Aquatic therapy may be an effective strategy as part of occupational therapy (OT) for patients with MS due to its positive effects on fatigue and balance, according to a systematic review and meta-analysis by Brandon S. Shaw, PhD, and colleagues published in Multiple Sclerosis and Related Disorders.

“While exercise has become a cornerstone in the comprehensive care of MS based on its beneficial effects, uptake of exercise in clinical settings remains low,” Dr. Shaw explains. “This may be because exercise is a tough challenge for patients with MS. However, the aquatic environment has broad rehabilitative potential, and it was supposed that this
mode of exercise could simultaneously address some of the main symptoms of the disease.”

The systematic review and meta-analysis by Dr. Shaw and colleagues included 16 studies with 794 participants. Among these studies, five compared aquatic therapy with a variety of land-based exercise therapies, such as Pilates, yoga, and home-based exercise programs; six compared aquatic therapy with conventional treatment, such as OT; and five had no control group. The duration of interventions ranged from 3 to 20 weeks, with each session lasting from 45 to 135 minutes.

Impact of Aquatic Therapy on Fatigue & Balance

Four studies examined the effect of aquatic therapy on MS-related fatigue using the Modified Fatigue Impact Scale. Compared with conventional treatment, aquatic therapy resulted in greater improvement in physical fatigue (standardized mean difference [SMD], -1.29; 95% CI, -1.65 to -0.93), cognitive fatigue (SMD, -0.75; 95% CI, -1.08 to -0.43), and psychological fatigue (SMD, -1.25; 95% CI, -1.59 to -0.90).

Benefits of aquatic therapy were also observed in the three studies that used the Fatigue Severity Scale in their assessments. In these studies, aquatic therapy improved fatigue to a greater extent than conventional treatment (SMD, -0.53; 95% CI, -0.86 to -0.20).

“Aquatic therapy reduces fatigue in patients with MS,” Dr. Shaw says. “This is noteworthy in that fatigue can occur at all stages of the disease and is the most common symptom of MS, occurring in 75% to 95% of patients.”

Balance was assessed in two trials using the Berg Balance Scale. In these studies, aquatic therapy led to significant improvements in balance compared with conventional therapy, with an SMD of 1.19 (95% CI, 0.62-1.76).

“Our study indicates that aquatic therapy improves balance in patients with MS irrespective of the part of the balance system affected (i.e., input, processing, output),” Dr. Shaw notes. “This finding has significant clinical implications, in that MS balance problems are one of the most common and potentially hazardous symptoms of the disease.”

Strengths & Limitations of Aquatic Therapy for MS

Dr Shaw and colleagues acknowledged several limitations in the systematic review. Several studies included only female participants, potentially limiting the generalizability of the findings. Additionally, due to the limited number of studies assessing the effects of aquatic therapy on fatigue and balance in patients with MS, not all studies included in the systematic review were randomized controlled trials. Case series were allowed, and some studies had small sample sizes, lacked a control group, and/or had a nonrandomized design, adding to the limitations.

However, Dr. Shaw still noted the benefits that were observed in their analysis (Figure).

“The aquatic environment provides a unique environment for patients with MS in that it can assist in the maintenance of core body temperature and reduction of body heat generated by exercise,” he says. “When combined with this exercise modality’s ability to simultaneously reduce fatigue and improve balance, aquatic therapy may provide an optimal environment to improve clinical and subclinical outcomes, even at a rate more rapid than experienced on land. Also, the enjoyability of aquatic therapy may have a role in increasing patients’ adherence to treatment, which may be another strength of this exercise intervention.”