Hydrotherapy for the Treatment of Pain in People with Multiple Sclerosis:
A Randomized Controlled Trial
Multiple sclerosis (MS) is a chronic demyelinating neurological disease afflicting young and middle-aged adults that impairs coordination, strength, cognition, and sensation. Although treatment with immunomodulatory agents can affect the course of MS, it is not currently curable. It is the most frequent disabling neurologic disease among young and middle-aged adults in North America and Europe.
Patients with MS often request complementary and alternative medicine (CAM) in different forms, but the effectiveness of these therapies has not been demonstrated in MS patients .A recent study found that 50–75% of patients with MS used CAM because it reduces the severity of painful symptoms and offers functional improvement .Many MS patients reported that they turned to CAM due to dissatisfaction with conventional pharmacological therapies and experienced a considerable improvement in symptoms as a result .However, although CAM is widely used by MS patients, there is no scientific evidence to support its effectiveness .The majority of MS patients use CAM alongside their conventional treatment and report that they receive a benefit from these alternative therapies . Survey results suggest that MS patients choosing to use both CAM and conventional medicine integrate both types of medicine to attain a more holistic healthcare approach. It is well known that female MS patients and those with a higher education and income are more likely to use CAM. The severity of the disease may also influence the use of CAM. MS patients appear to especially value mind-body therapies, perhaps attributable to their psychological effects in reducing stress, which is known to exacerbate MS symptoms.
Recent guidelines from the National Institute of Health and Clinical Excellence (NICE) affirmed that MS patients should be informed of findings on the benefits of certain approaches but declared that insufficient evidence is available to make a firmer recommendation. Named techniques include reflexology, massage, fish oils, magnetic field therapy, neural therapy, massage plus body work, Tai-Chi, and multi-modal therapy.MS patients also report the therapeutic use of exercise, vitamins, herbal and mineral supplements, relaxation techniques, acupuncture, cannabis, and massage, mainly for the treatment of pain, fatigue, and stress. .Maloni reported that Tai-Chi, meditation, and hypnotherapy may improve the quality of life and reduce pain in MS patients by interfering with pain conduction, producing analgesia through nociceptive pathways.
Aquatic exercise can refer to pool therapy, hydrotherapy, or balneotherapy.Hydrotherapy is frequently applied to patients with painful neurological or musculoskeletal alterations because the heat and floatability of the water can block nociceptors by acting on thermal receptors and mechanoreceptors and exert a positive effect on spinal segmental mechanisms. Warm water can also increase the blood flow, helping to dissipate allogeneic chemicals and enhance muscle relaxation. Finally, the hydrostatic effect of water can alleviate pain by reducing peripheral edema and sympathetic nervous system activity. A systematic review on crenobalneotherapy in patients with limb osteoarthritis found that it reduced pain and improved function and quality of life. CAM is frequently used in spa therapy in situ without exercise for various chronic diseases, with highly positive effects in middle-aged and elderly patients. The main aim of this paper was to determine the effectiveness of hydrotherapy to modify pain, quality of life, and other symptoms in MS patients.
Materials and Methods
We performed an experimental clinical trial with a control group (MS patients receiving relaxation exercise protocol in therapy room) and experimental group (MS patients undergoing an Ai-Chi exercise protocol in swimming-pool). The study period was from January 1 2009 through June 30 2010.
The patients were randomly assigned by a blinded researcher, using a computer-generated randomized list, to an Ai-Chi exercise group (n = 36) or relaxation exercise group (n = 37). Both groups received treatment sessions twice a week for 20 weeks, on Mondays and Thursdays for the experimental group and on Tuesdays and Fridays for the control group. Power calculations were carried out after 20 patients had been treated, estimating a minimal sample size of 33 participants per group for a power of 80% and standard deviation
The Ai-Chi exercise program was conducted in a swimming pool with a water temperature of 36°C. Patients took a shower with a water temperature of 35.5°C before entering the pool. The air temperature was maintained at 20°–25°C. A single physiotherapist led all of the Ai-Chi exercise sessions, teaching the 16 movements that constitute this therapy (which requires no additional material). There was a maximum of 10 participants per session. Ai-Chi exercises, all performed in shoulder-depth water, use a combination of deep breathing and slow, broad movements of the arms, legs, and torso to work on balance, strength, relaxation, flexibility, and breathing. The 16 movements or postures are designated as follows: contemplating, floating, uplifting, folding, soothing, gathering, freeing, transferring, accepting, accepting with grace, rounding, flowing, relaxing, and sustaining. Relaxation is induced by the slow and wide movements of arms and legs and by the focus on the breathing. The principles of Ai-Chi are Yuan (circular movements seeking internal and external harmony), Sung (internal and external relaxation to promote blood circulation), Ching (absence of tension in the body), Yun (movement at a given speed that is always controlled by the mind), Cheng (correct maintenance of balance and posture), Shu (easy, comfortable, and relaxed movement of the body), and Tsing (direction of thought towards the mind, concentration). Relaxing Tai-Chi music (album by Oliver Santi & Friends) was played to the participants during the sessions, which lasted 60 minutes, beginning and ending with 10 minutes of relaxation in the water. Throughout these 10 min relaxation periods, the patients performed abdominal breathing simultaneous with contraction-relaxation exercises of muscle groups in hands, arms, shoulders, face, neck, thighs, legs, and feet while standing in the shoulder-depth water.
The same physiotherapist also led the exercise sessions for the control group, which were conducted in a therapy room at a temperature of around 26°C. The patients underwent the same exercise program followed by the experimental group during the relaxation periods (abdominal breathing plus guided contraction-relaxation) but in supine position on an exercise mat (tatami). No ambient music was played during these control sessions.
According to these results, a 20-week Ai-Chi aquatic exercise program produces a significant pain reduction in MS patients that lasts for 10 weeks after the end of the program. It also improves other MS-related symptoms, including disability, depression, and fatigue. These effects of the Ai-Chi aquatic program were superior to those of an equivalent exercise program in a therapy room.