# Exercise as it relates to Disease/Effect of Aquatic Exercise on Fatigue and Health-Related Quality of Life in Patients with Multiple sclerosis

This is an analysis of the journal article "Exercise as it relates to Disease/Effect of Aquatic Exercise on Fatigue and Health-Related Quality of Life in Patients with Multiple sclerosis: Randomized controlled trial, 4-week and 8-week follow-up.

## Background

'Multiple sclerosis' (MS) is a relapsing-remitting and chronic progressive disease that affects the brain and spinal cord, resulting in loss of muscle control, vision, balance, and sensation. Due to the nature of MS, people with MS meet a variety of difficulties in their life such as loss of career,limiting social interaction, psychological problems and hardships to perform routine daily tasks. It is believed that 'fatigue' is a major problem among the patients with MS. Females are twice more likely to diagnose with MS early in their life between 20 and 50 years of age.
There is no cure for MS and a significant behavioral strategy treatment such as exercise programs are offered to slow the progression of the disease, reduce relapse, improve symptoms, as well as quality of life among the patients.
The American Physical Therapy Association recommends and promotes the aquatic exercise for people with MS due to following unique properties of water:
* Buoyancy (upward pressure of water against gravity)
* Viscosity (Resistance to movement which improves muscle strength)
* Temperature control(25-25 °C) (Maintaining low core temperature during the physical activity)

## Where is the research from?

This research was carried out by researchers from the University of Isfahan and the University of Queensland. The present research was approved by the Ethics Committee of the university of Isfahan and the Isfahan multiple Sclerosis Society (IMSS).

## What kind of research was this?

Kargarfard's study was a randomized controlled trial. This study aims to examine changes in fatigue and health-related quality of life (HRQOL) in patients with relapsing-remitting multiple sclerosis (RRMS) using a blind assessor using the Modified Fatigue Impact Scale (MFIS) and the Multiple Sclerosis Quality of Life-54 questionnaire (MSQOL). A mixed-model approach to repeated-measures analysis of variance was used to detect within and between subject effects.

## What did the research involve?

The 178 patients were screened by baseline test and the inclusion criteria by a neurologist.
The inclusion criteria were as follows:
* Diagnosis of clinically or laboratory-supported MS
* A minimum time of 2 years since the diagnosis was made
* No relapse within the 4 weeks preceding baseline
* Ability to participate in regular exercise sessions.
The 32 women diagnosed with relapsing remitting MS (mean age ±SD,32.6±8.0y) completed the trial. They were randomly allocated into 2 groups: exercise (N=16) and control (N=16). Three aquatic exercise session per week was delivered. 8 patients from the exercise group and 5 patients the controls were excluded because they had no data (due to experience of relapse, personal issue and absent in exercise training) at 4 or 8 weeks.
Only 21 patients (10 exercise and 11 control) were included in the analysis. All patients were asked to stop from use of medication, supplementary nutrition and consumption of caffeine and any rigorous physical activity within 48 hours before the baseline test.
All patients were examined by filling out a questionnaire comprising information socio-demographic, clinical and anthropocentric characteristics. The patients in the 2 groups were treated similarly except for the exercise training. Outcome measures were assessed by research assistants who were blind to the patients’ groups at the end of week 4 and week 8 of the study.

## What were the basic results?

* Patients in the exercise group have improved scores compared to control group at both 4 and 8 weeks in health perception, energy, role limitation (physical and emotional), bodily pain, health distress, and social functioning sub-scales.
* Patients in the exercise group had a significant improvement in the MFIS-overall (p=0.02) and MFIS-physical (p=0.009) and cognitive sub-scales from 4 weeks to 8 weeks where as in the control group had no significant difference. However, there was no statistical significant from baseline to week 4.
* Remarkable improvement in MSQOL-54 physical (p<0.001) and MSQOL-mental (p<0.001).
* There was no report of accident, increased fatigue, or adverse effect to the aquatic exercise.

## What conclusions can we take from this research?

The results of this study highlights the aquatic exercise for people with MS beneficial for their fatigue and HRQOL. An aquatic exercise program showed to be a great treatment or rehabilitation for people with MS to overcome these issue. The patient's sensitivity of heat, physical weakness and safety issues can be overcome by temperature control and buoyant effect. Also, it promotes longer periods of physical activity with less fatigue. To have an effective improvement, patients should be prescribed at least of 8 weeks or more of aquatic exercise program.

## Practical advice

* Larger sample size will produce more accurate and reliable data. This study had small size of participants (N=21).
* No reason of strong criteria in excluding patients from the study.
* Further randomised controlled trial that compares aerobic land based exercise and aquatic exercise can help demonstrate the relative effectiveness of these two exercises in MS patients.

## Further Information

* Aquatic exercise for people with multiple sclerosis (MS) -https://www.msaustralia.org.au/file/268/download?token=Cm3n9EVz
* Aquatic exercise guide for patients with MS -https://www.mymsaa.org/PDFs/aqua-patient-pub.pdf

## References

* 1 2 3 4 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;93(10):1701-1708
* ↑ Jackson MF, Quaal C, Reeves MA. Effects of multiple sclerosis on occupational and career patterns. Axone 1991;13:16-7,20-2.
* 1 2 Branas P, Jordan R, Fry-Smith A, Burls A, Hyde C. Treatments for fatigue in multiple sclerosis: a rapid and systematic review. Health Technol Assess 2000;4:1-61.
* ↑ Heesen C, Romberg A, Gold S, Schulz KH. Physical exercise in multiple sclerosis: supportive care or a putative disease-modifying treatment. Expert Rev Neurother 2006;6:347-55.
* ↑ Guthrie TC, Nelson DA. Influence of temperature changes on multiple sclerosis: critical review of mechanisms and research potential. J Neurol Sci 1995;129:1-8