Background and Purpose. The purpose of this case report is to describe the examination, intervention, and outcome of a patient with multiple sclerosis (MS) who participated in a comprehensive rehabilitation program that included aquatic therapy with a pool temperature of 94°F. There are few descriptions of aquatic exercise programs on muscle force, exercise tolerance, and functional outcomes in individuals with MS, and most authors recommend a water temperature of less than 85°F to prevent an exacerbation of symptoms. Description. The patient was a 33-year-old woman. Before, during, and after the aquatic program, she was monitored for body temperature, heart rate, blood pressure, and perceived exertion. She was also assessed for muscle force and functional abilities. Outcomes. The patient did not experience heat sensitivity or fatigue throughout the program, and her manual muscle test grades and mobility improved. Discussion. This patient's participation in aquatic therapy, in conjunction with land-based interventions, may have been associated with the improvement in functional abilities.
Multiple sclerosis (MS) is a chronic demyelinating disease that results in lesions in the white matter of the central nervous system (CNS). Common impairments are weakness and fatigue.1–4 Fatigue and a tendency to have a worsening in neurological function when exposed to elevated external and internal temperatures commonly occur in individuals with MS.5–8 Physical therapists, therefore, should develop therapeutic programs that progress patients to the desired outcomes while minimizing the negative effects of fatigue and sensitivity to heat.
Fatigue is a common symptom in MS,1–6,9 affecting up to 87% of patients.1 Freal et al2 sent a questionnaire to individuals with MS who had indicated in a previous study that they experienced fatigue. Ninety percent of the respondents described their fatigue as “tiredness or the need to rest,” and 48% of the respondents described their fatigue as “a worsening of symptoms.” Seventy-one percent of the respondents indicated that vigorous exercise made their fatigue worse, whereas 57% believed that moderate exercise helped to ameliorate fatigue. Krupp et al1 reported that fatigue was more frequent and more severe among patients with MS compared with age-matched subjects without MS.
Individuals with MS may also experience sensitivity to heat from external and internal sources.7 Heat sensitivity results in an increase of neurological symptoms.9 Common neurological symptoms include worsened oculomotor or visual disturbances, increased ataxia in the lower extremities,6 and weakness.7 About 80% of patients with MS deteriorate when heated.7 A rise in temperature is thought to decrease nerve conduction in demyelinated fibers; the greater the demyelinization, the greater the conduction loss.7,10–12 Ninety percent of the respondents in the study by Freal et al2 reported that their fatigue was made worse by warmer temperatures.
Conversely, reports have described exposure to cold as resulting in improved mobility and a reversal of symptoms.7 Chiara et al,13 however, found that a cold bath (24°C) produced no difference in oxygen consumption, no immediate change in perceived exertion during ambulation, and an increase in reflex activity in individuals with mild to moderate MS.
Some authors5–8 have reported that the change of body temperature necessary for a change in MS symptoms varies among individuals. A temperature change of as little as 0.18°F to as much as 4.14°F has been shown to exacerbate symptoms of MS.6
The American Physical Therapy Association (APTA) has established preferred practice patterns that provide a foundation for the physical therapy management of patients, including those with MS.14 Although the preferred practice patterns provide a guide, physical therapists need to manage patients individually because people with MS vary in their sensitivity to heat and their ability to tolerate exercise. The variability of heat sensitivity and fatigue associated with MS requires therapists to monitor responses to exercise and prescribe a therapeutic program based on an individual's responses. Therapists should watch for a decrease in functional status, a decreased ability to perform exercises, or extreme fatigue after therapy sessions. Costello et al9 recommended assessing a person's temperature sensitivity prior to beginning exercise. Therapists also should ask patients about their fatigue and how they respond to an increase in temperature. Costello et al recommended initially obtaining this information through patient interview to identify the individual's awareness of his or her sensitivity to temperature. In addition, assessment should be done with tympanic membrane thermometers when the individual performs vigorous activities of moderate to high intensity. The measurements should be taken prior to, intermittently throughout, and after exercise.
One intervention that may be beneficial for an individual with MS, which is included in APTA's preferred practice patterns,14 is an aquatic therapy program. The buoyancy and viscosity of water can assist movements as well as allow for exercise to increase muscle force. Buoyancy is the force opposite to gravity, which can assist a person in attaining full active range of motion using muscles that may be too weak to perform the same motion on land. Aquatic therapy may begin with buoyancy-assisted exercises, in which the buoyant force assists the movement toward the water's surface. Exercise then can be progressed to buoyancy-resisted activities by having the movement directed away from the water's surface. Using a floatation device and directing the movement away from the surface of the water can further challenge the muscles by creating floatation resistance.
Norm and Hanson15 recommended that the water temperature of a therapeutic pool should be between 92°F and 94°F to promote muscular relaxation, decrease muscle spasm and pain sensitivity, and increase ease of joint movement and peripheral circulation, but there is no research to indicate whether the use of this temperature really is beneficial. Whitlatch and Adema16 concluded that a 12-week exercise program conducted in a 94°F therapeutic pool produced improvements in range of motion, muscle force, and walking speed and a decrease in pain in a group of 56 community-dwelling individuals aged 42 to 94 years.
Although research about the effect of an aquatic exercise program on individuals with MS is limited, some authors17–19 have recommended water temperatures below 85°F for people with MS. Woods18 recommended low-repetition and low-resistance exercises and a temperature range of 83°F to 85°F to minimize overheating during the program. Woods reported on 2 cases. Patient 1 had used a wheelchair for 2½ years, and patient 2 was ambulatory with 2 straight canes. The exercise program for patient 1 consisted of passive stretching, active-resisted exercises, and standing or ambulation as tolerated. The swimming distance for patient 1 improved, but the authors did not describe functional status other than reporting that the progression of symptoms was minimal. The focus of aquatic therapy for patient 2 was ambulation and increasing lower-extremity (LE) muscle force. Although this patient's aquatic walking distance increased, the patient discontinued treatment due to exacerbation of symptoms. Patient 2 resumed an aquatic program after 1 year, was able to walk only 1 or 2 steps, and had some increase muscle force of upper limbs, but little change in the lower limbs.
Gehlsen et al19 examined the effects of an aquatic program on muscle force, endurance, work, and power in patients with MS. The water temperature was between 77°F and 81.5°F. The selection criteria required the subjects be ambulatory and their disease to be in remission. Ten subjects participated in a 10-week aquatic exercise program consisting of freestyle swimming and shallow-water calisthenics. The authors concluded that an aquatic exercise program for individuals with MS is not harmful to the muscular force and endurance. The results indicated that some positive changes in muscle force can be expected from an aquatic exercise program.
Gattenby20 measured peak knee flexor and extensor torques of 4 individuals with MS who participated in hydrotherapy with the water temperature at 94°F. The subjects were participating in the special physical education and recreation therapy program in hydrotherapy at Washington State University. Activities they did while in water included stretching, massage, and resistance exercises of the major muscle groups once a week for 2 hours for 21 weeks. Two individuals had a decrease in peak torque, and 2 individuals had an increase in peak torque. The author reported that the 2 individuals whose peak torque declined received medical treatment, whereas the 2 individuals who improved did not receive medical treatment during the experimental period. The author reported that the medical treatment may have influenced the decrease; 1 individual had prostate surgery, and 1 individual received chemotherapy. Gattenby concluded that a hydrotherapy program has the potential to increase torque of the knee extensors and flexors. The body temperature of these individuals was not recorded at any point in the study. These 3 studies18–20 provided information on the use of aquatic therapy with patients with MS and gave me an avenue to explore further as a treatment option with my patient.
The purpose of this case report is to describe the use of aquatic therapy in a warm medium for an individual with MS in conjunction with inpatient rehabilitation and a subsequent outpatient physical therapy program. The report is different from most reports of aquatic therapy with patients with MS because the water temperature was 94°F and the patient was monitored while she was in the warm medium. Although the water temperature in Gattenby's study was also 94°F, the duration of sessions was 2 hours compared with the 45 minutes that I used, a duration that is more like what can occur in practice. The water temperature of the pool was selected to promote muscular relaxation, decrease pain, and increase range of motion.15,16 It was not feasible to adjust the water temperature of the pool to accommodate other diagnoses. I felt that aquatic therapy with a water temperature of 94°F was worth attempting for the benefits of water exercise described while closely monitoring the patient's response to the warm environment.
The patient was a 33-year-old woman who had been diagnosed with MS 3 years prior to this episode of care. She was married with 2 children and worked part-time as a preschool teacher. Her first exacerbation, optic neuritis, occurred 3 years previously, and she had been taking Betaseron* for 2 years. She was admitted to an acute care hospital with a diagnosis of abdominal cellulitis unrelated to MS and was treated with an antibiotic. Magnetic resonance imaging showed lesions on the left thalamus, corpus callosum, and C5-T8. Two days after admission, she developed a fever, paraparesis, and bowel/bladder incontinence. A week later, she was admitted to an inpatient rehabilitation program with a diagnosis of C6 quadriplegia secondary to an exacerbation of MS. Initial medications included nortriptyline,† heparin,‡ Bactrim,§ and Medrol.‖ She was no longer taking Betaseron. In addition to physical therapy, the patient received occupational therapy, nursing care, psychological counseling, pastoral care, and therapeutic recreation. The goal during this admission was to return her to her functional status prior to the exacerbation. The patient was independent for community-level ambulation and activities of daily living.
The patient's major impairment was decreased LE muscle force with a manual muscle test (MMT) grade of 0, except for trace knee flexion and ankle plantar flexion on the left. Her upper extremity (UE) MMT grades were 4 throughout the right side, 4− at the left shoulder, and 3+ at the left elbow and wrist. I used the MMT grading system described by Kendall et al.21 Wadsworth et al22 reported that a paired t test revealed that no test-retest mean differences occurred during MMT for all muscle groups tested (ie, wrist extensors, elbow extensors, shoulder abductors, hip flexors, and knee flexors) (P >.05). They concluded that MMT for shoulder abduction, hip flexion, and knee flexion demonstrated good intrarater reliability. Their results also reflected the fact that MMT is less discriminating than muscle testing done with a handheld dynamometer in identifying differences in muscle force. The attending physician's assessment of deep tendon reflexes was 2+ for the right patella and left Achilles tendon reflexes and 1+ for the left patella and right Achilles tendon reflexes. The patient's functional limitations included requiring maximal assistance to transfer from a wheelchair to a bed with a sliding board, inability to walk, and requiring maximal assistance for bed mobility. Maximal assistance was defined as the patient being able to assist with up to 25% of the activity. The projected level of improvement for this patient was determined to be independence with bed mobility and wheelchair transfers. This prognosis was based on the patient's UE MMT grades, and a plan of care was developed to achieve these outcomes. An ambulation goal was not set initially because ambulation would require muscle recovery in the LEs. Most of the measurements obtained from this patient have questionable reliability, but the measures are widely used in practice.
The amount of time to reach the optimal level of improvement was set at 6 weeks. Table 1 shows the patient's functional status during inpatient rehabilitation and outpatient physical therapy, as measured by the Patient Evaluation Conference System (PECS).23 The PECS was developed by a multidisciplinary team to track functional rehabilitation status and goals among medical, physical, psychological, and social behaviors.23 The grading system and definitions used in the PECS are shown in the Appendix. All terms used to describe the patient's level of dependence in this report are based on the PECS definitions. Silverstein et al24 and Fisher et al25 reported correlations of .93 and .91, respectively, when comparing the PECS scores and scores obtained with the Functional Independence Measure. Correlations for interrater reliability ranged from .68 to .80 within various disciplines.23 Table 2 shows the MMT grades for the patient's LEs during her rehabilitation. The same physical therapist (CP) performed all MMT.
The initial interventions consisted of therapeutic exercise and functional mobility training 1½ hours a day Monday through Friday and a half hour on Saturday. The same therapist (CP) conducted the interventions. The therapeutic exercise included stretching of the LE muscles and sitting balance training with upright posture. The initial strengthening exercises were performed in positions in which the effect of gravity was minimal, with attempts to elicit contractions by using facilitatory techniques of quick stretch and tapping. The initial exercises were performed on all muscle groups of the LEs. Once muscle contractions were palpated, exercises progressed to active-assisted, active, and finally resisted exercises. A standing frame was also used with the patient, who attempted LE muscle contractions while standing upright. She was instructed to attempt squeezing the gluteal and quadriceps femoris muscles. The standing frame raised the patient from a sitting position to a standing position with anterior support at the knees and lower abdomen and posterior support from midthigh to shoulders. Functional mobility training included transfer training, bed mobility, and wheelchair mobility.
Aquatic therapy was initiated during the second week of rehabilitation, as prescribed by the attending physician. The attending physician was a physiatrist specializing in disabilities with lesions of the spinal cord. The physician regularly prescribes aquatic therapy for people with spinal cord lesions for the purposes of increasing range of motion and increasing muscle force. The possibility of the warm water causing fatigue or an increase in the patient's symptoms was discussed with the patient and the attending physician. The physician thought that the potential benefit of exercising in the therapeutic pool was worth a trial because the patient was young and had no health problems other than MS. The physical therapist, the physician, and the patient agreed to initiate a trial of aquatic therapy while the patient was monitored for adverse effects. The therapist and the physician decided that the patient would be removed from the water immediately if she reported feeling fatigued or could not tolerate the exercise or if her body temperature increased by more than 2°F from the initial reading. Two degrees was decided on because it is in the middle of the range of body temperature increases that is thought to exacerbate symptoms of MS.6 The aquatic program would be terminated if the patient experienced a decline in her current functional status or muscle force either during or after the aquatic exercises.
The patient said that she understood the risks described and agreed to participate in 45-minute aquatic sessions 2 times per week throughout her inpatient and outpatient rehabilitation. The aquatic sessions were scheduled at 8:30 am and were conducted by the same physical therapist (CP). The patient entered and exited the pool using a lift until the first week of outpatient physical therapy when she was able to negotiate the stairs. The pool temperature was set at 94°F. A gauge in the water measured the temperature, which was recorded twice daily. The patient's blood pressure, heart rate (radial pulse), perceived exertion as measured by the Borg scale,26,27 and tympanic temperature were monitored upon entering the pool, in the middle of the pool session, and upon exiting the pool (Tab. 3). Measurements were taken using the First Temp Genius#,28,29 for close monitoring of the patient's response to exercising in warm water. The First Temp Genius measures the temperature through the tympanic membrane. Most authors report monitoring temperature only before and after activities.7 The patient's head was never immersed in the water during the aquatic sessions, which minimized the variability of the tympanic temperature. Smith and Fehling28 claimed good intertester reliability using the First Temp Genius, reporting a correlation coefficient of .81. The Figure shows the temperature changes recorded during each aquatic session. The patient was also monitored in the afternoon of the aquatic sessions by the same physical therapist (CP) for any changes in impairments using MMT to monitor muscle force.21 Functional limitations were monitored using the PECS.23–25
At the initiation of aquatic therapy (week 2), the patient's functional abilities had already improved. She could transfer with a sliding board using standby assistance. She could stand when sitting between the parallel bars, with moderate assistance and a knee strap secured on the parallel bars to prevent the knees from buckling. Moderate assistance was defined as the patient being able to assist with 25% to 75% of the activity. She used primarily UE muscles to hold the standing position for 2 to 3 minutes. Initial aquatic interventions consisted of bilateral LE buoyancy-assisted and floatation-assisted exercises. The patient performed side-lying hip flexion and extension, with an inner tube around her waist, the therapist keeping the knee flexed to 90 degrees, and a floatation device strapped on the foot. In the same position, she performed knee flexion and knee extension while the therapist maintained the hip in a neutral position. After doing the exercises on each side, she turned to a supine position, with an inner tube under her arms and her head resting on the inner tube, a waist float at the hips, and a foot float. In this position, the patient did hip abduction and adduction exercises. All of the described exercises were performed bilaterally. She initially did 2 sets of exercises at 10 repetitions each, with rest between sets. When she could do 2 sets of exercises at 10 repetitions each without rest, the number of repetitions was increased, and she then did 2 sets of exercises at 20 repetitions each. The patient rested by sitting on a step in waist-high water 3 or 4 times throughout each aquatic session.
Resisted exercises were initiated when the patient could do 20 repetitions twice without rest. Buoyancy-resisted and floatation-resisted exercises were initiated during week 4. The patient did side-lying abduction of the LE that was closest to the bottom of the pool to achieve buoyancy-resisted exercises. The patient moved into knee flexion and hip extension in a supine position for buoyancy resistance. She also did hip flexion and knee extension exercises in a prone position by holding on to the side of the pool. These exercises progressed from buoyancy-resisted exercises to floatation-resisted exercises by adding a foot float when the patient could do 2 sets of buoyancy-resisted exercises at 10 repetitions each.
During week 4, the patient started standing in waist-high water with UE support at the side of the pool and the therapist assisting her with hip extension and knee extension. Ambulation in waist-high water was initiated during week 6. She was able to ambulate in waist-high water for 7.6 m (25 ft) with the therapist was positioned in front of her with the patient's hands resting on the therapist's shoulders for support and the therapist's hands supporting the patient's hips. She experienced some difficulty, however, pushing her right LE through the buoyancy of the water and extending her knee so that her foot could contact the bottom of the pool. At this time, the MMT grades were 2 for the right hip extensors and 3 for the knee extensors. The patient did not experience this difficulty on land, possibly due to gravity assisting the movement out of the water. In the water, the hip and knee extensors may not have been able to overcome the buoyancy. This problem was remedied by adding a 0.45-kg (1-lb) weight to the right ankle during water ambulation.
The patient was discharged from the inpatient rehabilitation program after 6 weeks. She was able to perform one-half stand-pivot transfers and bed mobility independently. She could do stand-pivot transfers and ambulate 30.5 m (100 ft) with a rolling walker and bilateral ankle-foot orthoses (AFOs) with minimal assistance. Minimal assistance was defined as the patient being able to assist with 75% or more of the activity. Negotiating 4 stairs using bilateral rails and bilateral AFOs required minimal assistance. She exceeded the desired outcomes identified during the initial examination.
The patient continued with aquatic therapy as an outpatient for 5 sessions over a 2-week period. During the first week of outpatient aquatic therapy, she was able to ambulate in waist-high water without UE support but with minimal assistance. On land, she initiated ambulation with bilateral Lofstrand crutches and bilateral AFOs, requiring minimal assistance. During the last session of aquatic therapy, she was able to ambulate in waist-high water with only intermittent contact guard assistance. On land, she walked 30.5 to 45.7 m (100–150 ft) with a straight cane, right AFO, and contact guard assistance. Because of these abilities, the patient and the therapist decided to focus on land-based interventions to reach an independent level of ambulation in the few remaining sessions of outpatient physical therapy.
The patient continued outpatient physical therapy 2 times a week for another 1½ weeks. The interventions in the last 3 sessions focused on progression of gait without assistive devices, upgrading the home exercise program, and standing balance activities. At the time of discharge, she was able to stand-pivot transfer to a wheelchair, ambulate with a straight cane 152.4 m (500 ft), and negotiate 10 stairs with one rail independently. The last contact with the patient was approximately 1 year ago. She reported that she had resumed working part-time and was ambulatory without assistive devices.
This patient was able to tolerate a warmer water temperature (94°F) than traditionally used for people with MS.17–19 Aquatic therapy at a warm temperature in a pool with warm water did not result in a decrease in the patient's functional limitations or make her impairments worse, and she did not experience heat sensitivity or fatigue. On the contrary, functional mobility and patient satisfaction improved following aquatic exercises in warm water, in conjunction with a land-based program.
The aquatic program was designed to allow the patient to actively move her LEs through a full range of motion before she was able to do so on land. I believe that this program assisted in the strengthening of the muscles through the full range of motion. The buoyancy of the water, creating weight relief,15,30 helped her to ambulate in waist-high water with less assistance and no orthoses before being able to achieve this on land. Additionally, experiencing the success of walking without devices in the water appeared to be an important motivating factor for this patient. The patient was able to ambulate successfully in waist-high water, possibly due to the buoyancy and density of the water facilitating the required movements. The resistance of the water, in my opinion, also allowed the patient more time to react to the movements and adjust as necessary.
The interventions during aquatic therapy consisted of LE exercises, standing, and ambulation in waist-high water. The activities were chosen in an effort to focus the interventions on the underlying impairments of muscle weakness and to decrease the patient's functional limitations, specifically during walking. I decided not to have the patient do traditional swimming strokes, where her body would be more immersed while performing a strenuous activity compared with the positions in which she performed the exercises. Moreover, I believe swimming strokes would not decrease functional limitations. Whether functional training in water had a direct effect on performance of land activities could not be determined. Research is needed to determine a causal relationship.
The attending physician and I decided prior to initiating aquatic therapy that if the patient's temperature increased more than 2.0°F, the aquatic session would end. The rest periods were provided to lessen the risk of overheating. The greatest temperature change throughout an aquatic session was 1.5°F, with the exception of one change of 2.3°F. On this day (session 1 of week 3), the starting temperature was below normal (94.9°F), with an ending temperature of 97.2°F. Aquatic therapy continued, however, because the starting temperature was low and the patient's perceived exertion rating was very, very light exertion, according to the Borg scale.26,27
Despite receiving aquatic therapy at the same time of the day (8:30 am), the patient had elevated initial temperatures (100.7°F, 100.3°F, 100.6°F) during the last 3 outpatient aquatic sessions. The reason for these high temperatures was unclear; however, the patient had a 45-minute session of occupational therapy immediately prior to these aquatic sessions, which may have contributed to the elevated temperatures.
The patient did not experience a decline in functional status despite an increase in body temperature during each aquatic session. This individual may have decreased heat sensitivity compared with other individuals with MS, or her temperature increase may not have reached the point that it would exacerbate the symptoms of MS.
The level of the patient's perceived exertion remained relatively low throughout all aquatic sessions, which may have been due to the selection of interventions used during the aquatic sessions. The rest periods throughout each 45-minute session also may have prevented the perceived exertion from being rated higher. During the aquatic session in which the patient's temperature rose 1.5°F, her perceived exertion rating was 6 to 7 throughout the session, which is defined as very, very light exertion.26,27 This rating is in contrast to the patient's highest perceived exertion rating of 12, defined as somewhat hard exertion,26,27 which was associated with a temperature increase of 1.0°F.
The patient's heart rate and blood pressure changed minimally during aquatic sessions. This relatively stable state may have been due to her age, absence of cardiovascular disease, and low strenuous level of aquatic activities.
For patients with MS, I believe that aquatic therapy with water temperatures over 85°F should be used with caution. Each patient's sensitivity to heat needs to be considered before attempting therapy in water warmer than 85°F. The success this patient had while undergoing remission of her disease process, however, suggests that physical therapists can consider water temperatures greater than 85°F when lowering the water temperature of a therapeutic pool is not feasible (as in this case).
This case poses questions for future research: When a cooler medium is not available, can other patients with MS tolerate water temperatures greater than 85°F? Is the patient's report of heat sensitivity and perceived exertion an indicator of tolerance or intolerance in an aquatic program with water temperatures greater than 85°F? Can people with MS tolerate a warmer water temperature with low-intensity exercise and have positive outcomes?
The author thanks Dr Vasilios Stambolis for providing initial guidance on commencing an aquatic program with this patient; Tim Hanke, PT, MS, for continual guidance, support, and encouragement throughout the project; and the patient for allowing the author the opportunity to present this important information.
↵* Berlex Laboratories, 15049 San Pablo Ave, Richmond, CA 94804.
↵† Novartis Pharmaceutical Corp, 59 Rt 10 E, Hanover Park, NJ 07936.
↵‡ Wyeth-Ayerst Laboratories, PO Box 8299, Philadelphia, PA 19101.
↵§ Roche Pharmaceuticals, 340 Kingsland St, Nutley, NJ 07110.
↵‖ Duramed Pharmaceuticals, 5040 Duramed Dr, Cincinnati, OH 45213.
↵# Intelligent Medical Systems, 2233 Faraday Ave, Carlsbad, CA 92008.
- Received September 12, 1999.
- Accepted October 24, 2000.
- Physical Therapy