Vol.1, No.2, 22-30 (2013) Open Journal of Therapy and Rehabilitation
Hydrotherapy treatment for patients with psoriatic
arthritis—A qualitative study
Maria H. Lindqvist1,2, Gunvor E. Gard1
1Department of Health Sciences, Lund University, Lund, Sweden
2Samrehab, Sjukgymnastiken, Värnamo Sjukhus, Värnamo, Sweden;
Email: maria.lindqvist@lj.se, gunvor.gard@med.lu.se
Received 10 September 2013; revised 12 October 2013; accepted 19 October 2013
Copyright © 2013 Maria H. Lindqvist, Gunvor E. Gard. This is an open access article distributed under the Creative Commons At-
tribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is prop-
erly cited.
Purpose: To describe how patients living with
psoriatic arthritis experience long-term hydro-
therapy group treatment. Studies for this group
of patients are lacking. Method: Qualitative in-
terviews were conducted with ten informants
after hydrotherapy treatment. The treatment in-
cluded exercises for increased mobility, coor-
dination, endurance, aerobic fitness, stretching
and relaxation. The interviews were analysed
with content analysis. Results: A theme “hy-
drotherapy—a multidimensional experience” and
two categories emerged: situational factors and
effects of hydrotherapy. The category “situ-
ational factors” comprised the subcategories:
warm water, training factors and a competent
instructor, and the category “effects of hydro-
therapy” comprised the subcategories: psy-
chological effects, improved physical capacity,
social effects, changed pain experience and
changes in work and participation in daily life.
Conclusion: Positive effects of regular hydro-
therapy in a group setting were shown in
physical ability, energy, sleep, cognitive function,
work and participation in daily life. The instruc-
tors had an important coaching role, which
needs to be promoted.
Keywords: Hydrotherapy; Psoriasis Arthritis;
Rehabilitation; Qualitative Study
Psoriathic arthritis (PsA) is an inflammatory arthritis,
often related to psoriasis. Nearly a third of patients with
psoriasis also have inflammatory arthritis and enthesitis
[1]. PsA has emerged as a specific disease independent
of rheumatoid arthritis (RA) [2]. It is a chronic disease
with a wide range of impairments, limitations and restric-
tions [3]. The prevalence of psoriasis and psoriathic ar-
thritis varies from 20 - 420 per 100,000 inhabitants
across the world [4]. PsA can develop at any time but for
the majority of people, it appears between the age of 30
and 50. Both genders are affected equally [5].
PsA has been grouped into five subtypes: distal inter-
phalangeal, symmetric polyarthritis, assymetrical oli-
goarthritis and monoarthritis, spondylitis and arthritis
mutilans [5]. There has been a controversy over the se-
verity of peripheral PsA compared to RA. Except from
the mutilans form (resorption of bone with dissolution of
the joint), PsA was earlier found to be a milder disorder
than RA. However, it has been suggested in recent re-
ports that PsA can be as severe as RA. A recent study
showed that function and quality of life scores are the
same for both groups, but the joint damage in RA is sig-
nificantly greater than in PsA after equivalent disease
duration [6]. Another study showed that pain/disability
and well-being were significantly lower in patients with
PsA than in patients with RA [7]. Approximately 40% of
patients with PsA may develop radiographic joint de-
struction [8]. It is common with axial disease in PsA.
These patients have been said to experience severe pain
and are therefore more hindered in their ability to func-
tion than patients with peripheral PsA [9]. Inflammatory
spinal pain occurs in 40% of PsA-patients and radiologi-
cally defined sacroilitis in 78% of the patients [10,11].
Al- though there are similarities between axial PsA and
ankylosing spondylitis (AS), important differences have
been described [11]. PsA patients have reduced male
preponderance, less overall disease severity, less severe
sacroiliitis, less cervical involvement, and relative ab-
sence of ligamentous ossification compared to patients
with AS [11]. The Bath Ankylosing Spondylitis Disease
Copyright © 2013 SciRes. OPEN ACCESS
M. H. Lindqvist, G. E. Gard / Open Journal of Therapy and Rehabilitation 1 (2013) 22-30 23
Activity Index (BASDAI) showed significantly lower
scores in PsA than in AS [12], and the correlation with
external indicators of disease activity has shown con-
tradictory results [12,13]. One study of physical func-
tioning and disability in patients with PsA showed that
28% of the patients seemed resistant to become dis-
abled over ten years but the remaining patients experi-
enced permanent disability or moved between disability
states [14]. There are three main groups of drug therapies
which are used in treating PsA: Non Steroidal Anti In-
flammatory Drugs (NSAID), Disease Modifying Anti
Rheumatic Drugs (DMARD) and Tumor Necrosis Factor
Alfa (TNF). Since 2002, there have been several ad-
vances in the therapeutics of spondyloarthropaties, par-
ticularly in AS and PsA due to the use of TNF blockers
[15]. Enthesitis is characteristic for PsA patients [16].
Non-steroidal inflammatory medications, physiotherapy
and steroid injections are recommended as being poten-
tially effective treatments. Despite this, case series or
controlled trials with Spondyloarthritis (SpA) patients
treated with these could not be found [16].
Physical Therapy/Hydrotherapy
Physical therapy is as an essential part of the man-
agement of PsA. Swimming and group training is rec-
ommended especially for patients with axial disease [17]
and stretching of muscles around the affected joints.
Hydrotherapy is defined as supervised structured ex-
ercises of specific extremities and joints in warm water.
Immersion in warm water reduces the load on painful
joints according to the law of Archimedes (287 BC) and
allows exercise against water resistance. Thanks to the
effects of temperature and pressure on nerve endings and
muscle relaxation, pain may be relieved, which may fa-
cilitate mobilizing and strengthening of affected joints
and muscles [18-20]. People with RA and PsA highly
value hydrotherapy. Few randomized studies have stud-
ied the effect of hydrotherapy [21-23] or compared the
benefits of hydrotherapy with exercises [24,25]. One
recent study showed that patients with RA were more
likely to report improved well-being after a hydrotherapy
treatment program compared to exercise treatment [24].
Also in a randomized trial with people with AS, hydro-
therapy had better short-term improvement in cervical
rotation than exercise alone [25]. Within rheumatology,
patients consider that it is important both with evalua-
tions of treatments which can increase well-being and
reduce fatigue and with studies of physical outcomes
such as pain and disability [26,27]. Hydrotherapy may
increase well-being, physical functioning and reduce
fatigue among patients with rheumatologic diseases. So
far, no scientific study of the effects of hydrotherapy for
patients with PsA has been performed.
The aim of this study was to describe how patients
living with PsA experience hydrotherapy.
2.1. Participants and Data Collection
A hydrotherapy group led by physiotherapists, phy-
siotherapy assistants or leaders in a patient organization
was contacted to find informants. They recruited infor-
mants at three different hospitals. Information was also
given by a leaflet. The informants were consecutively
included in the study as soon as they agreed to partici-
Ten informants participated in the study, eight women
and two men. The inclusion criteria were: being eighteen
years or older, having a diagnosed PsA for at least one
year, having the capacity to understand and speak Swed-
ish, having participated in 10 or more hydrotherapy ses-
sions, the latest treatment period not more than 3 months
prior to the interview. The mean age of the participants
was 55 years, ranging from 33 to 70 years. Their mean
duration of illness was 10 years, ranging from 2 to 27
years. They had participated in hydrotherapy for an av-
erage of 9 years ranging from 0.5 to 27 years. Two were
receiving social benefits for part-time sick leave and
three were receiving full time sick leave or pension. Two
were working and three were retired. Six were married
and four lived alone or with their children.
2.2. Qualitative Interview Study
A qualitative interview study was performed. Qualita-
tive studies are performed to increase the understanding
of patients’ experiences, thoughts and actions for exam-
ple when living with chronic diseases [28] and to de-
scribe experiences of a phenomenon [29,30]. To use an
interview guide is recommended [29] and we used a
semi-structured interview guide which covered the fol-
lowing fields: hydrotherapy as an exercise form, the ef-
fects of hydrotherapy on bodily functioning, activity and
participation. A pilot interview was conducted before the
study to check the procedure and complete the interview
guide. Each interview started with an open question
about the experience of hydrotherapy: can you tell me
about your experience of hydrotherapy? The interviews
were conducted during a period of 6-months. The inter-
viewer was not involved in the informants’ treatment.
Before the interview, the aim of the study was presented
and the informants had the opportunity to ask questions.
They were informed that their participation was optional
and that they could end their participation at any time.
They were also assured of confidentiality and signed a
letter of informed consent [29].
The interviews took place in a setting chosen by the
informants. Each interview was recorded and transcribed
verbatim by the author. Each interview lasted between 35
Copyright © 2013 SciRes. OPEN ACCESS
M. H. Lindqvist, G. E. Gard / Open Journal of Therapy and Rehabilitation 1 (2013) 22-30
Copyright © 2013 SciRes. OPEN ACCESS
and 60 minutes. This project has been approved by the
central ethical review board in Linköping, number
2.3. Data Analysis
The data analysis was performed with content analysis
following the steps recommended by Graneheim and
Lundman [31]. The data was reviewed multiple times in
order to assure a complete and thorough understanding
of the collected data. The text was divided into meaning
units which were condensed and abstracted and labeled
with codes. Examples of meaning units, condensed
meaning units and codes are shown in Table 1. The
whole text was considered when condensing and labeling
meaning units with codes. The various codes were com-
pared concerning differences and similarities and sorted
into two categories with eight sub-categories constituting
the manifest content. The categories were discussed by
the authors. A process of reflection and discussion re-
sulted in an agreement about how to sort the codes. Fi-
nally the underlying meaning, the latent content, of the
categories was formulated into a theme.
2.4. Hydrotherapy Program
The hydrotherapy group was led by physiotherapists,
physiotherapy assistants or leaders in a patient organiza-
tion. Each hydrotherapy session lasted 45 - 50 min (at
35˚C) and was conducted in groups of 5 - 17 patients.
The informants participated once or twice a week. The
program included exercises for increased mobility, coor-
dination, endurance, aerobic fitness, stretching and re-
laxation. It comprised exercises for all parts of the body.
The pace of the exercises was guided by music.
A theme “hydrotherapy—a multidimensional experi-
ence” and two categories emerged; situational factors
and effects of hydrotherapy. The category “situational
factors” comprised the subcategories: warm water, train-
ing factors and a competent coach and the category “ef-
fects of hydrotherapy” the subcategories: psychological
effects, physical capacity improvements, social effects,
changed pain experience and changes in work and par-
ticipation in daily life Table 2.
3.1. Situational Factors of Hydrotherapy
3.1.1. Warm Water
All informants, but one described that warm water or
enough warm water was important “Its very important, I
prefer being in the warm pool which is 34˚C - 36˚C.
Table 1. Description of the content analysis process.
Meaning unit Condensed meaning unit Code
Vacuum cleaning still hard, but manage to do it today,
became really poorly as I vacuum cleaned,
manage to do shopping today
Manage to perform daily routines like vacuum
cleaning and do shopping, which earlier were
hard to perform. Manage daily routines much better
Table 2. Theme, the two main categories, subcategories and codes.
Sub-category Psycho-logical
improvements Social effectsChanged pain
Changes in work
and participation
in daily life Warm water Training
factors Competent
Increased self
More happiness
Less worrying
Increased harmony
Improved sleep
Positive impact on
Live in the present
Increased relaxation
Belief in the future
Subdue passivity
and negativism
Walk longer
Stimulation to
Sharing of
Met with
for each other
Support from
group gave
energy broke
social isolation
Less pain
Pain changed
less intense or
Reduced pain
Training did
not produce
pain in contrast
to other
training forms
Positive impact
on work ability
Positive impact on
way back to work
Manage daily
routines much
Increased capacity
to cope with stress
and psychological
demands in their
daily life
Enough warm
water otherwise
start a relapse
Direct impact on
well-being and
movements that
were normally
Train the whole
body in contrast
to walking
Variation in
the training
Use of music
Group training
easier than
Train on
important at
the beginning
about intensity
M. H. Lindqvist, G. E. Gard / Open Journal of Therapy and Rehabilitation 1 (2013) 22-30 25
When its cold, then I also have contractions in the tho-
racic spine. When its getting cold you feel your muscles
tighten and then I get pain” (Inf. 3). The water also
seemed to have a direct impact on well-being and relaxa-
tion and enabled the informants to perform movements
that were normally impossible more easily and with less
pain. The informants could train the whole body in the
3.1.2. Training Factors
The hydrotherapy was experienced to be improved by
different training factors, such as regular training, the
group composition, variation in the training and the use
of music. Regular training was important to get positive
treatment effects. Without regular training the positive
training effects gradually disappeared, with increased
tiredness and reduced energy for work and/or leisure
activities as a result. It took two to three sessions before
any effects of the training could be experienced “I got a
break from the hydrotherapy due to an operation on my
hands, I felt after a while that my condition had become
worse, it will take time to catch up again and achieve the
same level I had before I took the break” (Inf. 1).
The group composition and homogeneity of the group
in age and physical capacity was experienced to be im-
portant, together with the opportunity to train on differ-
ent intensity levels. It was also easier to perform the ex-
ercises when doing them in a group. Variation in hydro-
therapy exercises and the use of music in the training
were experienced as important. It increased the joy and
motivation and also helped the informants to perform the
movements in the correct way.
3.1.3. A Competent Instructor
Most informants experienced that having a competent
instructor was very important. The instructor should be
competent, understanding and empathic. Feeling safe
with the instructors… they have to be capable” (Inf. 7).
The instructions from the coach were especially im-
portant at the beginning of the hydrotherapy session
since the patients were afraid of performing the exercises
in an incorrect manner. Some informants had experi-
enced setbacks at the beginning of their training and
found it difficult to choose the intensity of the training.
Most informants got enough information from the in-
structor about how to tailor the training to themselves.
3.2. Effects of Hydrotherapy
Different effects of the hydrotherapy treatment were
experienced such as psychological effects, improved
physical capacity, social effects and a positively changed
pain experience.
3.2.1. Psychological Effects
Psychological effects were experienced as an impor-
tant subcategory, including experiences of increased self-
efficacy, increased mood-energy, and increased relaxa-
tion. Hydrotherapy was experienced to increase the in-
formants’ self-efficacy, self-confidence and beliefs in the
future, which allowed them to try new tasks. It helped
them to succeed and to subdue passivity and negativism.
I have much more belief in that I will not end up in a
wheelchair and feel that I will manage more and more
(Inf. 4).
Improved mood was experienced as more happiness,
less worrying, experiences of doing something fun, in-
creased harmony, feelings of freedom and contentment
about positive achievements. “It is important for me to
be able to plan and do something I can manage, I feel
fine to be able to do something that I find fun, and in that
way I also feel better. In other words if I can cope with
pain I am happier” (Inf. 8). Some experienced an in-
crease in energy already the same day, others the day
after a session, with positive impact on many aspects in
their lives. Some informants experienced a positive
tiredness directly after training and the increased energy
was experienced after one day. Some experienced im-
proved sleep and relaxation which had positive impact
on emotions and cognitions and increased their ability to
live in the present moment.
3.2.2. Improved Physical Capacity
Improved physical capacity was experienced. Almost
all informants experienced increased mobility and de-
creased stiffness in general or decreased morning stiff-
ness which for some enabled them to take a greater part
in leisure activities and for some the ability to walk
longer. “I feel less pain because I can control my body in
another way when I walk. The body becomes limp not
trained in the pool, I become stiff and then I cant get my
body to follow when I walk. I walk longer distances to-
day” (Inf. 2). Others described increased strength or the
possibility to retain strength. Improved physical fitness,
improved balance, stability and a stimulation to increase
physical activity were other important areas of improve-
3.2.3. Social Effects
The social effects were very important for the majority
of the informants. The sharing of experiences with others
living with PsA or other rheumatic deceases and to be
met with understanding were two important factors.
Meet others who are in the same situation is important.
I can tell my husband that I feel so or so but he cant
grasp it anyway, but if I tell someone who suffer from the
same condition they understand what it is and that I
think is very important” (Inf. 5). The group helped the
Copyright © 2013 SciRes. OPEN ACCESS
M. H. Lindqvist, G. E. Gard / Open Journal of Therapy and Rehabilitation 1 (2013) 22-30
informants not to feel alone in their situation. The group
also created a positive solidarity and acceptance for each
other. To joke and laugh were considered very positive
experiences. The support from the group gave energy
and broke social isolation.
3.2.4. Positively Changed Pain Experience
Most informants experienced less pain after the train-
ing and/or that their pain changed into being less intense
or troublesome. The training also reduced their pain fixa-
tion. The hydrotherapy training did not produce pain, in
contrast to other forms of training for example strength
training. “I think that I should have felt mentally and
physically worse… and probably have been more closed
up in myself with the pain” (Inf. 9).
3.2.5. Changes in Work and Participation in Daily
Changes in work and participation in daily life were
also experienced. Half of the group experienced that hy-
drotherapy had a positive impact on their work ability; or
on their prospects of finding their way back to work. An
increased participation in daily life and in recreational
pursuits was experienced. My body gets stronger, it
makes me manage more, it has had an impact on my
whole life, actually, the training in the pool. I improve
my mobility so I can take part in life in another way (Inf.
2). Some informants experienced an increased capacity
to cope with stress and psychological demands in their
daily life. Some informants felt that they managed their
daily routines with more ease and others that they pos-
sessed the strength and energy to do other things.
To our knowledge, no earlier study has explored how
patients living with (PsA) experience hydrotherapy. In
the present study, hydrotherapy was experienced as a
multidimensional experience, influenced by factors in the
treatment situation as well as by different effects. Situ-
ational factors experienced were warm water, training
factors and a competent instructor. Almost all the infor-
mants stressed the importance of warm water, approxi-
mately 35˚C. The warm water had a direct impact on
wellbeing and relaxation, which only to some extent has
been confirmed earlier [18,32]. A 50% increase in car-
diac output has been found at a water temperature of
35˚C (30). This, 35˚C, may be the most favourable tem-
perature for hydrotherapy for patients with PsA and
stresses the importance of facilitating pools with warm
water for this group. Regular training was considered as
very important. An earlier study of hydrotherapy for pa-
tients with RA has shown that the energy level can
be maintained three months after the end of hydrotherapy
treatment [22]. Regarding muscle strength, one study
showed that positive effects of hydrotherapy may last for
about two months [32], while another study showed less
positive results [22]. Flexibility was maintained in one
study at a three month follow up [33]. It appears that this
group of patients benefit from continuous training. In
addition, they required two to three sessions of training
before any positive effects could be noticed. Geytenbeck
found that the length of hydrotherapy training periods in
different studies ranged from four days to 36 weeks with
an average of 10 weeks [34]. The frequency of hydro-
therapy training ranged from daily to weekly with an
average of (2 - 3) times per week. She also states that
researchers do not recommend any specific frequency or
duration. Stenström and Minor, who have studied differ-
ent forms of exercises for patients with RA state that
strength training, is recommended be performed 2 to 3
times per week [35]. Other studies of duration of strength
training state that eight to ten weeks training provide
positive effects [36]. The duration of hydrotherapy for
patients with rheumatic diseases needs to be further
In this study some informants experienced that it was
important to train in groups at tailored intensity training
levels to be satisfactory. Too intense training sessions
may cause setbacks and increase pain for some patients.
That group training can be more effective than individual
training has been confirmed in earlier studies [37].
A majority of the informants in this study experienced
that music made the training more fun and inspiring and
that it helped them in performing the movements. This
has only to some extent been notified earlier [38]. An
instrument, the Brunel Music Rating Inventory-2, can
help instructors to select music that has a motivational
effect. Karageorghis et al. state that motivational music
might increase exercise enjoyment [38] and decrease
pain and depression and promote individual empower-
ment [39] which is of great importance for these patients.
Also competence development for instructors may imply
more motivating training sessions and a positive differ-
ence in treatment effects. Concerning coaching, the in-
formants stressed competence, understanding and empa-
thy. The role as a coach demands a significant amount of
knowledge and commitment. During this study the in-
structors had different qualifications. We consider it im-
portant that the instructors can update their competence
regularly. The instructor’s motivation and engagement is
important for positive training effects [40] and to
strengthen patients’ vitality [40]. The importance of the
training instructor needs to be further explored [41]. In
addition, the informants found it difficult to know at
what intensity they should begin to exercise. It has been
recommended to begin with very light weights to avoid
setbacks in training for patients with RA [42], but studies,
comparing frequency and intensity of strength training
Copyright © 2013 SciRes. OPEN ACCESS
M. H. Lindqvist, G. E. Gard / Open Journal of Therapy and Rehabilitation 1 (2013) 22-30 27
are lacking [42]. In clinical practice it is well known that
patients with PsA often have more pain after training
than AS patients. This study stresses the importance of
further studies about the dosage of strength training for
PsA patients.
Different effects of hydrotherapy were noted. Psycho-
logical effects such as increased self-efficacy, mood-
energy, and relaxation were experienced, which to some
extent have been confirmed by earlier research on RA
patients [21,22,33,34]. Positive mood enhances per-
ceived self-efficacy and low mood diminishes it [43].
Hydrotherapy was also experienced as beneficial as the
informants succeed in doing something they managed to
do. Some informants experienced better sleep or required
less sleep, which is new knowledge for this patient group.
It has earlier been shown that total sleep time may in-
crease and total nap time may decrease among patients
with fibromyalgia who participated in hydrotherapy.
[44]. Many patients with RA and PsA are very tired,
which may be due to suffering from disturbed sleeping
patterns. This needs to be further researched, since pa-
tients identify fatigue as an important outcome, and lack
of sleep can be related to that [26].
The patients in this study got increased energy from
the hydrotherapy training, influencing all aspects of their
lives. This is very important since fatigue is as severe
and frequent as pain among PsA patients [45,46]. Some
informants stated that the relaxation they experienced
had a positive influence on their cognitive capacity. It is
well known from modern pain research that long lasting
pain has an influence on the cognitive capacity [47,48].
Hydrotherapy has been shown to have effect on cogni-
tive function in patients with fibromyalgia [49]. Further
research of patients with PsA would be valuable. In this
study the informants experienced physical capacity im-
provements which included increased joint mobility,
reduced stiffness, increased strength, improved balance,
and/or increased walking distance. The physical effect of
increased joint mobility [25,50] has to some extent been
confirmed on patients with RA and AS and decreased
stiffness on patients with AS [25]. Increased strength has
been confirmed on patients with RA [22,23] Improved
balance [51] and an increased physical activity level have
to some extent been confirmed by earlier studies on pa-
tients with RA [23]. Hydrotherapy as a measure to in-
crease physical activity is very important from a health
perspective since patients with RA and patients with
other rheumatic diseases have an over representation of
cardiovascular diseases [52].
The informants in this study experienced that group
training increased their energy and broke their pattern of
social isolation. Social support and its impact on physical
health has been studied by Wallstone et al. [53], showing
that there is a link between social support and physical
health. It is important to belong to a particular group, it
can predict improved health for women and fewer symp-
toms for men [54]. This needs to be further investigated
in patients coping with rheumatic diseases. In other
studies on patients with RA, social functioning and social
support from the family and friends have been focused.
Improved social functioning has been shown after three
months of intensive hydrotherapy training [22]. In this
study most, but not all, informants experienced less pain
after hydrotherapy. As previously described, more pain
could possibly be due to too much intense training [42].
Hydrotherapy helped some informants in breaking pain
fixation which is important for self-management [43].
Less pain after hydrotherapy treatment has been con-
firmed earlier [25,50] from patients with RA and AS.
Half of the group in this study described that hydro-
therapy had a positive impact on their work capacity
and/or return to work. No quantitative study has shown
any positive effect on work capacity among patients with
RA, attending hydrotherapy [33], probably due to a too
short training period [33]. A long-term study of the ef-
fects of hydrotherapy on work ability and participation in
daily life can be recommended as also participation was
experienced to be improved in the present study. An ear-
lier study has shown that 51 of 91 (53%) ICF-categories
concerning activity and participation were affected by
PsA in at least 30% of participants [3]. A similar study of
patients with RA showed that 16 of 48 (33%) categories
were affected. Increased participation in daily life in the
area of physical capacity has been confirmed by earlier
studies on RA patients [22,33].
All informants were given the option of receiving a
copy of the transcribed interview and had the opportunity
to add information, but no one did. All data was also
transcribed by the same person, the first author, these
actions may have implied credible data [55]. The quota-
tions were translated by a professional translator. Even
though a consecutive selection was used, a variation of
age and various experiences were achieved. We had both
men and women, of various ages and with different ex-
periences in our study which may have increased the
credibility of the study [31]. A limitation was that only
one informant had his/her origin from outside the Nordic
countries and that only two men accepted to participate.
The participating ten informants were the only available
informants fulfilling the inclusion criteria in the region.
However, it may be so that if the researcher, as in our
study, is well acquainted with the research method and
have thorough knowledge about the field, also a not so
large number of informants can be enough to give a rich
material [56]. In qualitative studies when using content
analysis the pre understanding of the author always
Copyright © 2013 SciRes. OPEN ACCESS
M. H. Lindqvist, G. E. Gard / Open Journal of Therapy and Rehabilitation 1 (2013) 22-30
needs to be reflected upon. In this study a co-author who
does not work with rheumatology patients assisted in
categorizing the data which lends credibility to the study
[31]. The transferability of a qualitative study can be
facilitated with a clear description of the aim and context,
selection of informants, data collection and process of
analysis [31]. As authors we have considered these fac-
tors and mean that the results can be transferred to hy-
drotherapy treatment for patients with PsA in a similar
hydrotherapy context. We recommend quantitative stud-
ies of hydrotherapy with the use of the psoriatic arthritis
quality of life (PsAQoL) instrument, (which is the only
reliable and valid instrument so far for this specific pa-
tient group) and to study [57] if quality of life of this
patient group may be improved. There is also a need of
further development of physical outcome measures for
this specific patient group.
Positive effects of hydrotherapy were experienced on
physical function, energy, sleep, cognitive function, abil-
ity to work and participation in daily life. Further con-
trolled studies are needed. The hydrotherapy instructors
had an important coaching role, which needs to be pro-
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