Original article| Volume 93, ISSUE 10, P1701-1708, October 2012

Effect of Aquatic Exercise Training on Fatigue and Health-Related Quality of Life in Patients With Multiple Sclerosis


      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.


      To examine the effectiveness of aquatic exercise training on fatigue and health-related quality of life (HRQOL) in women with multiple sclerosis (MS).


      Randomized controlled trial, 4-week and 8-week follow-up.


      Referral center of a multiple sclerosis society.


      Women (N=32) diagnosed with relapsing-remitting MS (mean age ± SD, 32.6±8.0y) were recruited into this study. After undergoing baseline testing by a neurologist, participants were randomly assigned to either an intervention (aquatic exercise) or a control group.


      The intervention consisted of 8 weeks supervised aquatic exercise in a swimming pool (3 times a week, each session lasting 60min).

      Main Outcome Measures

      At baseline, 4 weeks, and 8 weeks, fatigue and HRQOL were assessed by a blind assessor using the Modified Fatigue Impact Scale and the Multiple Sclerosis Quality of Life-54 questionnaire, respectively. A mixed-model approach to repeated-measures analysis of variance was used to detect within- and between-subject effects.


      Findings are based on 21 patients (10 from the exercise group and 11 from the control group) who had data available on outcomes. There was no significant difference between the 2 groups at the baseline. Patients in the aquatic exercise group showed significant improvements in fatigue and subscores of HRQOL after 4 and 8 weeks compared with the control group. Results obtained from the intention-to-treat analysis were consistent with those of per-protocol analysis.


      The findings suggest that aquatic exercise training can effectively improve fatigue and HRQOL of patients with MS and should be considered in the management of this relatively common public health problem.

      Key Words

      List of Abbreviations:

      ANOVA (analysis of variance), BMI (body mass index), EDSS (Expanded Disability Status Scale), HRQOL (health-related quality of life), IMSS (Isfahan Multiple Sclerosis Society), ITT (intention-to-treat), MFIS (Modified Fatigue Impact Scale), MS (multiple sclerosis), MSQOL-54 (Multiple Sclerosis Quality of Life-54), RRMS (relapsing-remitting multiple sclerosis)
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        • Hirtz D.
        • Thurman D.J.
        • Gwinn-Hardy K.
        • Mohamed M.
        • Chaudhuri A.R.
        • Zalutsky R.
        How common are the “common” neurologic disorders?.
        Neurology. 2007; 68: 326-337
        • 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
        • Kargarfard M.
        • Etemadifar M.
        • Mehrabi M.
        • Maghzi A.H.
        • Hayatbakhsh M.R.
        Fatigue, depression, and health-related quality of life in patients with multiple sclerosis in Isfahan, Iran.
        Eur J Neurol. 2012; 19: 431-437
        • Jackson M.F.
        • Quaal C.
        • Reeves M.A.
        Effects of multiple sclerosis on occupational and career patterns.
        Axone. 1991; 13 (20-2): 16-17
        • Iriarte J.
        • Katsamakis G.
        • De Castro P.
        The Fatigue Descriptive Scale (FDS): a useful tool to evaluate fatigue in multiple sclerosis.
        Mult Scler. 1999; 5: 10-16
        • Fisk J.D.
        • Pontefract A.
        • Ritvo P.G.
        • Archibald C.J.
        • Murray T.J.
        The impact of fatigue on patients with multiple sclerosis.
        Can J Neurol Sci. 1994; 21: 9-14
        • Fisk J.D.
        • Ritvo P.G.
        • Ross L.
        • Haase D.A.
        • Marrie T.J.
        • Schlech W.F.
        Measuring the functional impact of fatigue: initial validation of the fatigue impact scale.
        Clin Infect Dis. 1994; 18: S79-S83
        • Moller A.
        • Wiedemann G.
        • Rohde U.
        • Backmund H.
        • Sonntag A.
        Correlates of cognitive impairment and depressive mood disorder in multiple sclerosis.
        Acta Psychiatr Scand. 1994; 89: 117-121
        • Rudick R.A.
        • Miller D.
        • Clough J.D.
        • Gragg L.A.
        • Farmer R.G.
        Quality of life in multiple sclerosis.
        Arch Neurol. 1992; 49: 1237-1242
        • Rietberg M.B.
        • Brooks D.
        • Uitdehaag B.M.
        • Kwakkel G.
        Exercise therapy for multiple sclerosis.
        Cochrane Database Syst Rev. 2005 Jan 25; (CD003980)
        • Heesen C.
        • Romberg A.
        • Gold S.
        • Schulz K.H.
        Physical exercise in multiple sclerosis: supportive care or a putative disease-modifying treatment.
        Expert Rev Neurother. 2006; 6: 347-355
        • Snook E.M.
        • Motl R.W.
        Effect of exercise training on walking mobility in multiple sclerosis: a meta-analysis.
        Neurorehabil Neural Repair. 2009; 23: 108-116
        • Motl R.W.
        • Mcauley E.
        • Snook E.M.
        Physical activity and multiple sclerosis: a meta-analysis.
        Mult Scler. 2005; 11: 459-463
        • Romberg A.
        • Virtanen A.
        • Ruutiainen J.
        • et al.
        Effects of a 6-month exercise program on patients with multiple sclerosis: a randomized study.
        Neurology. 2004; 63: 2034-2038
        • Surakka J.
        • Romberg A.
        • Ruutiainen J.
        • et al.
        Effects of aerobic and strength exercise on motor fatigue in men and women with multiple sclerosis: a randomized controlled trial.
        Clin Rehabil. 2004; 18: 737-746
        • Petajan J.H.
        • Gappmaier E.
        • White A.T.
        • Spencer M.K.
        • Mino L.
        • Hicks R.W.
        Impact of aerobic training on fitness and quality of life in multiple sclerosis.
        Ann Neurol. 1996; 39: 432-441
        • Cramer S.R.
        • Nieman D.C.
        • Lee J.W.
        The effects of moderate exercise training on psychological well-being and mood state in women.
        J Psychosom Res. 1991; 35: 437-449
      1. Guide to physical therapist practice.
        Phys Ther. 1997; 77 (Anonymous): 1160-1656
        • Weikert M.
        • Dlugonski D.
        • Balantrapu S.
        • Motl R.W.
        Most common types of physical activity self-selected by people with multiple sclerosis.
        Int J MS Care. 2011; 13: 16-20
        • Guthrie T.C.
        • Nelson D.A.
        Influence of temperature changes on multiple sclerosis: critical review of mechanisms and research potential.
        J Neurol Sci. 1995; 129: 1-8
        • Peterson C.
        Exercise in 94 degrees F water for a patient with multiple sclerosis.
        Phys Ther. 2001; 81: 1049-1058
        • Pariser G.
        • Madras D.
        • Weiss E.
        Outcomes of an aquatic exercise program including aerobic capacity, lactate threshold, and fatigue in two individuals with multiple sclerosis.
        J Neurol Phys Ther. 2006; 30: 82-90
        • Stuifbergen A.K.
        Physical activity and perceived health status in persons with multiple sclerosis.
        J Neurosci Nurs. 1997; 29: 238-243
        • Roehrs T.G.
        • Karst G.M.
        Effects of an aquatics exercise program on quality of life measures for individuals with progressive multiple sclerosis.
        J Neurol Phys Ther. 2004; 28: 63-71
        • Gehlsen G.M.
        • Grigsby S.A.
        • Winant D.M.
        Effects of an aquatic fitness program on the muscular strength and endurance of patients with multiple sclerosis.
        Phys Ther. 1984; 64: 653-657
        • Salem Y.
        • Scott A.H.
        • Karpatkin H.
        • et al.
        Community-based group aquatic programme for individuals with multiple sclerosis: a pilot study.
        Disabil Rehabil. 2011; 33: 720-728
        • Kurtzke J.F.
        Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS).
        Neurology. 1983; 33: 1444-1452
        • Multiple Sclerosis Council
        Fatigue and multiple sclerosis clinical practice guidelines.
        Paralyzed Veterans of America, Washington (DC)1998
        • Pilutti L.A.
        • Lelli D.A.
        • Paulseth J.E.
        • et al.
        Effects of 12 weeks of supported treadmill training on functional ability and quality of life in progressive multiple sclerosis: a pilot study.
        Arch Phys Med Rehabil. 2011; 92: 31-36
        • Mills R.J.
        • Young C.A.
        • Pallant J.F.
        • Tennant A.
        Rasch analysis of the Modified Fatigue Impact Scale (MFIS) in multiple sclerosis.
        J Neurol Neurosurg Psychiatry. 2010; 81: 1049-1051
        • Kos D.
        • Kerckhofs E.
        • Carrea I.
        • Verza R.
        • Ramos M.
        • Jansa J.
        Evaluation of the Modified Fatigue Impact Scale in four different European countries.
        Mult Scler. 2005; 11: 76-80
        • Vickrey B.G.
        • Hays R.D.
        • Harooni R.
        • Myers L.W.
        • Ellison G.W.
        A health-related quality of life measure for multiple sclerosis.
        Qual Life Res. 1995; 4: 187-206
        • Acquadro C.
        • Lafortune L.
        • Mear I.
        Quality of life in multiple sclerosis: translation in French Canadian of the MSQoL-54.
        Health Qual Life Outcomes. 2003; 1: 70
        • Miller A.
        • Dishon S.
        Health-related quality of life in multiple sclerosis: psychometric analysis of inventories.
        Mult Scler. 2005; 11: 450-458
        • Ghaem H.
        • Borhani Haghighi A.
        • Jafari P.
        • Nikseresht A.R.
        Validity and reliability of the Persian version of the multiple sclerosis quality of life questionnaire.
        Neurol India. 2007; 55: 369-375
        • Hochberg Y.
        A sharper Bonferroni procedure for multiple tests of significance.
        Biometrika. 1988; 75: 800-802
        • Bland J.M.
        • Altman D.G.
        Multiple significance tests: the Bonferroni method.
        BMJ. 1995; 310: 170
        • Perneger T.V.
        What's wrong with Bonferroni adjustments.
        BMJ. 1998; 316: 1236-1238
        • O'Connor P.
        • Lee L.
        • Ng P.T.
        • Narayana P.
        • Wolinsky J.S.
        Determinants of overall quality of life in secondary progressive MS: a longitudinal study.
        Neurology. 2001; 57: 889-891
        • Patti F.
        • Cacopardo M.
        • Palermo F.
        • et al.
        Health-related quality of life and depression in an Italian sample of multiple sclerosis patients.
        J Neurol Sci. 2003; 211: 55-62