km/h–1.
TABLE 2: Means (SD) for respiratory exchange ratio (RER), ratings perceived exertion for breathing (RPE)
and oxygen cost per stride (V̊O2/str : mL/min–1)
Variable Water speed (km/h–1) Land (km/h–1)
2.5 3.5 4.5 2.5 3.5 4.5
RER 0.83 (0.1) 0.86 (0.1) 0.95** (0.08) 0.86 (0.07) 0.9* (0.07) 0.92* (0.07)
RPE–breathing 8.78 (1.6) 10.9* (1.6) 12.8** (2.1) 8.87 (2) 10.4* (1.9) 11.53** (2)
VO2/str 5.9 (1.5) 7.04* (2) 8.9**^ (2.9) 6.45 (2.1) 6.42** (1.9) 6.92** (1.9)
* 3.5 km/h–1 is significantly greater then 2.5 km/h–1 within conditions (pPRI 9.2_crc v4 6/30/03 1:12 PM Page 66
66 Hall et al.
1.2
1
VO2 (L/min–1)
0.8
0.6
0.4
Land Water
0.2
2.5 3.5 4.5
Speed (km/h–1)
FIGURE 3: Heart rate during land and water treadmill walking. As speed increased on land and water, heart rate
increased significantly (pPRI 9.2_crc v4 6/30/03 1:12 PM Page 67
Treadmill walking in RA patients 67
TABLE 3: Mean (±SD) systolic and diastolic blood pressure, mean arterial pressure and pulse pressure before
exercise, resting in water before exercise and immediately after exercise on land and in water (mmHG)
Land Water
Systolic BP
Before exercise—standing on land 113.33 (15.6) 116.7 (15.5)
Before exercise—standing in water 113 (16)
After exercise 129.6 (18.3)* 126 (13.6)*
Diastolic BP
Before exercise—standing on land 79.3 (11.8) 81.3 (9)
Before exercise—standing in water 71.2 (13.3)**
After exercise 80.5 (11.7) 67.6 (10.8)
Mean arterial pressure
Before exercise—standing on land 90.7 (12.5) 93.1 (10.3)
Before exercise—standing in water 85.1 (11.5)***
After exercise 96.9 (12.9) 87.1 (8.4)
Pulse pressure
Before exercise—standing on land 34 (8.6) 35.3 (11.2)
Before exercise—standing in water 41.8 (17.9)
After exercise 49.1 (12.4)† 58.4 (17.6)†
* Systolic blood pressure increased significantly with exercise whether on land or in water (Student’s t-test =
–5.7 and –5.3, respectively; df = 14; p = 0.001).
** Diastolic blood pressure was significantly reduced by water immersion (Student’s t-test = 3.4; df = 14; p =
0.004).
*** Mean arterial pressure was significantly reduces by water immersion (Student’s t-test = 3.8; df = 14; p =
0.002).
† Pulse pressure increased significantly with exercise on land and in water (Student’s t-test = –56.2 and 6.8,
respectively; df = 14; p = 0.001).
*
16
*
14
12
RPFL
10
8
Land Water
6
2.5 3.5 4.5
Speed (Km/h–1)
FIGURE 5: Rate of perceived exertion — legs (RPEL) during land and water treadmill walking. As speed
increased on land and in water RPEL increased (pPRI 9.2_crc v4 6/30/03 1:12 PM Page 68
68 Hall et al.
16
15
14
13
12
RPEL
11
10
9
8
Land Water
7
6
0.4 0.5 0.6 0.7 0.8 0.9
VO2 (L/min ) –1
FIGURE 6: RPEL–V̊O2 relationship. Rate of perceived exertion (RPE) is approximately 15–20% higher in
water than on land during treadmill walking (pPRI 9.2_crc v4 6/30/03 1:12 PM Page 69
Treadmill walking in RA patients 69
causing a lower metabolic demand than on ancy, although less than at slower speeds,
land. Muscle activity during slow movement was still evident.
is less in water than on land and this may In water, at rest, systolic BP was similar
account for both the lower HR and V̊O2 at to land, but diastolic BP was lower by
2.5 km/h–1 (Kelly et al., 2000). Furthermore, approximately 10 mmHg, which confirms
the exercise intensity at 2.5 km/h–1 was low other reports (Weston et al., 1987; Sramek
and so the lower HR may be a consequence et al., 2000). Similar increases in systolic
of the cephalad redistribution of blood BP after land and water exercise were
during HOWI (head-out water immersion), observed and corroborate with data from
which increases stroke volume with slight other studies on exercise in water, albeit
decrements in HR (Weston et al., 1987). At cycle ergometry in water (Christie et al.,
3.5 km/h–1 V̊O2 was lower in water and HR 1990; Sheldahl et al., 1992; Hanna et al.,
similar to land walking, suggesting that the 1993). This finding suggests that the cardio-
effects of exercise were beginning to super- vascular adjustments during dynamic exer-
sede the effects of HOWI. A lower V̊O2 at cise were not changed by water immersion,
this speed differs from previous reports that despite the assumed increase in cardiac
have shown similar (Hall et al., 1998) and output.
higher values (Gleim and Nicholas, 1989) One of the aims of the present study
during water treadmill walking. These was to determine if the cardiorespiratory
results vary from the present data and may system could be stimulated in line with
be a consequence of differences in water ACSM recommendations for improvement
depth and subject characteristics. The in aerobic capacity (40–85% VO 2max ,
effects of buoyancy on percentage weight- 55–90% HR max, 12–16 on the 6–20 Borg
bearing in women have shown that immer- RPE scale). Because it was not possible to
sion to the xiphoid process unloads the perform maximal tests of aerobic capacity
lower limbs by 72%, resulting in only one- in the sample, the data were compared with
third of the body weight being transmitted those of other studies to estimate VO2max. It
to the ground (Harrison and Bulstrode, is known that within four years of diag-
1987). Immersion to the anterior superior nosis aerobic capacity is 25–30% lower in
iliac spines produced a percentage weight- patients with RA compared with age- and
bearing of 47%. Therefore, it is plausible sex-matched control subjects, and Ekdahl
that differences between waist- and chest- and Broman (1992) reported VO2max values
depth immersion could alter the metabolic between 1.24 L/min–1 and 1.47 L/min–1 in
demand of exercise in water because buoy- 43 women with RA aged between 23 and
ancy supports the body weight and reduces 65 years (Ekblom et al., 1974; Beals et al.,
postural muscle activity (Sugajimo et al., 1985; Melton-Rogers et al., 1996; Minor
1996). At 4.5 km/h –1 V̊O 2 in water was et al., 1988). Comparing these data with
similar to land and HR higher. Higher V̊O2 data presented here suggests that walking
has been noted at this speed, suggesting that at 4.5 km/h–1 in water required 55–65% of
the effects of buoyancy are superseded by VO 2max . At the same speed in water, HR
the greater resistance to movement as speed ranged from 55% to 75% of the predicted
increases (Gleim and Nicholas, 1989; Hall maximal heart rate (PMHR) and RPEL
et al., 1998). However, the similar V̊O 2 scored 14 at 4.5 km/h –1 . Although it is
between water and land treadmill walking acknowledged that the use of normative
presented here suggest that effect of buoy- data for VO2max introduces a degree of errorPRI 9.2_crc v4 6/30/03 1:12 PM Page 70
70 Hall et al.
(most likely underestimating VO2max in the water than on land. This means that the use
present study sample given the relatively of land-based values would underestimate
young age of participants and short disease metabolic demand in water. To ensure
duration), it is considered that that the similar exercise intensity to land these data
range of exercise intensity at 4.5 km/h –1 suggest that HR and RPEL values be
was high enough to stimulate an aerobic increased by approximately 9 beats/min–1
response in all subjects. and by 1–2 points, respectively.
Whether walking at 4.5 km/h –1 on a A higher HR for a given V̊O 2 in water
water treadmill for the recommended dura- may be a thermal response, but, notwith-
tion of 15–60 minutes three to five times a standing the significant 0.37˚C rise in sub-
week for at least six weeks will result in the lingual temperature, this is considered
anticipated gains in aerobic capacity was unlikely as the water was approximately
outside the scope of the present study. Anec- thermoneutral, the exercise intensity was
dotal evidence, based on patients’ percep- moderate and the duration short. A more
tions, suggested that some patients would appealing theory relates to the unfamiliar
have tired before the minimum time period biomechanical demands of walking against
elapsed. Therefore, an interval-type training the resistance of the water, which makes it
method may be the most efficacious way of diff icult to generate the limb speeds
improving aerobic capacity in patients with observed on land. The present study
RA. conf irms previous reports that stride
The patients in the present study could be frequency is significantly lower in water (by
considered as a relatively homogenous sub- approximately 30%) and a lower cadence
set of the larger RA population, in that they implies longer contraction times, which may
were young and with a disease duration of result in reduced oxygen delivery and
five years or less. Generalization of the study greater reliance on anaerobic pathways (Yu
results to older patients of longer disease et al., 1994; Frangolais et al., 1996; Hall et
duration is not possible, but given that older al., 1998; Hall et al., 2001). Anaerobiosis
patients with longer disease duration may implies preferential Type II muscle fibre
have a greater degree of deconditioning than recruitment, with consequent increased
younger patients with short disease duration, metabolic activation of the chemoreceptors
it may be postulated that the latter may be in the active muscles, which augments
unable to generate the required walking sympathetic nervous activity and hence HR.
speeds to stimulate an aerobic response Preferential Type II muscle fibre activation
because of the resistance of the water. is also suggested by the greater percentage
Research is required to support this theory. increases in V̊E relative to V̊O2 in water when
A second aim of the present study was to compared with land, although further
compare the relationship of V̊O2 to HR and research in which the speed increments are
RPEL, respectively, between water and land. extended is recommended to examine the
Similar relationships between the two envi- linearity of response. As subjects were
ronments would suggest that the use of land- utilizing approximately 60% of VO 2max at
based HR or RPEL values to predict 4.5 km/h–1, with a RPE of 14, it is possible
exercise intensity would be accurate in that the ventilatory threshold had been
water. However, the results showed that HR reached. Furthermore, the RER was 0.95,
was higher by approximately 9 beats/min–1, suggesting that more carbohydrate than fat
and RPEL by 1–2 points, for a given V̊O2 in was metabolized. The shift from fat toPRI 9.2_crc v4 6/30/03 1:12 PM Page 71
Treadmill walking in RA patients 71
carbohydrate metabolism occurs, in part, outside the scope of the study to examine
because of the recruitment of fast muscle the duration at which 4.5 km/h–1 could be
fibres, which may be activated in response correctly maintained; anecdotal reports
to the increasing resistance as speed suggested that an extended training period
increases in water. may be required before the minimum
A higher RPEL for a given V̊O2 in water recommended course of 15 minutes could
than on land has been reported, and its impli- be achieved. Furthermore it is postulated
cations for exercise prescription have been that older patients with longer disease dura-
discussed (Svedenhag and Seger, 1992; Hall tion may be unable to elicit an aerobic
et al., 1998). A greater perceived exertion response because the peripheral challenge
ties in with the theory forwarded for the supercedes the central one. Future research,
similar greater increases in HR for given utilizing accurate exercise prescriptions for
V̊O2. This disparity between perceived effort water exercise and conforming to the
and physiological cost has been observed in demands of rigorous research designs, is
other studies (Svedenhag and Seger, 1992; required to test the hypothesis that
Hall et al., 1998). In the present study, RPE hydrotherapy provokes increased aerobic
was divided into central and peripheral capacity in patients with RA.
signals by asking patients to complete the In clinical terms the study showed that
scale with reference to their perception of prescribing and monitoring exercise inten-
effort for both breathing and legs, respec- sity based on land-derived values of HR or
tively. At 3.5 km/h–1 and at 4.5 km/h–1, RPEL RPEL during water treadmill walking in
was higher in water than on land but RPEB patients with RA will underestimate exer-
was similar between conditions and speeds. cise intensity. Therefore it is recommended
This suggests that the limiting factor was that land-based HR and RPEL should be
local rather than central fatigue, and implies increased by 9 beats/min–1 and by 1–2 points
that the cardiorespiratory challenge was on the Borg 6–20 scale, respectively.
curtailed by the lack of peripheral muscle However, hydrotherapists should be aware
strength. Thus patients with RA who have that the results of the study may not trans-
strength deficits may take longer to achieve late across to other forms of water activity
similar V̊O2 improvements compared with because of biomechanical differences.
those without muscle atrophy. Walking on a water treadmill is considered,
biomechanically, to mimic terrestrial gait
IMPLICATIONS most closely when compared with other
forms of walking and running in water. For
Accepted wisdom states that appropriate example, it differs from shallow-water
hydrotherapy improves aerobic capacity in walking, during which subjects traverse the
patients with RA. The present study has pool using a heel–toe gait pattern, in terms
shown that energy expenditure is linked to of reduced frontal resistance and therefore
velocity, which in turn is linked with leg encourages a normal posture. It may there-
muscle strength because of the increasing fore afford the best opportunity for transfer-
resistance in water as speed of movement ence of skills from water to land. However,
increases. In our relatively homogenous the scarcity of water treadmills makes
population the ACSM recommendations for shallow-water walking the nearest alterna-
increasing aerobic fitness were met when tive and it would be useful to replicate this
walking at 4.5 km/h –1 . However, it was study in shallow water.PRI 9.2_crc v4 6/30/03 1:12 PM Page 72
72 Hall et al.
ACKNOWLEDGEMENTS Frangolias DD, Rhodes EC, Taunton JE. The effect of
familiarity with deep water running on maximal
The authors gratefully acknowledge financial support oxygen consumption. Journal of Strength and
from the Royal National Hospital for Rheumatic Conditioning Research 1996; 10: 215–219.
Diseases, Bath, UK, and equipment load from PK Fries JF, Spitz P, Kraines RG, Holman HR. Measure-
Morgan Ltd, Kent, UK. They would also like to thank ment of patients outcome in arthritis. Arthritis and
the following for their help and support: Francis Ring, Rheumatism 1980; 23: 137–145.
for his vision; Hazel Gimblett, Michael Collier, Ian Gabrielsen A, Videbaek R, Johansen LB, Warberg J,
Bezodis, Owen Lewis and Jonathon Scott, for assis- Christensen NJ, Pump B et al. Forearm vascular
tance with data collection; Peter Dicken, Peter Laidler and neuroendocrine responses to graded water
and Shirley Yard, for equipment help; Paul immersion in humans. Acta Physiologica Scandi-
Armstrong, for statistical advice; and our patients for navica 2000; 169: 87–94.
their time and effort. Gleim GW, Nicholas JA. Metabolic costs and heart
rate responses to treadmill walking in water at
different depths and temperatures. American
REFERENCES
Journal of Sports Medicine 1989; 17: 248–252.
Allied Dunbar National Fitness Survey. Hakkinen A, Hannonen P, Hakkinen K. Muscle
SC/82/100M/6/92. London: The Sports Council strength in healthy people and in patients
and the Health Education Authority, 1992. suffering from recent-onset inflammatory
American College of Sports Medicine. Guidelines for arthritis. British Journal of Rheumatology 1995;
Exercise Testing and Prescription. London: Lea & 34: 355–360.
Febiger, 1991. Hall J, Blake D, Garbutt G. Acute physiological
Beals CA, Lampman RM, Banwell BF, Braunstein effects of exercise in water. Physical Therapy
EM, Albers JW, Castor CW. Measurement of Reviews 2001; 6: 215–229.
exercise tolerance in patients with rheumatoid Hall J, Macdonald IA, Maddison PJ, O’Hare JP.
arthritis. Journal of Rheumatology 1985; 12: Cardiorespiratory responses to underwater tread-
458–461. mill walking in healthy females. European Journal
Christie JL, Sheldahl LM, Tristani FE, Wann LS, of Applied Physiology 1998; 77: 278–284.
Sagar KB, Levandoski SG et al. Cardiovascular Hall J, Skevington SM, Maddison PJ, Chapman K. A
regulation during head-out water immersion exer- randomized and controlled trial of hydrotherapy
cise. Journal of Applied Physiology 1990; 69: in rheumatoid arthritis. Arthritis Care and
657–664. Research 1996; 9: 206–215.
Danneskiold-Samsoe B, Lynberg K, Risum T, Telling Hanna RD, Sheldahl LM, Tristani FE. Effect of
M. The effect of water exercise therapy given to enhanced preload with head-out water immersion
patients with rheumatoid arthritis. Scandinavian on exercise response in men with healed myocar-
Journal of Rehabilitation Medicine 1987; 19: dial infarction. American Journal of Cardiology
31–35. 1971; 71: 1041–1044.
Ekblom B, Lovegren O, Alderin M, Fridstrom M, Harrison R, Bulstrode S. Percentage weight-bearing
Satterstrom G. Physical performance in patients during partial immersion in the hydrotherapy
with rheumatoid arthritis. Scandinavian Journal of pool. Physiotherapy Practice 1987; 3: 60–63.
Rheumatology 1974; 3: 121–125. Hochberg MC, Chang RW, Dwosh I, Lindsey S, Pincus
Ekdahl C, Broman G. Muscle strength, endurance, T, Wolfe F. The American College of Rheuma-
and aerobic capacity in rheumatoid arthritis: a tology 1991 revised criteria for the classification of
comparative study in healthy subjects. Annals of global functional status in rheumatoid arthritis.
Rheumatic Disease 1992; 5: 35–40. Arthritis and Rheumatism 1992; 35: 498–502.
Cooke CB. Metabolic rate and energy expenditure. In: Kelly BT, Roskin LA, Kirkenhall DT, Speer KP.
Eston R, Reilly T (eds). Kinanthropometry and Shoulder muscle activation during aquatic and dry
Exercise Physiology Laboratory Manual: Tests, land exercises in nonimpaired subjects. Journal of
Procedures and Data. London: Routlege, 1996; Orthopedic Sports and Physical Therapy 2000;
141–160. 30: 204–210.
Frangolias DD, Rhodes EC. Metabolic responses and Kinnear PR, Gray CD. SPSS for Windows Made
mechanisms during water immersion running and Simple (third edition). London: Psychology Press,
exercise. Sports Medicine 1996; 22: 38–53. 1999; 228.PRI 9.2_crc v4 6/30/03 1:12 PM Page 73
Treadmill walking in RA patients 73
Melton-Rogers S, Hunter G, Walter J, Harrison P. Vybiral S. Human physiological responses to
Cardiorespiratory responses of patients with immersion into water of different temperatures.
rheumatoid arthritis during bicycle riding and European Journal of Applied Physiology 2000;
running in water. Physical Therapy 1996; 76: 81: 436–442.
1058–1065. Sugajimo Y, Mitarai G, Koeda M, Moritani T. Char-
Minor MA, Hewett JE, Webel RR, Dreisinger TE, acteristic changes in motor unit activity in hip
Kay DR. Exercise tolerance and disease related joint flexor muscles during voluntary isometric
measures in patients with rheumatoid arthritis and contraction during water immersion. Journal of
osteoarthritis. Journal of Rheumatology 1988; 15: Electromyography and Kinesiology 1996; 6:
905–911. 83–95.
Minor MA, Hewett JE, Webel RR, Anderson SK, Kay Svedenhag J, Seger J. Running on land and in water :
DR. Efficacy of physical conditioning exercise in comparative exercise physiology. Medical
patients with rheumatoid arthritis and Science in Sports Exercise 1992; 24: 1155–1160.
osteoarthritis. Arthritis and Rheumatism 1989; 32: Thompson PW, Hart LE, Goldsmith CH, Spector TD,
1396–1405. Bell MJ, Ramsden MF. Comparison of four artic-
Moening D, Scheidt A, Shepardson L, Davies GJ. ular indices for use in clinical trials in rheumatoid
Biomechanical comparison of water running and arthritis: patients order and observer variation.
treadmill running. Isokinetics and Exercise Journal of Rheumatology 1981; 18: 661–665.
Science 1993; 3: 207–215. Verhagen AP, de Vet HCW, de Bie RA, Kessels
Noble BJ, Robertson RJ. Perceived Exertion. Leeds: AGH, Boers M, Knipschild PG. Balneotherapy
Human Kinetics, 1996; 272–273. for rheumatoid arthritis and osteoarthritis
Rintala P, Kettunen H, McCubbin JA. Effects of (Cochrane review). In: The Cochrane Library,
water exercise program for individuals with Issue 2. Oxford: Update Software, 2000.
rheumatoid arthritis. Sports Medicine Training Weston CFM, O’Hare JP, Evans JM, Corrall RJM.
and Rehabilitation 1996; 7: 31–38. Haemodynamic changes in man during immer-
Sandford-Smith S, Mackay-Lyons M, Nunes-Clement sion in water at different temperatures. Clinical
S. Therapetuic benefit of aqaerobics for individ- Science 1987; 73: 613–616.
uals with rheumatoid arthritis. Physiotherapy Yu E, Kitagawa K, Mutoh Y, Miyashita M.
Canada 1998; Winter: 40–46. Cardiorespiratory responses to walking in water.
Scott J, Huskisson EC. Graphic representation of Medicine and Sport Science 1994; 39: 35–41.
pain. Pain 1976; 2: 175–184.
Sheldahl LM, Tristani FE, Connelly TP, Levandoski
SG, Skelton MM, Cowley AW. Fluid-regulating Address correspondence to: Dr J Hall, RACE/
hormones during exercise when central blood Physiotherapy Dept, Royal National Hospital for
volume is increased by water immersion. Amer- Rheumatic Diseases, Upper Borough Walls, Bath
ican Journal of Physiology 1992; 262: BA1 1RL, UK (E-mail: jhall_work@yahoo.co.uk).
R779–R785.
Sramek P, Simeckova M, Jansky L, Savlikova, (Submitted February 2003; accepted February 2004)You can also read
