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Does hydrotherapy improve the quality of life in multiple sclerosis patients

Submitted in partial fulfilment of

BSc (Hons) Physiotherapy

Faculty of Health and Wellbeing

Sheffield Hallam University

Name: George Taylor

Student Number: 22000366

May 2016

Word count: 2779

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Contents page

Introduction ……………………………………. 3

Background …………………………………….4

Search strategy .………………………………..6

Review of literature .………………………..….8

Discussion …………………………………….12

Summary & recommendations .……………..14

References …………………………………....15

Appendix 1 ………………………………….…18

Appendix 2 ………………………………….…28

Appendix 3 ………………………………….…29

Appendix 4 ………………………………….....30

Appendix 5 ………………………………….…31

Appendix 6 ………………………………….…32

Appendix 7 ………………………………….…33

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Introduction

The aim of this assignment will be to justify a chosen topic, critically discuss why this

is relevant within health and social care and discuss and critically appraise articles

from my chosen topic:

"Whether hydrotherapy helps improve the quality of life (QOL) in

multiple sclerosis patients"

This will be achieved by critically discussing a range of different resources such as

Randomized Controlled Trials (RCTs), systematic review, a case report and a case

series.

From this critical appraisal, I am looking to give newly qualified Physiotherapists a

different approach when trying to manage symptoms of multiple sclerosis (MS)

patients which may be mild, moderate or severe. Being able to manage the

symptoms at the earlier stages of MS the Central Nervous System (CNS) has a

greater potential for adaptation and recovery (MS Australia 2012); by improving

neurological related function and being creative makes a huge difference to enhance

the QOL of MS patients and their families (Burks, Bigley and Hill 2009).

Therefore I have chosen hydrotherapy as my chosen intervention as it enables

something different in a treatment approach.

By engaging with newly qualified Physiotherapists it will actively engage with their

CPD, enhancing what they've learnt and how this can affect their practice and also

apply this to their practice (Chartered Society of Physiotherapy 2014).

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Background

A report by the MS Society (2016) stated that within the UK alone the prevalence is

over 100,000 people with MS and each year 5,000 people are newly diagnosed with

this condition.

Multiple Sclerosis affects the Central Nervous System. This is where your immune

system which normally fights off infection mistakes the myelin (which coats the nerve

fibres) as a foreign body; this can partially or fully remove the myelin normally called

scarring on the nerve fibre (Multiple Sclerosis Society 2016). This, depending on

where the attacks happened can leave people with different symptoms of MS, due to

the wide variety of symptoms that people with MS present with (see Appendix 2)

hydrotherapy can be useful in improving and reducing some of the symptoms and

overall enhance their QOL.

Because of the heat and floatability of the water, it can block nociceptors by acting

on thermal receptors and mechanoreceptors and exert a positive effect on spinal

segmental mechanisms; the hydrostatic effect of water can also alleviate pain by

reducing peripheral oedema and sympathetic nervous system activity (Castro-

Sanchez et al. 2012).

This is relevant to my chosen target group as it will develop their theoretical

knowledge on what hydrotherapy does and how they are able apply it to this specific

patient group, also looking at it in the wider context of other common Musculo-

skeletal (MSK) conditions and other neurological conditions.

By trying to define Quality of Life it is very difficult, because this is very subjective

term. World Health Organization (1997) defines QOL as the individuals' perception of

their position in life in the context of the culture and value systems in which they live

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and in relation to their goals, expectations, and standards.

Being more topic specific with MS, Janardhan and Bakshi (2002) stated that fatigue

and depression are independent predictors of impaired QOL in MS patients; but also

diminished QOL by interfering with the ability to work, pursue leisure activities, and

carry out usual life roles (Zwibel and Smartka 2011).

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Search strategy

To enable an effective search strategy it requires a multitude of different databases

to offer a wide range of different articles to support any project (Penn State

University Libraries 2001). A comprehensive search strategy can be constructed by

implementing the population, intervention, outcome and some comparisons (NICE

Guidance 2012).

The way in which the search strategy was approached was using the Population,

Intervention, Outcome and Comparisons (PICO) method as mentioned by (NICE

Guidance 2012), this is a widely known strategy for forming a research question

(Aslam and Emmanuel 2010) by targeting each area you would have been able to

cover each aspect of the question. Sackett et al (1997) pointed out that breaking the

question into four components will help facilitate the identification of relevant

information.

To refine my search strategy, search terms were used including: 'MS, Multiple

Sclerosis, Hydrotherapy, and quality of life'.

Appendix 3 details the extent of my search strategy with further terms used. By using

a variety of synonyms, acronyms and abbreviations it offers a broader range of

available responses enabling a larger range of articles and resources to choose

from.

Collated from my search strategy was a multitude of different literature: Randomized

Controlled Trials (RCTs), a systematic review, case report, and a single study group,

here this enables me a wide variety of literature to review over a broad basis. Ciliska,

Dobbins and Thomas (2007) stated the most efficient way of searching for better

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"gold standard" evidence was looking from the top (RCTs), then working towards the

bottom (single studies), see (Appendix 4).

According to Randolph (2009) an inclusion and exclusion criteria should be explicit

and comprehensive enough so that any article that comes to light could be included

or excluded based on the criteria of the topic; although in my case this has been

restricted as I have found a limited amount of relevant literature.

The primary source of information has come from journal articles, as these are one

of the best sources of information as they can be selected for current and specific

topics (Nursing Times 2007). In finding my articles I have critically appraised these

as seen in (Appendix 1), by using the appropriate toolkits such as CEBMa (see

Appendix 5) and CASP toolkit (see Appendix 6 and 7)

Whilst I do believe that I have successfully identified a vast range of different sources

of literature, in future when having to undertake a literature review again, using more

physiotherapy specific databases such as Health Source: Nursing/Academic Edition

which has full text journals on medical subjects from as far back as 1975 to present.

What could be done as well as broadening my database searching would be using

more efficient search terms and Boolean phrases to try and get a bigger range of

literature.

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Review of Literature

Literature states that RCT and systematic reviews are known to be the "gold

standard" of literature for assessing the effectiveness of interventions, providing the

most robust form of clinical evidence (Panesar et al. 2006).

Mhaskar et al (2009) stated that choosing a variety of different studies and being

able to critically appraise research will enhance any healthcare professional's skill,

determining whether the research evidence is free of bias, and relevant to their

patients condition.

The majority of the articles did have a general consensus of hydrotherapy improving

different aspects of QOL in MS patients; however the systematic review by Heaton

(2001) found that aquatic exercise can be supporting in a different environment, but

further research may be required due to a lack of evidence.

The 2 RCT studies by Castro-Sanchez et al (2011) and Kargarfard et al (2012) see

(Appendix 1), participants were randomly allocated using a blind researcher to either

the experimental or control group; reducing the risk of observer bias. Kargarfard et al

(2012) used someone with no responsibilities by using shuffled, sealed envelopes

with group allocations in side; nonetheless there is a possibility of tampering as

researchers could open several envelopes and allocate participants to the desired

treatment (Torgerson and Roberts 1999). Whereas Castro-Sanchez et al (2011)

used a stratification system based upon their medication type; according to Suresh

(2011) this controls the influences of covariates which could jeopardize conclusions

of clinical research; this was followed by randomly assigning to groups using a

computer generated randomization list.

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The systematic review by Heaton (2013) assessed 63 participants across 5 studies

which were included in this review. In order to help with the comparisons with each

study as they varied from their intervention dose the FITT principle was used -

frequency , intensity, type and time (Heaton 2013). Whilst having a broader

Expanded Disability Status Scale (EDSS) with scores ranging from 1.5 - 8.0 this

improved the generalizability across MS patients; the transferability of these results

may be restricted as majority of the evidence was based in the community setting,

improvements to this could be allowing hospital based research within the review.

Kargarfard et al (2012) used 32 participants of whom were women specifically with

Relapse Remitting Multiple Sclerosis (RRMS); here they were referred on by private

and public neurologists with an EDSS score of ≤ 3.5; unlike the systematic review,

this reduced the generalizability of the study due to the limitations of the criteria

required of the participants.

Furthermore Castro-Sanchez et al (2011) had an inclusion criterion which was much

broader with ages between 18-75 years and an EDSS ≤ 7.5; this could allow for a

better generalizability for the MS population varying the level of disability to

treatment.

Both RCTs had intervention groups, Castro-Sanchez et al (2011) had intervention

group for 20 weeks where the same physiotherapist led the experimental and control

group. Kargarfard et al (2012) had 2 intervention groups, experimental and control.

The experimental group was supervised by a trained aquatic instructor; the control

group there was no details of whether it was the same instructor or a different one;

The study by Peterson (2001) was undertaken by the author and physician allowing

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consistency during the 6 weeks intervention, although this potentially could impact

on the level of bias, this sort of bias called also be known as the "Hawthorne effect",

where participants are being observed, impacting on their behaviour (McCambridge,

Witton and Elbourne 2014).

Data collection was done by the same physiotherapist at baseline measurements,

mid-way and at the end in all 3 studies: Castro-Sanchez et al (2011), Kargarfard et al

(2012) and Peterson (2001). This could in affect increase the risk of ascertainment

bias, where results are distorted by knowledge of which each participant is receiving

(Jadad and Enkin. 2007). The systematic review by Heaton (2001) had no clear

mention of how the data collection was undertaken and Rafeeyan et al (2009)

mentioned that the SF-36 questionnaire was done at baseline and at the end of the

research where bias is greater than the degree of improvement; this sort of bias

could be down to interviewer bias (Adams et al. 1999).

Unlike Kargarfard et al (2012) or Rafeeyan et al (2009), there was no further co-

variables involved. However Peterson (2001) during the research paper had running

in conjunction with hydrotherapy land based-exercise programme; whereas Castro-

Sanchez et al (2011) reported ambient music during the experimental group.

This could potentially affect the validity of the studies as other co-variables were

involved in both studies rather specifically looking at the sole impact hydrotherapy

had; as Castro-Sanchez et al (2011) reported "the provision of ambient music may

have contributed to the positive effects of the Ai-Chi sessions, by increasing

motivation and distracting participants".

Outcome measures (OMs) were used in 4 out of 5 of the research papers at

baseline. Peterson (2001) didn't start the baseline at week one but instead at week

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two, although the outcome measure used was a manual muscle test (MMT); this is

valid test widely used for documenting impairments in muscle strength (Bohannon

2005), however the reliability can become questionable as if trying to replicate this

study again MMT lacks sensitivity (Bohannon 2005). Kargarfard et al (2012), Heaton

(2001), Castro-Sanchez et al (2011), Rageeyan et al (2009) included only reliable,

and valid outcome measures such as the MFIS, MSQOL, SF-36 questionnaire, these

are widely used within assessments worldwide. This enables a more reliable

comparability across the remaining 4 research studies allowing them to be

repeatable.

Regarding the danger of thermo-sensitivity, only Petersons study (2001) mentioned

the caution of hydrotherapy on MS patients as they may experience temporary

worsening of clinical signs and neurological symptoms with heat exposure (Davis et

al. 2010). (Poulter 2016. pers.comm.) stated that "I always used to have a negative

view of it with MS patients as so many struggled with heat; and hydrotherapy pools

in hospitals are always very warm. However, I have become more flexible about this

as we have seen a few patients who really enjoyed hydrotherapy and had little

negative impact". Expert opinions are often deemed a lower standard of evidence,

often lacking in external validity. Opinions often stem from experiences which may

not be the consensus from the general population.

By researching the literature and discussing this within the assignment, it is apparent

that there are certain concerns regarding the methodological issues surrounding the

literature when introducing this into clinical practice. Regardless of the issues within

each study; the studies have shown to be effective in improving QOL; it is evident

from reading each article that further research is needed from gold standard pieces

of literature such as RCTs.

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Discussion

Following the critical appraisal of all studies it is evident that there are some

contrasting recommendations regarding the practice of hydrotherapy on multiple

sclerosis patients.

This could potentially be because through the systematic review by Heaton (2001)

where this review looked at all the available resources at that time; concluded that

there is a lack of evidence to support the proposed idea. However as the remaining

articles were more recent than 2001, a new systematic review may be undertaken to

apply a more recent review with more research available by using Rafeeyan et al

(2010), Castro-Sanchez et al (2011) and Kargarfard et al (2012). This could then

hopefully enable a more accurate, conclusive result.

A second reason for inconclusive recommendations may be due to the differing co-

variables during the studies; Castro-Sanchez et al (2011) and Peterson (2001) both

had co-variables such as music or outpatient and inpatient therapy intervention

running alongside hydrotherapy. The music or outpatient and inpatient intervention

could act as a potential impact on the final results, changing whether hydrotherapy

substantially benefitted the final results when the OMs were taken within the 2

studies.

A major attainment from appraising these articles is that the studies undertaken were

in a variety of settings, from a hydrotherapy pool in an acute hospital to the

community setting in a public pool, this is seen as having a greater transferability

within the wider MS population especially for patients who have a higher EDSS with

limited mobility allowing a much greater accessibility level.

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Castro-Sanchez et al (2011) applied an Ai-Chi exercise programme which was

shown to be effective in improving the QOL in MS patients. The programme utilised

a variety of individual exercises such as flexibility, strength and balance. There were

no definitive outcomes from the individual exercises; so it is not clear that applying

these as individual exercises may not be beneficial alone.

Since Peterson (2001) and Castro-Sanchez et al (2011) used co-variables during the

research, results from the studies could be deemed poor for the purpose of the aim

of the assignment.

However regardless of the co-variables it could potentially also act as a positive for

the purpose of further research and treatment by looking into the effect of music or

more RCTs.

Although all articles had different timescales from 6 weeks to 20 weeks, as a

treatment recommendation a hydrotherapy exercise programme somewhere

between 10 to 20 weeks would be beneficial for MS patients, as Peterson (2001)

study required further outpatient intervention to improve the functional ability of the

patient post 6 weeks hydrotherapy work.

Overall, whilst there is evidence supporting the application of hydrotherapy in MS

patients, all of the studies stated that further RCTs would be needed to support this,

with studies comparing between aquatic vs. land based exercises.

Therefore more reliable clinical recommendations could be applied to practice aiding

MS patients in there QOL.

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Summary and recommendations

The main finding from this research is hydrotherapy could potentially help improve

the quality of life in MS patients. Patients QOL did improve from baseline to end of

their programme on various different aspects.

A recommendation suggested was that clinicians and service providers are

recommended to consider aquatic exercise as an effective intervention in the

management of patients with MS (Kargarfard et al. 2012)

As a physiotherapist, you are able to help people living with MS find exercises that

meet their specific needs and abilities (MS Society. 2016). On the whole, junior

physiotherapist are able to apply these findings for not just MS patients but also

musculoskeletal alterations where applicable (Castro-Sanchez et al. 2011).

Drawing the evidence together, as junior physiotherapist evidence suggests that

hydrotherapy doesn't cause any other complications, but just to be aware of

worsening symptoms as MS patients are at greater risk of thermo-sensitivity heat

exhaustion. Through the critical appraisal the findings show that hydrotherapy has

some benefit to MS patients. However implementing these findings with caution for

practice as there are some simple insufficiencies with the evidence provided.

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Appendix 1

Effects of Aquatic Exercise training on fatigue and health-related Quality of Life in Patients with Multiple Sclerosis (Karagardfard et al. 2012)

Author / date / title

Research question / aim

Research approach design

Ethical issues Sample Data collection Data analysis Findings Generalizability / transferability

Implications for practice & usefulness

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

October 2012

Karagarfard M et al

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

Throughout the body of the text - the researchers aim has been clearly justified.

Researchers hypothesized 2 aims

General overview detailed in the abstract

Randomization was done by someone who had no responsibilities by using shuffled, sealed envelopes with group allocations inside each one

Referring neurologists requested to include patients with the Expanded Disability Status Scale (EDSS) ≤ 3.5

Questionnaire was filled out regarding socio-demographic information

Inclusion and exclusion criteria was detailed prior to start of study

Exercise group

Study was approved by the Ethics committee of the university of Isfahan and the Isfahan multiple Sclerosis Society (IMSS)

32 patients were randomly allocated into 2 groups: exercise and control

From the 32 patients started eventually was down to 21 patients

All participants in this study were woman with Relapsing remitting Multiple Sclerosis (RRMS)

All participants were referred onto by the IMSS

Outcome Measures (OM) used Health Related Quality of Life (HRQOL) / Modified Fatigue Impact Scale (MFIS)

The MFIS has used items derived from MS patients on how fatigue impacts on their lives

Reliability and validity has been established by MS patients

Research has stated that the MFIS shouldn't be used as a single over score- however for the purpose of the study it has been used along with the subscales: physical, psychosocial, and cognitive

used per-protocol analysis which included all patients data available at baseline

Sample t tests were used to compare the data of both exercise and control group

Repeated measures analysis of variance (ANOVA) performed on each OM - assumptions of sphericity and homogeneity Mauchly and Levene tests used

If any violation Huynh-Feldt correction was applied

The ANOVE model was

III found were slightly larger P values for limitation emotional score which found a P=.07 for ITT and P=.03 for the complete data

Scores in the MFIS-overall and the subscales had lower scores than the control group at both 4 weeks and 8 weeks and in the exercise group.

However statistically there was not a significant improvement from baseline to 4 weeks.

There was no report of accident, increase fatigue, or adverse

This study was undertaken in a controlled setting in a referral centre of multiple sclerosis society

This research was only done on women

OM used are MS and worldwide based so can be transferred to different settings

Small sample size is this applicable to the general MS population?

Due to the small sample size- could lower the statistical power

They only wanted and EDSS score of ≤ 3.5 and not have an EDSS score of higher of 3.5

Clinicians and service providers are recommended to consider aquatic exercise as an effective intervention in the management of patients with MS

Further research into comparison of aquatic vs land based exercise

Further RCTs are needed in aquatic based setting

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had a program of 8 weeks, 3 times per week for 60 minutes (10 minutes warm-up / 40 minutes exercises / 10 minutes cool-down)

No detail known of the control group

were used as OM

Measures taken at baseline, 4 weeks and 8 weeks.

compared with a mixed model longitudinal data analysis approach

Both approaches yielded identical conclusions

Sensitivity analysis or intention-to-treat (I-I-I) was performed to carry forward for all subjects even those that left the research

Statistical analyses were performed using IBM SPSS (version 20)

effects related to the aquatic exercise

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Hydrotherapy for the Treatment of Pain in People with Multiple Sclerosis: A randomized Controlled Trial (Castro-Sanchez et al. 2012)

Author / date / title

Research question / aim

Research approach / design

Ethical issues Sample Data collection Data analysis Findings Generalizability / transferability

Implications for practice & usefulness

Hydrotherapy for the Treatment of Pain in People with Multiple Sclerosis: A Randomized Controlled Trial

May 2011

Castro-Sanchez et al. 2011

To determine the effectiveness of hydrotherapy to modify pain, quality of life, and other symptoms in MS patients

Within the main body of text and the abstract the aim has been clearly stated

Justification of the study was detailed in the text

Experimental group vs. control group

20 week treatment program, twice a week

Experimental group undertook 20 weeks of Ai-Chi exercise, whilst the control group undertook 20 weeks of abdominal breathing and contraction-relaxation exercises in a treatment room

Experimental group had water and air temperature measured correctly and had ambient music played

Whilst control group had lower water temperature and no music played

Primary and Secondary OMs

Informed consent gained before entering the study in accordance with the Helsinki Declaration

The study was approved by the ethics and research committee of the university of Almeria

MS patients from the Multiple Sclerosis Association of Almeria (AEMA) in Spain

Originally 198 participants, 98 did not meet the criteria, 27 refused participation in the study

Group selection was balanced using a stratification system based on their medication type initially

Patients were randomly assigned by a blinded researcher using a computer generated randomized list.

Study period was from January 1st 2009 till June 30th 2010

Initial screening including medical history and pre-trial questionnaire

Experimental group came in on Monday and Thursday. Control group came in on Tuesday and Fridays

Both groups were evaluated at baseline, 4 weeks and 10 weeks.

Power calculations were carried out on 20 patients after treatment, estimating a minimal sample size of 33 participants per group for a power of 80% and standard deviation (SD) 3.1.

SPSS version 18.0 was used for the data analyses.

Demographical variables were analysed by means of the Kolmogorov-Smirnof test

Independent t-tests were used to compare baseline demographic characteristics between

Twice-weekly 20-week Ai-Chi aquatic exercise program significantly reduced pain levels in MS patients

The benefits of the aqua therapy lasted for 4 to 10 weeks after the end of the program

Results were much greater than control group in therapy room

Spasticity considerably improved by aquatic exercise, because patients are able to perform wider voluntary movements while immersed in water

Positive impact on fatigue

Provision of music may have

Participants may not have been blinded due to being members of the same association (AEMA)

Allowed higher EDSS scores giving a bigger generalizability within MS patients

Both male and female participants eligible

Same physiotherapist for both control and experimental group could have added bias

Did music have that big of an impact on the results in the experimental group

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used,Primary: VAS / PRI / PPI from the McGill Pain Questionnaire (MPQ) and the Roland Morris Disability Questionnaire (RMDQ)

Secondary: VAS / MSIS / MFIS / FSS / Becks Depression Inventory and Barthel Index

Inclusion and exclusion criteria

participants and dropouts and between experimental and control groups (randomisation test)2x4 repeated-measures analysis of variance (ANOVA)

Students' t-test for paired measures was used to determine the effectiveness of treatments.

P<0.05 was considered significant in all tests

helped the Ai-Chi sessions - used as a distraction and motivation from any discomfort experienced

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Case Report: Exercise in 94oF Water for a Patient with Multiple Sclerosis (Peterson 2001)

Did the study address a clearly focused question / issue?

Is the research method (study design) appropriate for answering the research question?

Are both the setting and the subject's representative with regard to the population to which the findings will be referred?

Is the researcher's perspective clearly described and taken into account?

Are the methods for collecting data clearly described?

Are the methods for analysing the data likely to be valid and reliable? Are quality control measures used?

Was the analysis repeated by more than one researcher to ensure reliability?

Are the results credible, and if so, are they relevant for practice?

Are the conclusions drawn justified by the results?

Are the findings of the study transferable to other settings?

Clear link between the title and the background and purpose of the study

The studies main aim is to look at the purpose of this case report with a patient who has Multiple Sclerosis (MS) in aquatic therapy in 94oF water

Plenty of justification for the study described in the introduction section

Aqua therapy sessions were undertaken for specifically 6 weeks - the patient was also undertaking during this time inpatient rehabilitation and outpatient physical therapy

Therapeutic exercise consisted of functional mobility training 1 ½ hours a day (Mon - Fri) and ½ hour on Saturday

Aqua therapy was only initiated during the second week as prescribed by the physician

Outcome Measures (OM) used were Manual muscle

No explanation of where the study was undertaken - however presuming that it was undertaken in a hydrotherapy pool in a hospital

A gauge in the water was used to measure the temperature of the water twice daily.

This trial was approved by the physician specialising in disabilities with lesions of the spinal cord

This patient was 33 years old and no other health related problems apart from MS

Not as such as a perspective, but raised if temperature was raised by 2oC

Throughout the case study, it is very much patient orientated rather than the end of the study during the discussion the researcher perspective was described at what she believed.

Used Patient Evaluation Conference System (PECS) and MMT

Scores by PECS were compared with scores obtained from the Functional Independence Measure

Patients' blood pressure, heart rate and perceived exertion was measured by the Borg scale

PECS definitions was developed by a multidisciplinary team (MDT)

All OM's used during this test are reliable tests undertaken

Same Physiotherapist for both land and aqua based work to keep reliability equal

Not particularly - during the aquatic exercise programme this patient was having land based therapy and inpatient rehabilitation

Unclear as to whether the 94oF water made a difference

During some hydrotherapy sessions the patient presented with elevated blood pressure - prior to these morning sessions the patient had some Occupational Therapy (OT) work.

Some of the OM's used had to rely on patient

Not necessarily, as the study didn't just specifically look at hydrotherapy, but also land based exercises in conjunction with aqua therapy

It is hard to determine how reliable the results are in respect to the aim of the study.

Probably not due to the nature of maintaining the pool temperature at such a precise temperature

Especially when other groups may need the pool usage

Even more so when the results are unclear as to whether the pool temperature made the difference in improving the functionality.

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testing (MMT)

Borg scale to understand the patients perceived exertion prior to starting

judgement - e.g. BORG score.

The results were incomplete after 6 weeks as the patient didn't manage to reach her end goal and had to continue with land-based strengthening work.

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Effect of aquatic exercise on the multiple sclerosis patients' quality of life (Rafeeyan et al. 2009)

Author / date / title

Research question / aim

Research Approach / design

Ethical issues Sample Data collection Data analysis Findings Generalizability / transferability

Implications for practice & usefulness

Effect of aquatic exercise on the multiple sclerosis patients' quality of life

December 2009

Rafeeyan et al. 2009

Aim explained in the abstract and justified well in the main body of the text

Research question has been researched previously by various different researchers

Research question deems to be backing up further researches previously done rather than creating a new main aim

Semi experimental, pre-test post-test, prospective single group study.

SF-36 questionnaire (QOL) questionnaire - approval from the Tehran University elites for validity and reliability was 0.87 for validity and 0.89 for reliability

Independent variable clearly defined as aquatic exercise

Dependant variable also clearly defined as Quality of Life (QOL)

Grouped by their residency

Pools used were in public pools in 2 different parts of the city

Informed consent were signed by the 34 participants

Approval stated, however unclear as to where the approval had come from. This was stated during the methods section and acknowledgement section of the text

Study period 2005-2007

Simple random sampling from the patients in MS Society in Isfahan

40 were eligible - from the 40, 34 were chosen who were "eagerly wanting to take part"

Out of the 34 patients, 22 patients completed the research through

Mean age of participants were 32.86

Due to the highest point of MS prevalence is between 20-40 - findings coordinate with other scientific research

SF-26 questionnaire measuring QOL which this questionnaire consisted of 9 different components

SF-36 scores were completed at the end of the program

Paired with the t test via SPSS software version 10

The paired t test showed significant differences in various aspects of QOL before and after aquatic exercise

8/9 different categories showed supposed significant difference

No P value used to identify the significant value of each score

The findings found that all aspects of QOL had improved

Aquatic exercise has beneficial values in the MS patients lives

The main aim of the research was met due to the scores is "definitely certified significantly"

From the results of this study training swimmers so patients getting referred to any swimming pool can benefit from this program

Study was completed in Iran - lower levels of generalizability

The study population was random sampling, but study never mentioned the ratio of (males: females)

Small study size - does this make it applicable to the population demographic group?

Population age range was that of the highest prevalence of MS patients

Study was done in public swimming pools making it accessible for others to use the facilities

Randomised sampling helping to reduce the sample bias

Single group study, this gives us a better idea of the specific effects of whether aquatic exercise is beneficial in MS patients QOL - however there is no comparison group to compare whether it is the best form of treatment

Results states it showed significant differences in "various aspects" whereas in the discussion section it reports it has "enhanced all aspects" - unclear results

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Pools were available from 7-8AM for patients with supervision of trained specialist

Training programme was given to trainers - these were approved by a consultant physician

Patients took part in 1 our sessions three days a week for 1 month

Clearly stated inclusion and exclusion criteria

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The effect of aquatic exercise on body function and structure, activity and participation in persons with multiple sclerosis (Heaton J. 2013)

Author / date / title

Research question / aim

Research Approach / design

Ethical issues Sample Data collection Data analysis Findings Generalizability / transferability

Implications for practice & usefulness

The effect of aquatic exercise on body function and structure, activity and participation in persons with multiple sclerosis

2013

(Heaton J. 2013)

Aim of this systematic review has been clearly stated in the main body of text

Justification as to why this literature review has been conducted to enable and aid physiotherapists' clinical decision making when recommending exercise to persons with MS

This is only the 2nd lit review related to this topic since 1995 - only to the authors knowledge

Only quantitative studies of experimental design were eligible for inclusion

Aquatic group classes in the community were accepted - studies in a patient-therapy hydrotherapy in hospital setting were not includedOutcomes that had the potential to influence participants' body structure and function, activity and participation was included - only if valid and reliable measures were used.

No ethical issues were clearly mentioned within this literature review

Participants who had a EDSS score of 1.0 to 6.5 enabled a wider base of degree of disability

Participants who have MS were accepted into this study.

Overall 63 participants were included

Age range 23-77

EDSS score was not reported on all studies however they ranged between 1.5 to 8.0

Electronic search was carried out between 1991-2011 due to a lack of current research

Manuel online journal "Multiple Sclerosis"

Therapists in MS 2011 and MS Society 2011

Methodological quality assessment was used - this was used as a single tool to enable consistency and ease comparison

Scoring 20 or more were included

20 studies were retrieved from the literature searches - out of those 20, 15 were included

Although the studies which were discarded they were still included as they had the potential to build on the limited knowledge base. Also highlighted the need for further research

Majority of the evidence has been shown to be undertaken in gym environment

findings shown that exercise adherence has been relatively poor with people with MS as being able to cater to all age ranges especially within this systematic review of ages between 23-77

Evidence for aquatic exercise however is limited to a few studies with a high risk of bias which has highlighted the need for further research.

Comparing other LTNC to this study would have given a wider scope to the study.

Due to the broad range of ages partaking within this study the findings of this study could be used within the wider population

Difference between the level of disability of EDSS score enables this to applicable to a broader range of MS patients

As the interventions used were in a community setting - you could argue the level of accessibility to some of the patients and the level of cost, some patients may not be able to afford the access to the community pool

Whereas having access to a patient-therapist

Using the WHO ICF model and applying the different themes - numerous inconclusive thoughts regarding the research stating further research is required

Had a broad range of different aspects which MS patients can become affected - enabling a fuller picture of different aspects of QOL which may be affected.

Some studies have been duplicated by the same researcher/team and repeated again - may have some bias due to the inconclusive evidence the first attempt

Author had

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led pool could be more effective and the level of compliance.

limited word count so unable to approach this literature review with further research

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Appendix 2

(Multiple Sclerosis Society. no date)

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Database Boolean logic Search terms Date Inclusion

criteriaArticles found

PubMed AND

MS, multiple sclerosis, chronic progressive disease, neurology, swimming, QOL, quality of life

0

MEDLINE ANDMS, multiple sclerosis, quality of life

0

MEDLINE ANDpool-therapy, multiple sclerosis

1

MEDLINESmart text Aqua-therapy,

multiple sclerosis

1

No Smart text 0

CINAHL AND

MS, multiple sclerosis, LTNC, hydro*, swim*, pool, aerobic, fitness, quality of life

4

CINAHLOR / (linked to Google scholar)

MS, multiple sclerosis, hydro*, quality of life

2006-2016

multiple sclerosis AND hydrotherapy

5

Google scholar OR / AND

MS, Multiple sclerosis, hydrotherapy, hydro*, swimming, quality of life

2006-2016 4,990

Appendix 3

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Appendix 4

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Appendix 5

Appraisal questions Yes Can't tell No

1. Did the study address a clearly focused question/ issue?

2. Is the research method (study design) appropriate for answering the research question?

3. Are both the settting and the subjects representative with regard to the population to which the findings will be reffered

4. Is the researcher's perspective clearly described and taken into account?

5. Are the methods for collecting data clearly described?

6. Are the methods for collecting data clearly described?

7. Was the analysis repeated by more than one researcher to ensure reliability?

8. Are the results credible, and if so, are they relevant for practice?

9. Are the conclusions drawn justified by the results?

10. Are the findings of the study transferable to other settings?

Questions needed when appraising a case report

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Questions to help make sense of the review Yes Can't tell No

1. Did the review address a clearly focused question?

2. Did the authors look for the right type of papers?

3. Did you think all the important, relevant studies were included?

4. Did the review's authors do enough to assess the quality of the included studies?

5. IF the results of the review have been combined, was it reasonable to do so?

6. What were the the overall results of the review?

7. How precise are the results?

8. Can the results be applied to the local population?

9. Were all important outcomes considered?

10. Are the benefits worth the harms and costs?

Appendix 6

Questions needed when appraising a systematic review

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Appendix 7

Questions needed when appraising the report of randomised controlled trial

Screening questions Yes Can't tell No

1. Did the trial address a clearly focused issue?

2. Was the assignment of patients to treatments randomised?

3. Were patients, health workers and study personnel blinded?

4. Were groups similar at the start of the trial?

5. Aside from the experimental intervention, were the groups treated equally?

6. Were all of the patients who enterered the trial properly accounted for at its conclusion?

7. How large was the treatment effect?

8. How precise was the estimate of the treatment effect?

9. Can the results be applied in your context? (or local population?)

10. Were all clinically important outcomes considered?

11. Are the benefits worth the harms and costs?