Abstract
Background: Fatigue, depression, and balance impairment are common in patients with multiple sclerosis (MS). Aquatic therapy is an exercise program which is effective in improving the well-being of patients with MS. So, we designed this systematic review to estimate the pooled effects of aquatic therapy on depression, fatigue and balance in subjects with MS.
Methods:Two independent researchers did a systematic and comprehensive search of PubMed, Scopus, EMBASE, Web of Science, Google Scholar as well as gray literature, including references of the included studies, and conference abstracts. The search was done on October 31st 2022. We extracted data regarding the total number of participants, first author, publication year, country of origin, mean age, EDSS, and results of fatigue, depression and balance.
Results:The first search identified 6403 studies. After deleting duplicates, 3347 studies remained, and 86 full texts were evaluated. Ten studies remained for meta-analysis. The pooled standardized mean difference (SMD) of BBS (after-before) was 0.67 (95% CI 0.19–1.16) (I²=11.6%, P=0.3). The pooled SMD of MFIS (after-before) was -0.4 (95% CI -0.71 to -0.09) (I2=21%, P=0.2). The pooled SMD of FSS (after-before) was -1.13 (95% CI -1.95 to -0.3) (I²=82.5%, P=0.003). The pooled SMD of BDI (after-before) was -1.83 (95% CI -2.31 to -1.35) (I²=30.1%, P=0.2).
Conclusion:The results of the present systematic review and meta-analysis show that aquatic therapy is effective for depression, fatigue, and balance improvement in subjects with MS.
Keywords:multiple sclerosis, fatigue, depression, balance.
INTRODUCTION
Multiple sclerosis (MS) is an autoimmune disease of the central nervous system (CNS), with a wide range of consequences such as physical, psychological, social, and financial problems (1, 2). It is the main cause of disability in youth, which affects women more than men (mostly in reproductive age) (3). Most patients lose their jobs and have marital problems due to MS.
Depression is the most common psychological complication, while fatigue is another disabling symptom that interferes with daily activities and quality of life (4, 5). On the other hand, gait imbalance is one of the main disabling physical complications in patients with MS, which affects nearly half of patients (6). Gait and balance problems are associated with mobility difficulties, limited community participation, social withdrawal, and impaired quality of life (7-9). So, rehabilitation plays an importantrole.
Exercise is one of the most important topics in the rehabilitation of subjects with MS; it helps muscle strength, mobility improvement, psychological wellness, and finally, quality of life improvement (10, 11). Several studies demonstrated that exercise therapy was effective in postponing and slowing down the progression of MS (10, 12, 13).
An exercise in the water (aquatic therapy) is one of the programs recommended by the American Physical Therapy Association (14). The environment of water makes exercise beneficial for subjects living with MS (turbulence, hydrostatic pressure and resistance) (15). Aquatic therapy could be a valuable adjunct to traditional treatment in subjects with MS (16, 17). Previous studies showed that aquatic therapy was effective in improving strength, fatigue, cardiovascular condition, psychological well-being and quality of life (17-20).
A recent systematic review and meta-analysis showed that aquatic therapy was effective for fatigue and balance. We designed the present systematic review to estimate the pooled effects of aquatic therapy on depression, fatigue and balance in subjects with MS.
METHODS
We followed Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 for reporting our systematic review and meta-analysis (21).
Eligibility criteria
Before-after studies reporting scores of walking tests, fatigue and depression were used as inclusion criteria, while letters to the editor, case-control, case reports and cross-sectional studies were all excluded.
Information sources
Two independent researchers did a systematic comprehensive search of PubMed, Scopus, EMBASE, Web of Science, Google Scholar, and also gray literature including references of the included studies and conference abstracts. The search was done on October 31st 2022.
Search strategy
The following MeSH terms were used: ((((((((((((((((((((((((((Hydrotherapy[MeSH Terms]) OR (aquatic therapy[MeSH Terms])) OR (Hydrotherapy[Text Word])) OR (aquatic exercise*[Text Word])) OR (aquatic therap*[Text Word])) OR (water exercise*[Text Word])) OR (water-based exercise*[Text Word])) OR (water therap*[Text Word])) OR (pool exercise*[Text Word])) OR (pool therap*[Text Word])) OR (underwater exercise*[Text Word])) OR (underwater therap*[Text Word])) OR (Therapy, Aquatic[Text Word])) OR (Aquatic Exercise Therap*[Text Word])) OR (Exercise Therapy, Aquatic[Text Word])) OR (Therapy, Aquatic Exercise*[Text Word])) OR (Water Exercise Therap*[Text Word])) OR (Exercise Therapy, Water[Text Word])) OR (Therapy, Water Exercise[Text Word])) OR (Therapy, Pool[Text Word])) OR (Aquatic training[Text Word])) OR (Water training[Text Word])) OR (Water-based training[Text Word])) OR (Water-based therap*[Text Word])) OR (water[Text Word])) OR (aquatic[Text Word])) AND (((((((Multiple Sclerosis[MeSH Terms]) OR (Multiple Sclerosis[Text Word])) OR (Sclerosis, Multiple[Text Word])) OR (Sclerosis, Disseminated[Text Word])) OR (Disseminated Sclerosis[Text Word])) OR (Acute Fulminating Multiple Sclerosis[Text Word])) OR (Multiple Sclerosis, Acute Fulminating[Text Word])).
Screening the studies and data extraction
After obtaining all retrieved studies, duplicates were deleted, and two researchers independently screened titles and abstracts. Full texts of eligible studies were evaluated and extracted data were entered the Excel sheet. In the case of discrepancy, the third one solved the problem.
We extracted data regarding the total number of participants, first author, publication year, country of origin, mean age, EDSS, and the results of fatigue, depression and balance.
Risk of bias assessment
The Cochrane Collaboration's tool was used for assessing the risk of bias of clinical trials (ROB2) and ROBINSON RISK OF BIAS for non-randomized studies (22, 23).
Statistical analysis
All statistical analyses were performed using STATA (Version 14.0; Stata Corp LP, College Station, TX, USA).
To determine heterogeneity, inconsistency (I2) was calculated.
We used the fixed or random-effects model for meta-analysis if heterogeneity between study results (I2) was either less or more than 50%. The standardized mean difference (SMD) was calculated as the effect size.
RESULTS
Our first search identified 6403 studies. After deleting duplicates, 3347 studies remained, and 86 full texts were evaluated. Ten studies remained for meta-analysis (Figure 1).
Data extracted from studies showed that Iran was the country of origin for the majority of authors, study participants’ mean age ranged between 33.7 and 55.9, EDSS between 2.1 and 6.3, and study duration varied between three and 20 weeks (Table 1).
The pooled SMD of BBS (after-before) was 0.67 (95% CI 0.19–1.16) (I2=11.6%, P=0.3) (Figure 2).
The pooled SMD of MFIS (after-before) was -0.4 (95% CI -0.71 to -0.09) (I2=21%, P=0.2) (Figure 3).
The pooled SMD of FSS (after-before) was -1.13 (95% CI -1.95 to -0.3) (I2=82.5%, P=0.003) (Figure 4).
The pooled SMD of BDI (after-before) was -1.83 (95% CI -2.31 to -1.35) (I2=30.1%, P=0.2) (Figure 5).
The quality assessment of non-randomized studies is summarized in Table 2.
The quality assessment of randomized studies is summarized in Table 3.
DISCUSSION
In this systematci review and meta-analysis we focused on the effects of aquatic rehabilittaion on fatigue, depression and balance in patients living with MS. The results showed that aquatic therpay led to a significant decrease of Modified Fatigue Impact Scale (MFIS), Fatigue Severity Scale (FSS), and Beck's Depression Inventory (BDI) scores as well as an improvement of Berg Balance Scale (BBS) scores.
The BBS is an objective assessment of balance, including 14 questions (each scored between 0-4). Higher scores indicate higher levels of balance. In our study, the pooled SMD of BBS was 0.67, which was significant, indicating that aquatic therapy was useful for improving balance in patients with MS.
In a study conducted by Salem et al, 10 patients with MS participated in a five-week aquatic exercise programme (twice weekly for an hour). Their results showed that the mean BBS improved from 24 to 27, while MFIS change was not significant (24).
Aidar et al evluated 13 cases in the aquatic group and 13 in the control group. The aquatic group attended three times per week and 45-60 minutes per session. Their results revealed a significant improvement of BBS in the intervention group, but no significant change in the control group (31).
The MFIS consists of 21 questions (each scored between 0 and 4), with higher scores indicating more fatigue experience.
Scorcine et al recruited 29 patients with MS who underwent 12-week aquatic therapy. The reported MFIS score was 47.7 before therapy and 38.4 after therapy. Also, Roehrs et al enrolled 18 subjects with MS who underwent a 12-week aquatic program; the mean MFIS score reported by them was 48.7 before the intervention and 43.5 after the intervention (17). We found that the pooled SMD of MFIS was -0.4 (significant difference), showing that aquatic therapy was effective in improving fatigue in subjects with MS.
The FSS is another questionaire used to evaluate the severity of fatigue, which consits of nine questions (each could be scored between 1 and 7). Like FSS, higher scores are indicative of higher fatigue experience.
Castro-Sanchez et al randomly assigned 73 patients into an intervention group and a control group. The intervention group received 20 week aquatic program. Their results showed that median FSS score decreased from 6 to 3 in the intervention group and from 5 to 4 in the control group. They also found that the BDI score decreased from 14 to 5 in the intervention group and from 15 to 13 in the control group (29).
In our meta-analysis, the pooled SMD for FSS was -1.13 (significant decrease), showing that aquatic therapy would help subjects with MS to improve their fatigue experience.
The pooled SMD of BDI was -1.83 (significant), which was indicative of positive effects of aquatic therapy on depression in people suffering from MS.
Depression is the most frequent psychological consequence in patients with MS, which is positively correlated with fatigue in these patients (5). Fatigue is related with physical disability in subjects with MS, and treatment of fatigue is a challenging issue (33). Nowadays, medications such as amantadine, modafinile, L-carnitin are used for treating fatigue in subjects with MS, while their efficacy is not satisfactory (34). The aquatic therapy program may help patients with MS to improve their mood status as well as their fatigue experience.
The present systematic review has two main strengths. Firstly, we evaluated the effects of aquatic therapy on depression, ftaigue, and balance. Secondly, we included more studies than previous systematic reviews.
Our study has also some limittaions. Firstly, the duration of follow-up is not similar for all studies. Secondly, all studies did not evaluate our outcomes.
CONCLUSION
The results of this systematci review and metaanalysis show that aquatic therapy is effective for depression, fatigue and balance improvement in subjects with MS.
Conflict of interests: none declared.
Financial support: none declared.
Ethical approval: This prospective study was approved by the Institutional Review Board of Istanbul Medeniyet University, Istanbul, Turkey, in accordance with the Declaration of Helsinki. Informed consent was obtained from all patients. This study conforms to all CONSORT guidelines and reports the required information accordingly.
FIGURE 1.
Flow chart of study inclusion
FIGURE 2.
The pooled SMD of BBS
FIGURE 3.
The pooled SMD of MFIS
TABLE 1.
Data extracted from studies
TABLE 1.
Data extracted from studies
FIGURE 4.
The pooled SMD of FSS
FIGURE 5.
The pooled SMD of BDI
TABLE 2.
Quality assessment of non-randomized studies (ROBINS-I)
TABLE 3.
Quality assessment of randomized trials (ROB2)
Contributor Information
Negin NAEIMI, Department of Physical Medicine and Rehabilitation, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
Mohsen RASTKAR, Student’s Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran.
Alireza SHAHRAKI, Department of Physical Medicine and Rehabilitation, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
Mina ABDI, Department of Physical Medicine and Rehabilitation, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
Mahsa GHAJARZADEH, Multiple Sclerosis Research Group (MSRG), Universal Scientific Education and Research Network (USERN), Tehran University of Medical Sciences, Tehran, Iran.
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