Method:In November 2018, a systematic review of the literature was performed in the databases MEDLINE, SciELO, LILACS, PEDro, Cochrane, Web of Science, SPORTDiscus, SCOPUS e CINAHL. Two independent researchers selected randomized clinical trials, which evaluated the effects of hydrogymnastics over healthy elderly women performance on functional tests performance on functional tests. From each study they selected the number of participants in both experimental and control groups (EG and CG), age, intervention protocol, mean and standard deviation before and after the intervention for the following variables: legs and biceps muscular strength, posterior muscle chain extensibility, and agility - all of which compose the functional autonomy on Rikli and Jones test.
We analyzed the methodological quality and the risk of bias through the Jadad Scale and the Cochrane tool respectively. We performed the data analysis through the random effects model and the mean difference between CG and EG. The analysis of the publication bias was done with Egger Test.
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IntroductionThe aging process encompasses multiple dimensions which embrace a series of biological, psychological, social and cultural ), ( aspects. All of which leads to a natural process of progressive losses, especially of muscle mass and flexibility ), (. A sedentary lifestyle can be an aggravating factor, causing a decrease of physical-functional performance. In light of this, functional autonomy has been the subject of many studies over the last years for it relates to physical independence and the ability to execute daily activities by elderly people ), ( ), (.Given the fact that the number of seniors is bound to triple by 2050 a change in public policies will be mandatory. However, the population studies that have observed the senior population present major limitations that interfere in the quality of life, and the functional autonomy is decisive in determining the independence in the daily life ), ( ), ( ), ( ), (.Regular physical exercising seems to contribute to the improvement and/or maintenance of functional autonomy in seniors.
Aquatic exercises, hydrogymnastics specifically, provide postural stability due to the hydrostatic pressure ), (, reduction of joint overload, owing to the thrust force and water resistance, as a consequence of the viscosity.Taking the benefits into consideration, it is possible to apply the practice of hydrogymnastics as an alternative modality for physical fitness ), (. The regular practice of this exercise warms up joints and muscles at the same time. It is also responsible for increasing the levels of muscle force, aerobic capacity, physical resistance, and flexibility.Therefore, the objective of the present meta-analysis was to verify the effects of hydrogymnastics over elderly women functional autonomy.
Search strategyA systematic search without time or language filters was performed in April 2019 on the following databases MEDLINE(US National Library of Medicine), SciELO (Scientific Electronic Library Online), LILACS (Latin American and Caribbean Literature in Health Sciences), PEDro (Physiotherapy Evidence Database), SPORTDiscus, CINAHL(Cumulative Index to Nursing and Allied Health Literature), SCOPUS e Web of Science. The search phrases were developed with the Boolean logic operators “OR” between synonyms and “AND” between descriptors. Although the terms “hydrogymnastics” and “functional capacity” were not identified on the descriptors DeCS and MeSH, they were inserted in the main descriptors as search strategy because they have appeared in several previous studies on the theme.
We researched reference lists and other sources to find further studies.We performed a preliminary analysis of the titles and abstracts that met the inclusion criteria. Then, we read the full version of the ones that were more relevant for the present work. Methodological quality evaluationWe chose to use the Jadad scale, applied by two independent and qualified researchers. We requested a third researcher to decide on discordant assessments. We considered the following methodological criteria: 1a); the description of the study as randomized; 1b) the randomization was properly performed; 2a) it was a double-bind trial; 2b) the blinding was properly performed; 3) description of the sample loss. In case the items 1a, 2a and 3 were met, the study got 1 point per item. If the items 1b and 2b were observed, the study got another point per item.
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Moreover, in case of items 1b and 2b were not met, it caused the study to lose 1 point regarding items 1a and 2a, respectively. Data analysisWe used the program Review Manager 5.3 - available at to analyze the following data: variables of biceps and legs muscular force, agility, and posterior muscle chain extensibility, which compose the functional autonomy in the Rikli and Jones test. The variable was continuous, the statistic method was the inverse-variance, and the analysis model was the random effect. The effect measure was the difference between the means with a 95% confidence interval from the studies and the meta-analysis and the distribution of the studies by the weight of each one in the meta-analysis.
We analyzed the risk of publication bias both qualitatively, with funnel plot, and quantitatively, with Egger test, on Stats Direct Software, version 3. Assessment of evidence levelTwo independent researchers used the tool Grading of Recommendations Assessment, Development and Evaluation Approach (GRADE) to assess the level of evidence for each outcome ), ( ), ( ), (. There are four classification levels to assess the quality of evidence: high, moderate, low and very low. The controlled randomized studies start from high quality of evidence whereas the observational studies start from low quality of evidence. Five aspects can lower the quality of evidence (methodological limitations), inconsistency, indirect evidence, inaccuracy and publication bias) and three aspects can increase the quality of evidence (effect size, dose-response gradient and confusion factor) ), ( ), ( ), (.
Author / yearGroups (n)Age (years)Intervention protocolSit and stand up (rep)Arm Flexion (rep)Sit and reach (cm)Sitting, walk 2,44m, go back and sit(s)x ± dpx ± dpx ± dpx ± dpAlves et al. / 2004GE = 30 GC = 30GE = 78 ± 3 GC = 79 ± 524 sessions o f 45 minutes 2 times a week, 1 minute of execution per exerciseGE = 14,9 ± 1,8. GC = 8,5 ± 1,7GE = 21,6 ± 2,8. GC = 10,5 ± 2,7GE = 5,2 ± 9,20. GC = -5,0 ± 11,3GE = 5,8 ± 1,0.
GC = 7,1 ± 1,5Bocaliniet al. / 2008GE = 27 GC = 20GE = 64 ± 1 GC = 63 ± 136 sessions of 60 minutes 3 times a week, with series of 10 to 15 repetitions and intensity of 70% of the FCGE = 37 ± 3. GC = 23 ± 1GE = 25 ± 1. GC = 21 ± 2GE = 36 ± 2.
GC = 23 ± 2GE = 5,5 ± 1. GC = 7,8 ± 1,3Filho et al. / 2016 (a)GE = 24 GC = 24GE = 65,42 ± 5,31 GC = 69,35 ± 336 sessions of 60 minutes 3 times a weekGE = 11,34 ± 1,44 GC = 11,43 ± 1,66GE = 13,02 ± 2,42 GC = 12,58 ± 2,32GE = 1,77 ± 3,77. GC = 1,55 ± 3,17GE = 6,46 ± 1,05 GC = 6,72 ± 1,06Filho et al. / 2016 (b)GE = 24 GC = 24GE = 65,42 ± 5,31 GC = 69,35 ± 372 sessions of 60 minutes 3 times a week with 1 minute of execution per exercise and 1 minute of recoveryGE = 11,66 ± 1,57 GC = 11,48 ± 1,77GE = 14,31 ± 3,71. GC = 12,68 ± 3,31GE = 1,91 ± 3,33.
GC = 1,54 ± 3,67GE = 6,24 ± 1,12. GC = 6,72 ± 1,08Tsourlouet al. AuthorRandomizationAllocation of randomizationBlinding of participantsBlinding of the evaluatorsIncomplete OutcomesReport of Selective outcomeOther sources of biasRisk of biasAlves et al. (2004)HIGHHIGHLOWUNCERTAINLOWLOWLOWHIGHBocalini et al. (2008)UNCERTAINUNCERTAINLOWUNCERTAINLOWLOWLOWUNCERTAINFilho et al. (2016)UNCERTAINUNCERTAINLOWUNCERTAINLOWLOWLOWUNCERTAINTsourlou et al.(2006)LOWUNCERTAINLOWUNCERTAINLOWLOWLOWUNCERTAINMoreiraet al. (2018)HIGHUNCERTAINLOWLOWLOWLOWLOWUNCERTAINNote: The items referring to the blinding of the participants were considered as low risk of bias, even when not explicit in the RCT, since the studies that use physical exercises as intervention cannot neutralize this bias., - Funnel plot.
DiscussionThe meta-analysis of the four controlled and randomized experiments showed that 177 of the elderly women who have practiced hydrogymnastics presented an average reduction of -1,21 (95% CI = -1.70 to - 0.72) seconds to cover 2.44m on foot, which means a significant increase in agility. 165 of the elderly women who practiced hydrogymnastics performed 4.11 (95% CI = -0.02 to 8.24) more repetitions of sitting and standing up from a chair, which means a significant increase in leg strength and endurance. However, the biceps strength performance did not vary among the 105 elderly women who practiced hydro gymnastics and the 98 elderly women in the control group , the same occurred regarding the posterior muscle chain extensibility among 177 participants who practiced the activity and 168 of the control group.The viscosity creates resistance through particle displacement while walking in the water. Thus, it is necessary to make a bigger effort to walk and at the same time, it is 790 times more difficult to walk in water than on land due to the counter-resistance ), (.
Therefore, when we compare an individual walking in the water to someone walking on land, at the same execution speed, the reduced resistance caused by the airflow will result in a lower movement time in comparison to the water ), (. Consequently, exercises like walking, running and lateral movement, practiced at least 2 to 3 times a week, for 12 weeks of intervention, maybe the reason why the elderly women assessed in the test “sitting, walk 2.44m, go back and sit” experimented an increase in agility.Such increase in agility is relevant within the aforementioned age group because it reduces the risk of falling while performing basic activities of the daily life, such as deviating from people, obstacles and moving quickly to answer the phone or to take a bus. The performance of leg exercises, like plyometric training, leg curl and extension, hip adduction and abduction, running and walking throughout the studies, practiced at least 2 to 3 times a week, for 12 weeks of intervention, maybe the reason why the participants showed an increase in leg strength revealed by the test “sit and stand up”. Leg strength is considered an important factor in what comes to reducing the risk of falling in daily activities such as sitting and standing up from a chair for a meal or walking to the bank or to the supermarket.Walking, running, and lateral movements are applied to improve the agility of elderly women. When the leg strength is increased, we recommend plyometric training, leg curl/extension, and hip adduction/abduction from 2 to 3 times a week, at least for 12 weeks in order to achieve the results obtained in both tests.Three years ago, Reichert, Prado, Kanitz, Kruel conducted a meta-analysis, which showed a substantial increase in all of the outcomes herein studied: leg strength, biceps strength, agility, and posterior muscle chain extensibility.
ConclusionHydrogymnastics seems to be an effective tool for Physical Education professionals when it comes to increasing the agility and leg strength of elderly women. Otherwise, the modality did not affect the posterior muscle chain extensibility and biceps strength due to the absence of specific exercises aimed to improve such physical qualities.Therefore, we suggest that new studies should be carried out, as long as they use the complete battery of tests to combine all the variables to provide the prognosis of the functional capacity and the risk of functional loss among the senior population and, especially, that these new studies bring specific exercises for each trainable physical quality of the functional capacity.