Aquatic Therapy May Positively Impact Fatigue, Balance in Multiple Sclerosis


Compared with conventional treatments, which included routine pharmaceutical treatments or occupational therapy without exercise, aquatic therapy showed several benefits in physical, cognitive, and psychosocial fatigue for patients with MS.

Brandon S. Shaw, PhD, executive director, University of Essex

Brandon S. Shaw, PhD

Findings from a meta-analysis of trials that assessed long-term aquatic exercise training in multiple sclerosis (MS) suggest that this type of therapeutic approach has positive effects on fatigue and balance, and could be a potentially effective strategy in occupational therapy of patients with MS.1

Led by Brandon S. Shaw, PhD, executive director, University of Essex, a total of 16 trials comprising of 794 participants met the eligibility criteria and were further analyzed. Trials were either experimental, such as case-control studies, randomized and non-randomized controlled trials, and case series. The studies included adults aged 19 years and older with MS, had a land-based therapy, control, conventional therapy, or other intervention as the comparison separate from aquatic therapy, and reported on balance, fatigue, and motor function outcomes.

Trials ranged from having a minimum of 2 patients to a maximum of 73. In 5 trials, aquatic therapy was compared with land-based exercise therapies, including ergometer-land exercises, home exercise program, pilates exercise group, and yoga exercises. In 6 other trials, aquatic therapy was compared with a control group with conventional treatment such as occupational therapy. The duration of the interventions ranged from 3 weeks to 20 weeks, and the duration of each session varied from 45 minutes to 135 minutes.

Using the Modified Fatigue Impact Scale (MFIS), 4 trials spanning 163 patients demonstrated improved physical fatigue to a greater extent with aquatic therapy than control group (standardized mean difference [SMD], –1.29; 95% CI, –1.65 to –0.93; I2 = 88%). Similarly, investigators also found that using aquatic therapy significantly improves cognitive function compared with controls on MFIS (SMD, –0.75; 95% CI, –1.08 to –0.43; I2 = 78%).

Not only did investigators conclude that this modality should be considered as an effective strategy for patients with MS, but that the "safety and enjoyability of aquatic therapy may have roles in increasing the patients’ adherence to treatment, which is another strength of this intervention."

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Psychosocial fatigue, as assessed by MFIS based on data from 4 trials of 163 patients, was improved through aquatic therapy relative to a control group of conventional treatment (SMD, –1.25; 95% CI, –1.59 to –0.90; I2 = 79%). Static balance, assessed by the Berg Balance Scale, was significantly improvement through aquatic therapy in patients with MS (SMD, 1.19; 95% CI, 0.62-1.76; I2 = 11%). Additionally, the investigators noted the lack of reported adverse events from aquatic therapy as another promising finding from the review, citing that it may be due to water’s buoyancy, which facilitates moving and exercising in water.

There were several notable limitations to the systematic review, including that some studies may have only included females, which may have decreased the generalizability of the findings. Second, some studies had small sample size, lack of control group, non-randomized design, and compared the effects of aquatic therapy to no treatment. Third, because of the limited number of studies specifically focusing in on this intervention in patients with MS, the investigators included case reports, case series, and non-randomized trials in the review, which may have increased the risk of bias. 

1. Shariat A, Najafabadi MG, Fard ZS, Ansari AN, Shaw BS. A systematic review with meta-analysis on balance, fatigue, and motor function following aquatic therapy in patients with multiple sclerosis. Mult Scler & Relat Disord. 2022;68:104107. doi:10.1016/j.msard.2022.104107
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