Effect of Hydrokinesia in Elderly Subjects with Backward Disequilibrium: A Systematic Review

Background: Water based exercise are significant in improving both static as well as dynamic balance. Elderly subjects already are known to have decreased balance. Changes in the musculoskeletal system are one of the major causes of decreased balance. Physiotherapy regimen is important in improving both static and dynamic balance in elderly. Aquatic therapy is painless and easy way to improve balance in geriatric. However, despite its widespread knowledge of importance of aquatic therapy in improvement of balance, the efficacy of aquatic therapy in elderly is limited. Purpose: The aim of this systematic review is to analyze the importance of aquatic therapy on fall perspective in elderly population. Methods: The authors searched Google Scholar and PubMed from 1996 to 2017. Only downloadable randomized controlled trials (15), randomized clinical trials (14) and experimental studies (3) were included in the study. Results: The duration of treatment varied significantly in comparison to various studies. Subgroup analysis was performed on factors considered for measuring of fall risk parameters in elderly subjects. Conclusion: The result of the present study shows strong evidence to support the water based exercises in which Hydrokineitic therapy showed significant reduction in kinesiophobia and fall risk rate. Hence the therapy can be considered effective for geriatric population.


Introduction
Falls are one of the major risks in geriatric population causing mortality and morbidity. People aged 65 years and older fall each year and this ratio increases with age. The cause of fall can be various like; history of previous fall, disturbed gait due to neurological and balance problems, poor vision and chronic diseases such as arthritis 1 .
Backward Disequilibrium (BD) is a postural disorder observed in elderly subjects who have distortion in their perception of vertical posture. It is commonly seen as the age increases, as the distortion in their perception of vertical posture is reduced. BD commonly may be due to musculoskeletal changes as well as psychological changes. BD may lead to fall of the individual which has many consequences as mentioned above 2 .
Reduction of fall has become one of the major focuses on research nowadays. Some of those interventions are; land based exercises, home safety ergonomic advices, multifactorial interventions and others have shown to be effective. Unfortunately, aquatic therapy is understudied with perspective of fall risk in geriatric population, thus limiting the ability to use traditional systematic review to examine the comparative effectiveness of all published interventions of water based exercise therapy in geriatric population. Hence this study is been undertaken 3 .

Quality Assessment
Quality of the studies recruited in this study was assessed by quality list from Cochrane Collaboration recommendations. Data were extracted independently and checked for accuracy for the purpose of methodological quality.

Data Analysis
Information was extracted from each included trial on: 1. Descriptive characteristics of study (first author, Journal name, published year, Title, sample size); 2. Sample characteristics (average age, >65); 3. Type of intervention; 4. Fall-related outcome measure (length of follow-up, effect of the intervention).

Data Extraction
Following data was extracted from the study: 1. Trial design (sample size and inclusion and exclusion criteria); demographic data of subjects (age, gender, risk of falls); type of intervention (experimental and control components, duration); and outcomes measured as (rate of fall, risk of fall, kinesiophobia, health related quality of life, risk of fracture).

Data Synthesis and Statistical Methods
Statistical heterogeneity of treatment effects between trials was assessed with a significance level at p<0.05, and the I² statistic, as per the Cochrane handbook guidance.

Results
Electronic searches identified 100 records, after removal of duplicates, screening the titles and abstracts of 75 records was done. Full-text articles were assessed for 65 records and resulted in 32 eligible studies were taken into consideration. 18 RCTs studies involved a total of 693 subjects, among which 363 were in water based exercises group and 330 were in control group/non-water based exercise group. 12 Randomized Clinical Trials consisted of 459 subjects among whom 233 subjects were given with water therapy and 226 various other therapies. And 2 experimental studies in which; 53 sample size was considered.

Conclusion
Hydrotherapy uses S.W.E.A.T method, Aquatic aerobics and Deep water running form of water based exercises, showed significant effect in reducing the rate of fall in elderly subjects. S.W.E.A.T method principle are; change in surface area and speed, working positions like rebound, neutral, suspended and extended, enlargement of movement, working around the body, travelling through water forward, backward or diagonal. The results indicate a mean difference of 12.59 (95% CI 0.10 to 40.5).

Funding
Self funding.