Aquatic Exercise for MS: A Practical Guide to Improving Mobility, Spasticity, and Fatigue

We've all seen the transformative power of aquatic therapy for a variety of patient populations, but the evidence for its use in multiple sclerosis is becoming particularly compelling. The latest research, primarily from systematic reviews and meta-analyses, gives us a strong evidence base to recommend aquatic exercise for improving mobility, reducing spasticity, and combating the pervasive fatigue that so many of our MS patients struggle with. In this brief, we'll dive into the specifics of what the research says and how we can translate it into effective clinical practice. The most robust evidence we have comes from two recent meta-analyses. The first, a 2022 study by Shariat et al., pooled data from 16 trials with a total of 794 participants. They found that aquatic therapy had a significant positive effect on both fatigue and balance. Specifically, they saw improvements in physical, cognitive, and psychological fatigue, as measured by the Modified Fatigue Impact Scale (MFIS), and a reduction in overall fatigue severity on the Fatigue Severity Scale (FSS). Balance, as measured by the Berg Balance Scale (BBS), also showed significant improvement. A more recent 2024 meta-analysis by Naeimi et al. further solidified these findings, including ten studies and also finding significant improvements in fatigue (measured by both MFIS and FSS) and balance (measured by BBS). This study also looked at depression, finding a significant improvement in Beck Depression Inventory (BDI) scores. So, what does this mean for our clinical practice? It means we can confidently recommend aquatic therapy as an effective, non-pharmacological intervention for our MS patients. The unique properties of water – buoyancy, hydrostatic pressure, and viscosity – create an ideal environment for exercise. Buoyancy reduces the effects of gravity, making movement easier and less stressful on joints. This is particularly beneficial for patients with weakness or spasticity. Hydrostatic pressure can help to reduce swelling and improve circulation. The viscosity of water provides resistance to movement, which can help to improve strength and endurance. One of the most critical considerations when implementing an aquatic therapy program for MS patients is water temperature. Uhthoff's phenomenon, the temporary worsening of MS symptoms with an increase in body temperature, is a real concern. Therefore, it's crucial to maintain a water temperature that is warm enough to be comfortable and promote muscle relaxation, but not so warm that it triggers an exacerbation of symptoms. The research suggests an optimal temperature range of 30-32°C (86-90°F). This temperature range allows for vasodilation, which enhances blood flow to the muscles and reduces stiffness, without the risk of overheating. It is essential to monitor patients closely for any signs of heat sensitivity and to adjust the water temperature or exercise intensity as needed. In terms of dosing, the research provides some helpful parameters. Most studies used a frequency of 2-3 sessions per week, with each session lasting between 45 and 60 minutes. The total program length varied from 3 to 20 weeks. This gives us a good starting point for designing our own aquatic therapy programs. We can tailor the specific exercises to the individual needs and goals of each patient, focusing on activities that challenge balance, improve mobility, and increase strength and endurance. Examples of exercises that can be incorporated into an aquatic therapy program for MS include walking, marching, knee lifts, and gentle stretching. Of course, there are some contraindications and precautions to keep in mind. In addition to Uhthoff's phenomenon, we need to be aware of other potential issues such as cardiovascular conditions, as warmer water can cause arterial hypotension. Open wounds or infections are a clear contraindication to aquatic therapy. We also need to consider the issue of incontinence, which can be a concern for some MS patients. It's important to have a clear protocol in place for managing incontinence to ensure the safety and hygiene of the pool environment. With these considerations in mind, aquatic therapy can be a safe and highly effective treatment modality for our MS patients.