J Rehabil Med 2015; 47: 376–381

Short Communication

Aquatic Circuit Training Including Aqua-Cycling in Patients

with Knee Osteoarthritis: a feasibility study

Stefanie Rewald, MSc1, Ilse Mesters, PhD1, Pieter J. Emans, PhD2, J. J. Chris Arts, PhD2,
Antoine F. Lenssen, PhD3 and Rob A. de Bie, PhD1
From the 1Department of Epidemiology, CAPHRI School for Public Health and Primary Care, Maastricht University,
2
Department of Orthopaedic Surgery and 3Department of Physiotherapy, Maastricht University Medical Centre,
Maastricht, The Netherlands

Background: Aqua-cycling is easy to learn, acceptable, and fitness-trend in Europe and combines stationary cycling with
safe for patients with knee osteoarthritis. It can therefore be the advantages of exercising in an aquatic environment. Previ-
an ideal component of aquatic circuit training. ous research on rehabilitation after anterior cruciate ligament
Objective: To investigate the feasibility of a small group- reconstruction and total knee surgery showed that aqua-cycling
based aquatic exercise programme including aqua-cycling. in addition to usual care resulted in greater improvement in
Design: A feasibility study using quantitative (pre-post) and range of motion (ROM) and more rapid reduction in knee joint
qualitative (cross-sectional) assessments. swelling compared with standard care (3, 4). A small pre-post
Participants: A volunteer cohort of 10 women and men, age test study with 19 patients with rheumatic diseases showed a
range 46–77 years, with knee osteoarthritis. positive influence on well-being, strength and mobility after
Methods: Focus group interviews explored participants’ ex-
10 weeks’ aqua-cycling (5). Based on the results of previous
perience with the training. Pre- and post-exercise knee pain,
studies it is hypothesized that participants with knee OA
attendance, progression in training, and adverse events were
would also accept this type of exercise. However, aqua-bikes
registered.
are expensive. Most therapy pools do not have enough space
Results: Seventy percent of patients attended all sessions.
Focus groups revealed high levels of satisfaction with the se- to store several aqua-bikes. We developed an aquatic circuit
lection of exercises, and participants valued the immediate training for small groups of 3 participants consisting of aquatic
pain relief experienced. Participants progressed well. How- exercises and aqua-cycling.
ever, aqua-cycling in an out-of-the-saddle position was too The present study aims to evaluate the feasibility of an
demanding for most participants. 8-week aquatic circuit training in terms of adherence, possibil-
Conclusion: An aquatic circuit training that includes aqua- ity to progress in exercise level, occurrence of adverse events,
cycling is feasible for patients with knee osteoarthritis. Par- operational aspects and patient acceptance.
ticipants reported pain reduction and were positive about
the diverse exercise programme. Aqua-cycling in a seated
position is a safe and controlled type of movement. METHODS
Key words: osteoarthritis; aquatic therapy; aqua-cycling; hydro- Design
therapy. A convergent mixed-methods design was used to describe differ-
ent aspects of feasibility. The study was a proof of concept of a
J Rehabil Med 2015; 47: 376–381 full-scale trial, which was approved by the local ethics committee
(NL42617.068.12, NTR 3766).
Correspondence address: Stefanie Rewald, Department
of Epidemiology, CAPHRI School for Public Health and Participants
Primary Care, Maastricht University, PO Box 616, Maastricht,
Recruitment was carried out from February to April 2011 at Maas-
NL-6200 MD, The Netherlands. E-mail: stefanie.rewald@
tricht University Medical Centre. Participants were identified by their
maastrichtuniversity.nl orthopaedic surgeon and signed a written informed consent. Eligible
Accepted Oct 28, 2014; Epub ahead of print Feb 5, 2015 participants were diagnosed with knee OA and had an indication for
conservative therapy including pharmacological and exercise treat-
ment. Exclusion criteria were: a planned total knee arthroplasty; acute
INTRODUCTION infection/inflammation; neuromuscular disease; and severe cardio-
respiratory problems.
Water-based exercise is frequently recommended for patients
Measures and data collection procedure
with knee osteoarthritis (OA), especially when land-based
training is restricted by the experience of pain (1). The hydro- Focus group interviews were chosen to explore participants’ experi-
ences with aquatic circuit training. The question guide (Table I) was
static pressure, temperature and buoyancy of water result in based on typical questions for formative programme evaluation and
relief of body weight, muscle relaxation, decreased joint com- included questions about positive and negative aspects of the training
pression, and pain reduction (2). Aqua-cycling is an upcoming and aspects that should be changed, dropped or fine-tuned.

J Rehabil Med 47 © 2015 The Authors. doi: 10.2340/16501977-1937

Journal Compilation © 2015 Foundation of Rehabilitation Information. ISSN 1650-1977
 Aquatic circuit exercises in patients with knee osteoarthritis 377

Table I. Focus group questions reason given (n = 8); change of mind with respect to OA treat-
Introductory question: ment, decided to stop conservative treatment and to undergo
1. What did you expect from the training? total knee surgery (n = 2); satisfied with physiotherapy twice
Transition question: a week (n = 2); and too occupied (n = 1).
2. Why did you participate? The final cohort comprised 10 participants (7 women) aged
Key questions: between 46 and 77 years (mean 59.6 (SD 9.61)). The majority
3. If you compare this training with land-based training, what is the
of the cohort was employed (n = 6), 3 participants were retired,
difference from land-based training?
4. What did you like best about the programme? and 1 participant was seeking work. Radiological assessment
5. What did you like the least about the programme? of the tibiofemoral joint showed Kellgren-Lawrence scores of 2
6. What should be changed? (n = 2), 3 (n = 4) and 4 (n = 4). In addition, 2 patients had grade
7. What should be continued just as it is now? 2 patellar OA. Elapsed time since diagnosis of knee OA ranged
8. What should be continued but fine-tuned?
from 1 to 180 months (mean 62 months; SD 69.06). Treatment
9. What should be dropped?
history varied from injections (n = 5), physiotherapy (n = 5),
medical fitness training (n = 4) and pain medication (n = 3). Four
The focus groups were recorded and documented in a transcript. people exercised regularly and continued their exercise routines
Only the physiotherapist and the interviewer had access to the records (cycling on a home-trainer, exercises for the lower back and
and full transcripts. The statements of participants were separated from medical fitness) during the study period. Others had experiences
personal data by the following code: gender (male/female), age, and
focus group number. The focus groups took place in a meeting room
with medical fitness (n = 2) and aquatic fitness (n = 1), but were
of Maastricht University. Both focus groups lasted for 1.5 h with a not participating in these activities at the time of the study.
break after 45 min.
Quantitative data was collected on self-reported pre- and post-exer- Feasibility of the training protocol
cise knee pain on a numeric pain rating scale (NRS) (6, 7). Furthermore,
attendance, progression in training and adverse events was registered. The adherence rate for all sessions was 70%. Two people
In addition to patient-relevant information the physiotherapist regis- missed 1 and 4 sessions, respectively, because of holidays. For
tered experiences with execution of the training and supervision of the work-related reasons 1 participant could only attend 5 sessions.
groups and logistical aspects with the installation of the circuit training. All the exercises in the conditioning section consisted of 3
Intervention levels. Except for 2 exercises, all patients could progress to
Participants trained in small groups of maximal 3 participants, once a level 3. Pushing the pool noodle underwater up and down was
week for 45 min over an 8-week period. The aquatic circuit training was difficult for 2 participants because the buoyancy of the pool
offered free to the patients; they only had to meet the cost of transport. noodle raised their supporting leg from the floor. Based on the
The training was carried out in a heated therapy pool (32°C) of the physiotherapists’ judgement of a low exercise capacity (n = 4)
physiotherapy department of Maastricht University Medical Centre,
and too few sessions or too long breaks between the sessions
supervised by a physiotherapist who was also in the pool herself. The
circuit training comprises aqua-cycling on the AquaCruiser, functional to progress (n = 3) all women remained at level 2 with the
exercises, such as stepping and chair stands, ROM and strength exer- aqua-cycling exercise. Participants perceived resistance levels
cises. Gait exercises were performed as a warm-up and cool-down. A 2 and 3 as comfortable for pedalling, and scored aqua-cycling
detailed description of the content and goals of the exercises accord- at an individual chosen pedalling frequency as light (men) to
ing to the framework from van Leeden et al. is given in Table II (8).
moderate (women) on the Borg scale independent from the
Data analysis resistance. Cycling in an out-of-the-saddle position (level 3)
Focus group analysis was guided by the steps of framework analysis was evaluated as hard on the Borg scale.
for descriptive accounts (9). The raw data was summarized per ques- One adverse event occurred during the cooling down section
tion from the interview guide and linked with illustrative quotes from of 1 session. One participant’s foot slipped during gait training,
the raw data. To enhance clarity, recurring themes additional to the scoring 5 on the pain scale. Knee pain decreased quickly after
questions were developed in regular discussion between the physi-
otherapist and the interviewer.
the end of the session.
The Wilcoxon signed-rank test examined differences in pre- and A swimming pool with an adjustable floor is preferable, be-
post-exercise scores of knee pain. Results are presented as means and cause of the weight of the aqua-bike. Two people are needed to
z-scores (z). Standard deviation (SD) and 95% confidence interval immerse the bike if the floor of the pool is not height-adjustable
(CI) were calculated. A significance level of a 2-sided p < 0.05 was set. or has an entrance for disabled people.
Transportation of the aqua-bike inside and outside the pool is
easy as it has 2 wheels at the front. The saddle height is easily
RESULTS
adjustable by professionals or patients even when the bike is
Between February and April 2011 the orthopaedic surgeon immersed. A difference in body height of more than 20 cm can
identified 24 eligible patients, of whom 11 were willing to result in suboptimal levels of immersion among participants.
participate. One participant fell on her knee at home before In order to ensure that participant’s legs are underwater during
signing the informed consent, which exacerbated her com- cycling participants must be immersed to a minimum height
plaints and made it impossible for her to participate. The main of the navel and a maximum height of the xiphoid process.
reasons for not participating were: not interested, no specific During shallow-water exercises immersion to chest height is

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378 S. Rewald et al.

Table II. Description of the aquatic circuit exercises

Exercises: Water-based circuit training in groups of 3 patients, once a week, 45 min per session, supervised by 1 physiotherapist who is also in the pool.
Primary intervention goal:
- feasibility of aqua-cycling:
• ease of learning of correct aqua-cycling techniques
• exploring pedalling frequency and resistance during aqua-cycling
Secondary intervention goals (ICF):
- b770: gait pattern function (exercise 1)
- b710: mobility of joint functions (exercise 1, 2, 5, 7)
- b715: stability of joint functions (exercise 5, 3, 4, 9)
- b740: muscle endurance functions (exercise 2, 3, 5)
- b760: control of voluntary movement functions (exercise 1–9)
- b620: proprioceptive function (exercise 3, 4, 5, 6)
Level 1
1. Gait training (2–4 laps each direction):
1.1. Forward = normal gait and step length and correct foot movement (heel to forefoot)
1.2. Backward = reverse foot movement (forefoot to heel)
1.3. Sideways=  step to the left and bring right foot to the left v.v.
2. Aqua-cycling: cycling forward; move extended arms alternating forward/backward (10 min)
3. Stepping on an underwater step: step down and up
4. Squats
5. Flexion and extension of the unloaded knee (1-leg stance, bar work: 1-hand hold)
6. Hip abduction (bar work: 1-hand hold)
7. Cycle legs: Sitting on pool noodle or hanging on it (noodle in the back)
8. Stretching m. quadriceps, m. iliopsoas, adductors, hamstrings, calf (10 s, 3–4 reps)
9. Pool noodle balance: step over the immersed pool noodle, move the pool noodle around the body, sitting on the pool noodle
Level 2
1. Gait training (2–4 laps each direction):
1.1. Forward = normal gait and step length correct foot movement (heel to forefoot), 1 lap heels up, 1 lap heels to buttock
1.2. Backward = reverse foot movement (forefoot to heel)
1.3. Sideways = step to the left and bring right foot to the left v.v.
2. Aqua-cycling: cycling forward/ backward, change pedalling direction after 2 min (total duration 10 min)
3. Stepping on an underwater step: step up then over, turn and repeat
4. Squats: go up and down in 3 steps (hold each position for 5 s)
5. Flexion and extension of the unloaded knee (1-leg stance, freestanding)
6. Hip abduction/adduction (bar work: 1-hand hold)
7. Cycle legs: sitting on pool noodle or hanging on it (noodle in the back)
8. Stretching m. quadriceps, m. iliopsoas, adductors, hamstrings, calf (10 s, 3–4 reps)
9. Pool noodle balance: step over the immersed pool noodle, move the pool noodle around the body, sitting on the pool noodle
Level 3
1. Gait training (2–4 laps each direction):
1.1. Forward = normal gait and step length correct foot movement (heel to forefoot), 1 lap heels up, 1 lap heels to buttock
1.2. Backward = reverse foot movement (forefoot to heel)
1.3. Sideways=  step to the left and bring right foot to the left v.v.
2. Aqua-cycling: cycling in sitting* and half-sitting** position, change position after 4 min*, 1 min**, 2 min*, 1 min**, 2 min*
3. Stepping: go up and down in sideways
4. Squats, while pushing and pulling a pool noodle with arms on shoulder height
5. Push pool noodle down (under the foot of the free leg) while extending knee and hip, let the pool noodle come up gently until hip and knee reach 90° flexion (bar
work: 1-hand hold)
6. Lunge sideways
7. Cycle legs: sitting on pool noodle or hanging on it (noodle in the back)
8. Stretching m. quadriceps, m. iliopsoas, adductors, hamstrings, calf (10 s, 3–4 reps)
9. Pool noodle balance: step over the immersed pool noodle, move the pool noodle around the body, sitting on the pool noodle
General information
- Main focus on:
• correct aqua-cycling technique
• knee position (neutral knee alignment, active control of knee position) during the exercises
- Duration: warming-up: 5–10 min, exercise 1
exercise 2–6: 10 min with individually chosen pedalling frequency and resistance
exercise 3–6: 1 min (~15–20 repetitions) each with 1-min rest
cooling-down: 5–10 min, exercise 1 (in uneven weeks), 7, 8, 9 (even weeks)
- Resting time between exercises: 1 min (including change of workstation)
- Intensity: exercise 1, 7–9: 7–10 on Borg scale
exercise 2–6: 11–13 on Borg scale
- Progression to level 2 and 3 if:
• knee pain during and after the exercises < 5 on a NRS for pain
• patients performed the exercises with light to moderate exertion (Borg scale, no observation for any visible signs of overexertion)
• patients performed the exercise with good quality of performance (based on the visual inspection of the physical therapist)
- Training devices:
• Underwater step
• Aqua bike “AquaCruiser” (placed at the bottom of a pool; participants needed to be immersed to xiphoid process level)
NRS: numeric rating scale; v.v.: vice versa.

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 Aquatic circuit exercises in patients with knee osteoarthritis 379

Table III. Illustrative quotes from the focus group interviews

What did you expect from the training?
• “I expected it could do no harm and I thought: Let’s see!” (Male 57, group 2)
• “I thought: it is for my knee and if it is not helping, it could at least do no harm.” (Female 58, group 1)
Why did you participate?
• “…they said to me that cycling is a knee-friendly sport.” (Male 54, group 2)
• “We need to stay active in order to control pain and stiffness…” (Male 57, group 2)
• “I try to go to the gym every morning. I am motivated to do this because otherwise my (health) condition will deteriorate over a few years…” (Female 58, group 1)
What is the difference with land-based training?
• “Exercising in water is easier.” (Female 59, group 2)
• “While doing medical fitness I always keep a certain tension in my knee. This isn’t changing throughout the whole workout. This training aims to strengthen your
muscles. I didn’t feel this during the water-based training that was a relief.” (Male 54, group 2)
• “Training in water aims to improve and keep your flexibility.” (Male 57, group 2)
Comparison with land-based exercise/cycling
• “Pedalling is harder than on a usual bike, but at the same time it feels smoother.” (Female 58, group 1)
• “It is easier than normal cycling, it feels effortlessly.” (Female 77, group 1)
• “I often take the bike…but especially when I am cycling with a tempo of during uphill cycling I feel a certain pain under my patella. I never had this with aqua-
cycling even pedalling is more tiring.” (Male 54, group 2)
What did you like best about the programme?
Pain reduction
• “I could move with almost no pain.” (Female 58, group 1)
• “After the training I always felt better. The improvement depended of course on how I was doing during the day, but it always improved.” (Male 57, group 2)
• “I have noticed the positive effects of the training. Sometimes you move your leg in certain ways that it causes knee pain. You cannot prevent this during everyday
life. On those days I knew that the pain would be reduced after the AquaCruiser training.” (Male 54, group 2)
• “It reduced the pain, but the day after the pain was back.” (Female 60, group 1)
• “…the pain reducing effect lasted a little while after the training…” (Male 57, group 2)
Water temperature
• “The warm water felt very good.” (Female 58, group 1)
• “It is wonderful in that water.” (Female 60, group 1)
Selection of exercises
• “I came with pleasure to every session. It was fun to do the exercises” (Male 54, group 2)
• “The exercises in combination with the warmth of the water gave a good feeling.” (Female 58, group 1)
• “I really liked the combination of exercises.” (Female 59, group 2)
• “I would like to do aqua-cycling at the beginning and in the end, but always in combination with the other exercises.”
• “It is a total body workout.” (Female 77, group 1)
What did you like the least about the programme?
• “Everything was fine, it was really great!” (Female 58, group 1)
What should be changed?
• “Nothing! I am afraid of water and for me it really was an overcoming. In the beginning I needed much assistance, but this got better with every session.” (Female 77,
group 1)
Motivation to continue the training
• “I would like to know where I can continue this type of training.” (Female 77, group1)
• “I looked up information about aqua spinning classes, but I am not sure if this matches my exercise level.” (Female 51, group 2)
What should be continued but fine-tuned?
• “The training was scheduled around dinnertime. I would prefer to come in the morning or around noon.” (Female 58, group 1)
• “I think it would be even better to exercise two times a week.” (Female 60, group 1)
• “I experienced pain reduction that lasted a little while after the training, but I did it only once a week. I think you need to exercise more often to be able to evaluate its
effectiveness.” (Male 57, group 2)
• “A display with more information about training parameters during aqua-cycling like tempo, pedalling frequency would be useful for feedback and to guide
progression.” (Male 54, group 2)
What should be dropped?
No suggestions were made.

preferred so that participants can perform all exercises, such interviews because they were on holiday; another participant
as squatting without immersing their head. had other appointments (n = 1) on the day the focus groups
Participants could step on and off the aqua-bike without were held.
assistance and were able to start exercising with minimal Illustrative quotes from both interviews are shown in Table
instruction. In addition, the combination of arm movements III. Initially participants were asked about their expectations.
and cycling was easy to learn and participants needed no as- Participants answered that they were motivated to try-out the
sistance during hand-free cycling. Because the cycling part training because exercise was known as a means to control
lasted longer than the other exercises only 2 participants symptoms of OA. They knew that cycling and aquatic exer-
changed workstations at the same time, which allowed time cises are frequently recommended to people with knee OA
for tailored feedback. because of their low impact on the knee joints. Participants
described the training as a total body workout with the focus
Qualitative evaluation on joint mobility and a light to moderate exercise intensity. In
Two focus group interviews were conducted, with 4 and 3 comparison with land-based training the pain relief effect was
participants, respectively. Two people could not attend the highlighted. Other reported effects were release of a certain

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380 S. Rewald et al.

tension around the knee and higher self-efficacy about physical is less controlled and less stable. It might be that more training
functioning. Participants believed that the warmth and buoy- is needed before out-of-saddle movements are possible. A good
ancy of the water had a great impact on the reduction of pain, technique is crucial to hold a stable posture with the knees in
initiation and maintenance of movements. They felt that they line with feet and hips. For instance, Moser developed an aq-
could perform the cycling movements in the water more eas- ua-cycling programme for patients with rheumatic diseases and
ily, although they experienced pedalling on the AquaCruiser was able to introduce cycling in out-of the saddle position, but
as more tiring. The participants were very positive about the not before week 7 of a 10-week programme (5). These findings
selection of, and variety of, exercises. With regard to the suggest that 10 min of aqua-cycling is probably too short a time
aqua-cycling section participants stated that they would have to achieve progression, and that cycling in a seated position is
liked to cycle for longer than 10 min on the AquaCruiser. Nev- preferable during early aquatic circuit training. Moreover, the
ertheless, cycling alone with no other exercises would be too perception of patients, that aqua-cycling was effortless in the
monotonous. Participants evaluated the training as suitable for seated position, might be explained by the fact that participants
their needs and exercise capabilities. Even someone with fear in the present study cycled at a self-selected pace. Previous
of water could participate without problems. Participants only research on underwater treadmill walking in patients with knee
had few suggestions for further optimization of the training. OA showed that walking at a self-selected and comfortable pace
Participants who were not employed suggested scheduling the resulted in lower energy expenditure than land-based walking
training in the morning. Furthermore, all participants would (11). This might be explained by the fact that during slow un-
opt for a higher exercise frequency and a display on the aqua- derwater walking buoyancy dominates and the water resistance
bike with information about performance to make the training is not sufficient to raise the heart rate.
more efficient. Thus, participants should first progress their pedalling pace
before cycling in a standing position. Cycling in a seated posi-
Quantitative evaluation; self-reported pre- and post-exercise tion is a controlled movement and few instructions are needed,
knee pain which creates more time for tailored feedback for patients at
The self-reported pain scores were significantly lower after other workstations. However, if the period of aqua-cycling is
the training compared with the scores before the training, extended variation is needed to prevent monotony, which may
z = –2.524, p < 0.05, r = –0.21. Participants had a mean pre- require more supervision.
exercise pain score of 4.09 (SD 1.45; 95% CI 3.05–5.12). In conclusion, aquatic circuit training including aqua-cycling
After the training sessions participants had a mean pain value is feasible for patients with OA. Aqua-cycling in a seated
of 3.18 (SD 1.33; 95% CI 2.23–4.13). position is a safe and controlled movement that enables the
physiotherapist to spend more time on supervision of other
patients. Therefore, aqua-cycling is easy to incorporate in
DISCUSSION circuit training and enables institutions to provide small group
trainings even with 1 aqua-bike. Further research is needed to
This study investigated the feasibility of group-based aquatic investigate patient acceptance of a higher exercise frequency
circuit training for patients with knee OA. The training con- of 2 or 3 sessions weekly and its impact on symptoms of
sisted of gait training, shallow-water toning exercises, flex- knee OA. The feasibility and effects on knee OA of exercise
ibility exercises for the lower limbs, and aqua-cycling. Due programmes incorporating more time spent aqua-cycling have
to the set-up of the training only one aqua-bike was needed. not yet been investigated.
Seventy percent of the participants attended all 8 sessions.
The short time-period for the research project, summer holidays
and limited access hours to the therapy pool made it difficult to AcknowledgementS
reschedule sessions for participants who were not able to attend
The AquaCruiser was provided by AquaKinetiqs. The authors thank Wiel
sessions due to holidays and work time. Participants perceived Wijnen at the Department of Orthopaedic Surgery for patient recruitment.
the training as a total body workout, focusing on flexibility. They George Roox kindly allowed the use of the pool facilities at Maastricht
were positive about the immediate pain reduction and the fact University Medical Centre.
that movements felt smoother. Also, self-reported pain showed a
1-point reduction immediately after the training. Evidence sug-
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