Presentation by Tania Burge

1. Community Based Cool Water
Aqua-therapy for People with MS
Tania Burge MS Specialist Physiotherapist
Bristol & Avon MS Clinical Centre, North Bristol NHS Trust

2. Disclosures
 Sanofi Genzyme
 MedDay Pharmaceuticals

3. Background
 People with MS, EDSS >5 resist challenging their balance
 Aqua-therapy utilises the buoyancy and resistance properties of
water
 PwMS are commonly advised to go swimming but rarely go
independently
 An exercise training programme in water may be beneficial to
maintain and improve function during land based everyday
activities (Marinho-Buzelli et al 2015)

4. Aims
 To develop a new service delivered at a local leisure centre to enable
PwMS to exercise safely in cooler water (290) under the supervision of
Specialist Physiotherapist and assisting staff
 To improve balance in PwMS who find land based rehabilitation
difficult
 To enable participants to continue to attend and independently
exercise at a suitable pool to self-manage their long-term condition
 To train leisure centre staff to have a specialist knowledge of MS to
enhance their ability to treat PwMS to maximise their function

5. Key considerations for partnership
working
 Maintaining NHS standards in a community setting
 Information governance (data storage, confidentiality)
 Safe guarding (vulnerable adults)
 Professional responsibility and roles (insurance, risk
assessments for the aqua session and individual patients risk
assessment)

6. Methods
 Referrals: from the Specialist MS Physiotherapy service at BrAMS
Inclusion criteria:
 Ambulant EDSS 6-7.5
 Balance problems
 Medically stable
 Continent (bladder and bowel)
 Able to follow instructions
 Attend ≥ 4 sessions (5 session course)

7. Outcome measures
(pre and post course)
Outcome measure Description
Berg Balance Scale
(BBS)
14 items test 0-4 (0= can’t do,
4= normal performance)
Timed 10m walk
(10mTW)
Time (m/sec) and cadence
Timed Get up and Go
(TUG)
Dynamic balance. Sit to stand,
walk 3m/turn return and resit
ABC Balance confidence
scale (ABC)
Self reported balance capability
of 16 daily activities
Multiple Sclerosis Impact
Scale-29
Impact score physical
/psychological Cattaneo et al 2006
Hobart et al 2001

8. Patient pool contract
Agreement of the following rules when entering the pool:
 Drink and eat breakfast before the aqua session
 Inform us if you are feeling unwell, or there is a change in
your MS
 Abide by the safety and risk assessments of the pool
 Entry and exit methods are the responsibility of the MS
physiotherapist

9. Hire of the Pool

10. The Pool

11. Negotiation to use walking aids and
wheelchair/scooters on poolside

12. Access

13. Delivery
 MS Specialist Physiotherapist led with support from
MS Assistant Practitioner and three swim instructors
 Participants attended a 5-week course of 1
hour/week aqua-therapy, maximum group size of 10
 On completion participants were invited to continue
to attend to independently exercise

14. Circuits
 Warm up
 20 circuit exercises based in 5 work stations for walking
and balance, upper and lower limb strengthening, core
stability and cardiovascular fitness
 Use of equipment to assist with balance stability (floats)
and to increase the difficulty of the exercise (weights)

15. New Starters

16. Independent users

17. Group activity
 Volleyball to work on multi-
tasking balance.

18. Results since starting the service
 14 courses completed
 92 participants taken part in the service (61 women)
 Age range 24-72 years. Mean age 52 (standard deviation 9 years)
 EDSS range 6-7.5
 29% of the participants now return and exercise independently

19. Results
Outcome measure Mean before Mean
after
P value
Berg Balance Scale (BBS) 41.6 45.26 <0.0001
Timed 10m walk (10mTW) 23.9 (steps)
21.0 (Sec)
21.81
21.20
0.0001
0.0108
Timed Get up and Go (TUG) 23.7 18.55 0.0017
ABC Balance confidence
scale (ABC)
42.5 46.63 0.0013
Multiple Sclerosis Impact
Scale-29
63.2 (physical)
26.2 (Psychol)
58.76
23.25
0.0044
0.0432

20. Questions from the data
Is there a significant effect
after a course of aqua?
Were the therapy sessions in
later courses more effective
than earlier courses?
Is there a change at baseline
between those who
benefitted from therapy and
those who did not benefit?
 Yes
 No evidence of change in
effect for the later groups
 No clear pattern of the 6
(7%) who did not benefit

21. Patient feedback
 ‘Brilliant course but hard. Enjoyed the social aspect and want to
come back and independently exercise.’
 ‘Great. Very positive thing to do. Feel the benefits – feel made to
realise that I can do more than I thought. Feel more positive and
really enjoyed the social aspect of the group.’
 ‘Enjoyed the course. I was scared initially of the water but
enjoyed it more than I thought.’
 ‘I was initially worried about starting the course but it went much
better than I expected.’
 ‘The overall benefit of continuing aqua therapy is evident in my
general well-being as well as my mobility, thus reducing in some
measure my call on other NHS services.’

22. The positives of social
interaction

23. Thank you