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The Effect of 8 Weeks Hydrotherapy on Balance in Women with Multiple Sclerosis

Fatemeh sarvari M.Sc1, Ahmad Ebrahimi Atri PhD1, Morteza Saeidi MD2,Milad Ameli M.Sc1, Amir Shahriar Ariamanesh MD3*

1. Faculty of Physical Education & Sport Sciences, Ferdowsi University, Mashhad, Iran
2. Department of neurology, Mashad University of Medical Sciences, Mashhad, Iran
3. Department of neurology, Mashad University of Medical Sciences, Mashhad, Iran

* Corresponding Author

Vol 2, Num 1, January 2015




Introduction:Individuals with multiple sclerosis (MS) often have difficulty maintaining postural balance. problems with keeping proper balance and body posture is so common in patients with MS that the risk of fractures as a result of falling, is 2 to 3 times higher in them as compared to healthy people (4, 6). Hydrotherapy is frequently applied to patients with painful neurological or musculoskeletal alterations. Water also provides a supportive environment for individuals who have difficulty with their balance and coordination. Therefore the purpose of this study was to examine the effects of aquatic exercise program on balance in patients with multiple sclerosis.

Materials and Methods:Twenty- six women with MS (age 34.12±8.1 years, height 159.65± 6.22 cm, weight 60.48± 11.03 kg, and mean EDSS 2.53± 1.34) were randomly assigned to either the exercise (n=14) or the control (n= 12)group. Exercise group participated in8 weeks of (3×week) aquatic exercise program. Balance was measured using the Berg Balance scale (BBS) and Functional Reach Test(FRT).

Results:In the exercise group, balance improved significantly in both BBS and FRT tests (p<0.05) while the scores of balance tests(BBS &FRT) did not change significantly in the control group.

Conclusion:The aquatic exercise program improved balance in patient with MS.

Keyword:Aquatic Exercise, Balance, Multiple sclerosis




MS is a demyelination disease that involved multiple parts of central nervous system. Ms is the most prevalent neurological problem in young people.(1) Balance is one of the essential needs in everyday life. Maintaining proper balance entails integration of the input from visual, sensory-motor, and Vestibular systems and designing appropriate motor responses.(2) Demyelination and axon trauma in the brain hemispheres, Brain stem, and spinal cord resulted from multiple plaque is evident in problems in moving, walking, and maintaining proper balance.(3) Balance problems and control of posture is so common in patients with MS that the risk of fractures as a result of falling is 2 to 3 times higher in them as compared to healthy people.(4,6)

Patients with MS usually want to receive CAM and other suggested medications in different forms, however the efficiency of some of these medications are not proved yet.(5) A recent study has shown that 50 to 75 % of patients with MS use complementary medications as these medications reduce the intensity of painful symptoms and improve the patients' performance.(6,7) Many of these patients reported that they took complementary medication because they were not satisfied with common medicines on one hand, and on the other, they had experienced significant improvements in their symptoms as a result of complementary medications.(5,8)

Hydrotherapy is a practical medication for patients who suffer from painful neurological or musculoskeletal alterations.(10) Water provides a supporting environment for those who have difficulty maintaining proper balance and coordination and thus reduces the risk of falling.

Water buoyancy helps the patients maintain their proper posture and standing position during exercise training.(9) Many studies have proved that aqua training had positive effects on keeping balance. Douris et al (2003) and Resende et al (2008)have shown that aqua training improved balance in middle-aged participants.(11,12) As physical properties of water along with exercise training may significantly help in accomplishing the suggested goals in a rehabilitationprogram, the present research aimed at investigating the effects of aqua training on balance in patients with MS.

Materials and Methods

This was a semi-experimental study. Thetarget population included all the 25 -45 year-old women with MS with EDSS (1-4) who came to Iran Multiple sclerosis society branch of Khorasan Razavi.

Exclusion criteria included:

taking part in regular exercise training in the last 3 month,

experiencing severe attacks or neurological problems during the last 4 weeks,

having severe cognitive problems,

or having orthopedic, metabolic or Cardiopulmonary diseases.

The participants included 26 MS patients who were randomly and according to their Expanded Disability Status Scale (EDSS) divided into two groups: a control group with 12 participants and an experimental group including 14 participants.

All the participants signed a consent form showing their willingness to take part in the study. They also had an approved medication form filled and approved by a physician. An introductory meeting was held before the study to familiarize the participants with the study's length and procedure. Then the experimental group took part in training sessions for 8 weeks. Being absent for more than 5 sessions led to the participant's exclusion from the study.

The training sessions were held in the mornings, three times a week, and for 8 weeks. 24 training sessions, 45 minutes each, were held in general, and in order to meet the overload principle, each session was 10 minutes longer than the previous one. The training sessions included:

1- Walking in water as a warm up (10 min.)

2- Step training in water (10 min)

3- Upper body and arm training (18 min)

4- Lower body training ( 7 min)

All the training sessions were held in the shallow end of Ferdowsi University's swimming pool.

A specific questionnaire was used to collect the participants' demographic information and information regarding their disease status. BBS and functional reach (FRT) tests were applied in order to measure the participants' balance.

BBS is designed to measure the balance in elderly people with clinical status. It can also be used in to measure postural balance in people who had a history of brain stroke or brain traumas.(1)

BBS has the following 14 tests: Sitting to standing, Standing unsupported , Sitting unsupported , Standing to sitting, Transfers, Standing with eyes closed, Standing with feet together, Reaching forward with outstretched arm , Retrieving object from floor , Turning to look behind, Turning 360 degrees, Placing alternate foot on stool, Standing with one foot in front , Standing on one foot. The patient' performance is graded from 0 (inability to perform) to 4 (natural performance). Total score of a patient is the sum of all the scores from the 14 tests and may vary from 0 to 56.(2) Measures of Central tendency and dispersion indexes were used to describe the data.

Statistical expansion was also applied in order to perform statistical analyses of the data and to generalize the results to the study population. All the statistical analyses were done using SPSS software (version 16).

Data regarding the type and length of the disease and the medicine taken is presented in tables 1and 2. As it is shown, 57.7% of the participants suffered from Relapsing – Remittingand 42.3% had Secondary - progressive patterns.

Table 1 also shows that in 50% of the participants the disease length was between 1 to 3 years. According to table 2, Betaferon was the most frequently taken medicine.

    Table 1: Frequency distribution of disease length in participants
    Table 2: Medicine taken by the participants


    26 participants (age 34.12±8.1 years, height159.65± 6.22 cm, weight 60.48± 11.03 kg, and mean EDSS 2.53± 1.34) took part in the present study.

    Kolmogorov-Smirnov test was applied to test the normality of data distribution. Table 3 presents data regarding descriptive statistics (including mean, SD, maximum, and minimum values) and results of Kolmogorov-Smirnov test in the study groups. It is clear that all the variables are statistically normal.

    Table 4 compares pre- and post-test results of BBS and FRT tests in the experimental and control groups.

    No significant difference was observed between the pre-test values of BBS and FRT in either of the groups (p>0.05), so both groups were similar regardingbalance level. Results of dependant t-test are presented in tables 5 and 6.

    According to table 5, there was a significant difference between the mean values of pre- and post test results of BBS in the experimental group (p<0.05) but not in the control group (p>0/05).

    As shown in table 6, the difference between mean values of pre- and post testresults of FRT was also significant in the experimental group (p<0.05) but not in the control group (p>0.05).

    Results from the present study showed that 8 weeks of aqua training could significantly improve balance in the experimental group, and the training protocol could successfully increase mean BBS scores for 2.71 points and mean FRT results for 5.53 cm.

    Table 3: Descriptive statistics and results of K-S tests of age, BMI, EDSS degree, BBS and FRT in the study groups.
    Table 4: Comparison between the pretest results of BBS and FRT in the study groups
    Table 5: Comparison between pre- and post test results of BBS in the two study groups
    Table 6: Comparison between pre –and post FRT results in the study groups


    Results from the present study indicated that aqua training could significantly improve balance in patients with MS. These findings are in line with those of soltani (2008), Douris et al (2003), Resende et al (2008), Cattaneo rt al (2007), Filipi et al (2010), Hosseini (2011), Ghasemi et al (2008), Giesser et al (2007) but contradicts those of DeBolt and McCubbi (2004).

    This contradiction could be the result of difference in the training protocols and balance measurements. DeBolt applied resistance training at home and used force platform to measure static balance while others took advantage of physiotherapy at home and at the hospital for 8 weeks.

    Postural balance is related to the performance of visual and vestibular systems and proprioceptive receptors.

    Apparently accomplishing tasks related to proprioceptive receptors are more difficult for patients with MS. BSS is a reliable and useful screening tool for balance problems in patients with MS.(2) Potential mechanisms for balance improvement resulting from exercise training could be improvement in strength and resistance of lower body muscles, facilitation of performing more work, the ability of muscles for faster contraction, improvement in muscle coordination (agonist and antagonist muscles), and putting more pressure on the neuromuscular system.(21)

    Viscosity of water slows down movements in it, delaying falling, and increasing the needed time to restore proper position when the body loses its balance.(13)

    Buoyancy could act as a support improving one's self-confidence, so one could do more work in water without the fear of falling down. Rissel (1987) claimed that water lets people do a wider range of activities without increasing the risk of falling or getting hurt and thus improves posture control.(22) Ruoti (1994) also stated that the supportive environment of water helps people maintain a standing and Steady position on their own.

    On the other hand, forces that counteract balance and stability provide good opportunities for balance and stability improving activities and engagement of balanc systems.(23) Repetition and the speedof movements in water may also increase muscular strength and improve reaction time. Aqua training puts more pressure on neuromuscular system to keep balance and thus people need dynamic balance while training in water.(21)


    In general, different physiological and mechanical responses of the body to buoyancy in water, have led to taking advantage of it in many clinical rehabilitation protocols and fitness programs. In addition, specific effects of water on improving balance in patients with MS may lead to a great change in their rehabilitation programs.

    Fatemeh Sarvari MSc
    M.Sc. in sport medicine and corrective exercise, Faculty of Physical Education & Sport Sciences, Ferdowsi University, Mashhad, Iran


    Ahmad Ebrahimi Atri PhD
    Associate professor, Department of sport medicine and corrective exercise, Ferdowsi University, Mashhad, Iran


    Morteza Saeidi MD
    Associate profess, Department of neurology, Mashhad University of Medical Sciences, Mashhad, Iran


    Milad Ameli MSc
    M.Sc. in sport medicine and corrective exercise, Faculty of Physical Education & Sport Sciences, Ferdowsi University, Mashhad, Iran


    Amir Shahriar Ariamanesh MD
    Assistant Professor, Orthopedic Knee Surgeon, Mashhad University of Medical Sciences, Mashhad, Iran
    Corresponding Author


    We wish to thank to Iran Multiple sclerosis society branch of Khorasan Razavi, and dear professors and laboratory staff of physical education faculty of Ferdowsi University for their kind help and support in data collection process andfacilitating the use of laboratory equipments.


    Financial disclosure:
    None declared.



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