# Exercise as it relates to Disease/Does aquatic exercise effect fatigue and quality of life in patients with multiple sclerosis?

The following is a critique of the research article "Effect of Aquatic Exercise Training on Fatigue and Health-Related Quality of Life in Patients With Multiple Sclerosis". A randomized control trial by The American Congress of Rehabilitation Medicine 2012.

## What is the background to this research?

Multiple Sclerosis is a chronic disease that slowly deteriorates the body’s muscular function. The most common symptoms include physical and mental fatigue, muscle weakness, impaired gait and balance and sensation. Due to these debilitating symptoms, patients lose their ability to perform simple, everyday tasks which commonly results in a high prevalence of depression and therefore a lower quality of life for patients within this community. (1)There is no cure for Multiple Sclerosis, however medication is usually prescribed to patients to reduce the amount of episodes they experience as it is a relapsing-remitting disease. (1) Multiple studies show the significant benefits exercise has on patients with Multiple Sclerosis, however these studies focus on land-based activities, not aquatic. These benefits include improved mental health (quality of life), balance, gait and a reduction in fatigue symptoms. Exercise has also been shown to reduce the overall progression of the disease. This study aims to discover if an eight week aquatic exercise intervention shows improvements in the patient's symptoms and disease progression.

## Where is the research from?

This research was supported by a grant from the University of Isfahan. The authors, Mehdi Kargarfard and Maryam Mehrabi are both professors at the Faculty of Physical Education and Sport Sciences at the University of Isfahan in Iran. Masoud Etemadifar works in the department of Neurology at the Isfahan University. Peter Baker and Reza Hayatbakhsh both work as Senior Lecturers at the School of Population Health at the University of Queensland, Australia.(1)

## What kind of research was this?

The research was a randomized control trial. A randomized control trial is considered to be the gold standard of intervention studies and it aims to reduce the bias of treatment for patients, as they are selected randomly to either be in the exercise or control group. The patients in this study were assessed at baseline, 4 weeks into the intervention and again at 8 weeks (end of trial). These assessments consisted of recording fatigue and the patient's quality of life, using questionnaires. The assessments were conducted by a blind assessor to reduce bias.(1)

## What did the research involve?

This study ran over a period of eight weeks in total and researched a cohort of 32 women between the ages of 24-41 years old who all have previously been diagnosed with Multiple Sclerosis. Females were exclusively chosen to participate in this study as there is a higher prevalence for Females to get the disease over Males. (1) The patients were all required to answer questions regarding their current health and Multiple Sclerosis symptoms to ensure they were healthy enough to meet the criteria for participation. Patients who experienced a relapse four weeks prior or during the intervention were immediately ceased from participation in the study. One hundred and forty six patients did not qualify for recruitment for this study and the individuals who did were randomly divided into two groups, one control and one exercise group. (1)
The aquatic exercise program was conducted in Isfahan University’s swimming pool, three days a week for 60 minutes each (10 minute warm up, 40 minute exercise, 10 minute cool down). The exercise intensity was prescribed at 50% - 70% maximal heart rate reserve and each patient took their own radial pulse six times during the 60 minutes of exercise. (1)

## What were the basic results?

The results of this intervention show that aquatic exercise has a significant, positive effect on the fatigue and quality of life in patients with multiple sclerosis. The patients recorded a large improvement of their physical and mental health, energy, social function and pain during the eight week intervention. There were no reports of adverse effects due to the exercise. The results for the control group show their scale of fatigue to become worse during the eight weeks, however there was no significant change in their rating of quality of life.
A summary of the results comparing the control group to the exercise group are shown in the table below.
Table 1: Intervention results after 8 weeks. (1) :
| Test | Control | Aquatic Exercise | P-value |
| Fatigue (mental) | 6.7 +/- 1.5 | 3.9 +/- 1.7 | 0.009 |
| Fatigue (physical) | 29.5 +/- 5.8 | 14.0 +/- 3.3 | 0.003 |
| Quality of Life (mental) | 43.6 +/- 8.9 | 70.2 +/- 5.7 | <0.001 |
| Quality of Life (physical) | 44.2 +/- 4.4 | 65.4 +/- 6.6 | <0.001 |
The results in table 1 show the scale of both mental and physical fatigue in the control group is much higher than the aquatic exercise group, although the p-value shows to be insignificant. The patient's mental and physical quality of life was significantly improved in the exercise group, in comparison to the control group after the eight weeks of intervention. (1)

## What conclusions can we take from this research?

Based on the evidence the researches of this article have provided, aquatic exercise does have a positive effect on fatigue and quality of life in patients with multiple sclerosis. The patient's scale of fatigue had improved during the eight weeks, however was not considered significant. The patient's recording of their perceived quality of life was shown to be a significant change from baseline to the end of the intervention. There were no recordings of any adverse effects due to the intervention, therefore it is important to promote aquatic exercise within the multiple sclerosis community in order to decrease symptoms and increase their overall quality of life. (1)
There are multiple studies that have previously researched the benefits of land exercise on multiple sclerosis symptoms, however there is a need for further research on aquatic exercise using larger sample sizes.

## Practical advice

While there remains to be no cure for multiple sclerosis, it is crucial for patients living with the disease to seek ways in which they can reduce symptoms and the overall degenerative progression. The exact frequency and volume specific for patients with Multiple Sclerosis has not yet been determined, however this intervention took place three times per week for 60 minutes each, at an intensity of 50%-75% of maximal heart rate reserve. This frequency and volume was beneficial for the patients in the study and therefore is a good guideline to use. (1)
Patients must always obtain clearance from their General Practitioner/specialist prior to participating in any form of exercise.

## Further information/resources

For further information on Multiple Sclerosis, please see the links below.
* https://www.msaustralia.org.au/what-ms
* https://www.healthdirect.gov.au/multiple-sclerosis-ms
* https://www.msqld.org.au/health-wellbeing/exercise-and-mobility/

## References

* ↑ Kargarfard M, Etemadifar M, Baker P, Mehrabi M, Hayatbakhsh R. Effect of aquatic exercise training on fatigue and health-related quality of life in patients with multiple sclerosis. Archives of physical medicine and rehabilitation. 2012 Oct 1;93(10):1701-8.
* ↑ White LJ, Dressendorfer RH. Exercise and multiple sclerosis. Sports medicine. 2004 Dec 1;34(15):1077-100
* ↑ Kargarfard M, Eetemadifar M, Mehrabi M, Maghzi AH, Hayatbakhsh MR. Fatigue, depression, and health‐related quality of life in patients with multiple sclerosis in Isfahan, Iran. European journal of neurology. 2012 Mar;19(3):431-7
* ↑ Kahan BC, Cro S, Doré CJ, Bratton DJ, Rehal S, Maskell NA, Rahman N, Jairath V. Reducing bias in open-label trials where blinded outcome assessment is not feasible: strategies from two randomised trials. Trials. 2014 Dec 1;15(1):456.