The aim of the study was to determine whether a Multimodal Physical Therapy Programme of 8 weeks duration had any effect on improving general health state (physical or mental components) and health-related quality of life in patients with chronic musculoskeletal disorders. With clinical relevance considered as 10% improvement , such improvement was not observed in any case (%-%). However, t-tests for paired data showed that there were statistically significant differences between baseline and post-intervention scores in all outcome measurements.
All variables analysed in this study showed significant differences after eight weeks of intervention (Table 2). These differences were clinically relevant in the variable EQ-5D (0.18), and close to that limit in the variable EQ-VAS (7.22). For their part, the evolution in physical health state (PHS) and mental health state (MHS) could be interpreted as statistically significant maintenance of the states of physical and mental health to achieve improvements of 1.68 and 3.15, respectively (Table 2).
No studies have been done to analyse the evolution of HRQoL using MPTP as an intervention in several CMSKD simultaneously. However, some previous studies have been conducted in pathologies included in this study individually.Two studies have used MPTP treatment for subjects with CLBP [27, 28]. In both studies the improvements observed in PHS and MHS were higher than those achieved in the present study. Thus, the participants improved PHS in 10.6 and 8.9  14.1 , 1.74 in the CLBP group and 1.68 in all participants of this study. These differences were also evident in MHS, with improvements of 22.1 , 3.41 in the CLBP group and 3.15 in the CMSKD group in this study. The explanation for these differences could be that the duration of treatment is longer, i.e. 15 , 12  and 8 (present study) weeks.
Other studies have examined the effect of an intervention based on therapeutic exercise in the other two CMSKD and observed differences between the pre- and post-intervention measures comparable to the present study. Martel et al.  and Michalsen et al.  reported improvements in PHS and MHS of 6.1 and 4.2  and 4.2 and 2.3 , respectively, after intervening CNP sufferers. These results, not being clinically relevant, could be interpreted as a maintenance of PHS and MHS in these patients, so they might be comparable to the results observed in the CMSKD (in general) and CNP (in particular) of the present study, who similarly achieved significant improvements of 0.65 and 1.68 in PHS and 3.10 and 3.15 in MHS, respectively.
On the other hand, two other studies that used exercise as a means of therapeutic intervention in patients with OA showed a significant maintenance of HRQoL. Frasen et al.  and Jigami et al.  observed how, in their intervention groups, patients achieved significant but not clinically relevant improvements of 4.0 and 0.9 in PHS and 0.9, in both studies, in MHS, respectively. These results are also comparable to those obtained in the OA group in this study, which achieved improvements of 3.45 and 2.99 (Table 2) in PHS and MHS, respectively. They are also comparable in the overall group CMSKD Sufferers, whose significant increases in PHS and MHS were 1.68 and 3.15, respectively.
Based on the results obtained in this study, and comparing them to other studies with similar characteristics, it is possible to affirm that a MPTP which integrates therapeutic exercise and health education achieved similar results if subjects are distributed by specific pathology groups or if they are integrated into a group of patients suffering CMSKD as presented in this study (CLBP, CNP and OA). This should be taken into account when planning and implementing a treatment program for these patients.
There is no control group is the most important limitation of this study. Beyond the lack of long-term follow-up, also indicated by Kamioka et al., (2010)  in relation to aquatic exercise research, should be taken into consideration for future research. The outcome measures used were on self-reported scales and thus very personal to each participant, depending upon that individual’s perception of quality of life and the values they place on aspects of their disease such as pain, physical/mental health etc. Individual perception of QoL will also change over time with different life experiences and aspirations. This very much depends upon the environment, culture and circumstances that one is exposed to. During the follow up sessions assessing the HRQoL, there was no indication as to any lifestyle changes encountered by the participants, or other variables such as changes in medication, exercise levels and changes within the grading of the participant’s chronic conditions that may have impacted on their scoring. These could all subsequently impact and affect the scoring of the outcome measures.
The SF12 as an outcome measure was chosen for its validity and practicality, yet it has been shown to yield less precise scores than the original SF36 outcome measure. However, the larger the sample size, as with this study, the smaller the effect of these differences, as the confidence intervals for group averages in health scores are largely determined by sample size.
Although the population sample was limited to persons from one region of Spain, the sample was fairly large and representative, and therefore the results are likely to be carried over to other regions and areas in Europe. It can be said that the results of the current study may be useful clinically, enabling physiotherapists to design an effective aquatic therapy programme and manage persons with chronic MSK disorders in a similar multi-modal intervention.