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Three Part Question

In [adult patients with Multiple Sclerosis], does [hydrotherapy] improve [physical and quality of life outcomes]?

Clinical Scenario

A 61 year old female with MS is about to start a programme of rehab. She has pain in her right hip, stiffness throughout her right lower limb. She finds it difficult to mobilise independently and to climb stairs.
Should the rehab programme be land based in rehab gym or a course of hydrotherapy?

Search Strategy

Medline, AMED and CINAHL
[exp Stroke or Multiple sclerosis or spinal cord compression or Parkinsons disease]and [exp Hydrotherapy] Limit to human adult and English, 2003-current

Search Outcome

Altogether 33 articles were found,7 of which were relevant to the study question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Salem et al 2010 USA	10 patients, 8 female, 2 male	Single group, pretest-posttest experimental study	10m walk test	Improved walking speed P<.001	Small study group Need larger scale, randomised, controlled clinical study
			Berg balance scale (BBS)	Significant improvement P<0.01
			Timed up and go test (TUG)	Significant improvement P<0.049
			Grip strength	Significant improvement Right P<0.01 Left P<0.02
			Modified Fatigue Impact Scale (MFIS)	Significant improvement P<0.03
			Visual Analogue Scale (VAS)	extremely beneficial, mean rating 9.3
Veenstra J et al 2003 USA	53 participants : 1 group with MS,currently participating in an aquatics programme/ 1 group with MS, not participating in an aquatics programme/ 1 group without MS currently participating in an aquatics programme.	Survey.	Aquatics participation scale	6 items of the scale were statistically significant : 3 physical, 1 life satisfaction, 1 cognitive and 1 emotional.	Very difficult to pull relevant results from the article. Results are complicated due to comparisons made between 3 different groups. Survey of general involvement in aquatics, not standardised or able to replicate.
			Satisfaction with life scale	Higher level of life satisfaction for participants with MS than without MS, but this was not statistically significant.
Pariser, G et al June 2006 USA	2 participants with multiple sclerosis	Case report	Graded exercise test of aerobic capacity/ CV fitness	VO2 peak increased by >11.4% for both participants	Only 2 participants. Not clear whether changes are significant. Although the FSS is standardised for MS, it may not be sensitive enough to assess changes in fatigue over time in patients with MS.
			Lactate threshold	Increased lactate threshold for both participants
			Fatigue severity scale	Decreased fatigue for 1 participant. No change in fatigue for the other participant.
Kargarfard et al 2012 Iran	21 women with relapsing remitting multiple sclerosis (10 in exercise group, 11 in control group).	Randomised Controlled Trial	Modified fatigue impact scale	Significant improvement from baseline to 8 weeks. Significantly greater improvement after 8 weeks than 4 weeks. No significant change after 4 weeks.	Small number of participants. Limited to women with an expanded disability status scale score of less than 3.5. No comparison with land based aerobic rehabilitation.
			Multipla sclerosis quality of life 54 questionnaire	significant improvement from baseline to 8 weeks. Significantly greater improvement after 8 weeks than 4 weeks.
Roehrs, Karst 2004 Canada	19 adults with progressive MS	Single group pretest/ post test quasiexperimental design. (Pilot)	The medical outcome study short form 36	Social function score significantly increased. All other scores unchanged.	Small sample group. Accepted 25% attendance (ie 3 weeks out of 12). No control group. No comparison with land based exercises.
			MS quality of life inventory	Modified fatigue impact scale and modified social support scale both significantly increased.
Salem et al 2011 USA	11 subjects with multiple sclerosis	Single group pretest/ post test design	10 metre walk test	Increased gait speed (P<0.049)	One group design with no control. Small number of subjects. Difficult to replicate due to large number of health professionals/ students involved to assist in the class, plus funding available for equipment.
			Timed up and go	Significant decrease (P<0.001)
			Berg balance scale	Significant improvements (P<0.008)
			Grip strength	Significantly improved (right : P<0.03, left P<0.03)
			Modified fatigue impact scale	No significant difference.
Broach E and Dattilo J 2003 USA	4 participants with relapsing remitting multiple sclerosis.	Single subject, multiple-probe design	Manual muscle tests : strength of dominant side	Quads : no evidence of increased strength. Hamstrings and hip flexors : not enough evidence of increased strength. Triceps : some support for increased strength in 3 participants. Biceps : increased strength in 3 participants. Shoulder abduction : increased strength in 3 participants. Results for strength not replicated across all participants so effect of aquatic therapy not established for strength.	Only 4 participants.

Comment(s)

None of the studies found took place in a warm water hydrotherapy pool, such as the one currently used by physiotherapists at Manchester Royal Infirmary (35-36 degrees). All the studies looked at group exercise in water, rather than one to one therapy in water.

The reasoning for using cool water (28-29 degrees), suggested in the majority of articles, is to dissipate the body heat generated during exercise so that patients with Multiple Sclerosis can, theoretically, exercise without causing fatigue due to heat sensitivity. For this reason, the outcome of this BET is not directly relevant to our clinical environment at Manchester Royal Infirmary, however, some conclusions relating to cold water may still be drawn.

Only one RCT was found and this used a small sample size of 21 women. It demonstrated a significant improvement in Modified Fatigue Impact Scale and Health Related Quality of Life from baseline to 8 weeks, but not from baseline to 4 weeks, suggesting a longer period of aquatic exercise is needed.

The remaining articles were not of good quality and had small sample sizes, so it is difficult to draw conclusions from them. Two articles suggested improvements in mobility outcome measures. Others suggested improvements in social function, fatigue and life satisfaction. Better quality, larger scale studies would be needed to confirm these results.

There are no current studies which compare aquatic therapy with land based therapy so we are unable to make comparisons.

Clinical Bottom Line

Based on the current best evidence, there is a small amount of evidence to suggest that hydrotherapy or “aquatic therapy” in cool water, may improve quality of life and fatigue scores for people with Multiple Sclerosis.

There are no current studies regarding warm water hydrotherapy or comparing hydrotherapy with land based exercise for people with Multiple Sclerosis.

Further research is needed.

References

1. Salem et al Effects of an Aquatic Exercise Program on Functional mobility in Individuals With Multiple Sclerosis: A Community-based Study The Journal of Aquatic Physical Therapy Fall 2010; 22-32
2. Veenstra et al Perceived benefits of aquatic therapy for multiple sclerosis participants American Journal of Recreation Therapy 2003; 33-48
3. Pariser, G et al Outcomes of an aquatic exercise programme, including aerobic capacity, lactate threshold and fatigue in 2 individuals with multiple sclerosis. Journal of neurologic physical therapy. June 2006; 82-90
4. Kargarfard et al Effect of aquatic exercise training on fatigue and health related quality of life in patients with multiple sclerosis Arch Phys Med Rehabil Oct 2012; 1701-8
5. Roehrs, Karst Effects of an aquatic exercise program on quality of life measures for individuals with progressive multiple sclerosis. Journal of neurologic physical therapy June 2004; 63-71
6. Salem et al Community based group aquatic programme for individuals with multiple sclerosis : a pilot study. Disability and Rehabilitation 2011; 33(9):720-728
7. Broach E and Dattilo J The effect of aquatic therapy on strength of adults with multiple sclerosis. Therapeutic recreation journal. 2003; 224-239