Effects of an Aquatic Fitness Program on the Muscular

Strength and Endurance of Patients with Multiple

Sclerosis
GALE M. GEHLSEN,
SUSAN A. GRIGSBY,
and DONALD M. WINANT

This study quantified the effects of an aquatic exercise program on muscular

strength, endurance, work, and power of patients with multiple sclerosis. Ten
individuals with a mean age of 40 years participated in a 10-week aquatic exercise
program. Two types of isokinetic dynamometers were used to assess the mus-
cular variables studied. A Cybex® II dynamometer was used to measure peak
torque, work, and fatigue in the knee flexor and extensor muscles and a biokinetic
swim bench was used to measure muscular force, work, fatigue, and power in
the upper extremities. Five velocity settings were selected for each of three
testing trials (pretrial, midtrial, and posttrial). For the lower extremities, analysis
of variance indicated a significant improvement of peak torque for knee extensor
muscles from the pretrial to midtrial (p < .05). Peak torque values from pretrial
to midtrial for knee flexors and from midtrial to posttrial for both the knee extensor
and flexor muscles indicated a nonsignificant difference at each velocity studied.
Fatigue and work values in the lower extremities improved significantly between
the pretrial and posttrial (p < .05). For the upper extremities, an analysis of
variance indicated a significant increase in all force measurements from pretrial
to posttrial (p < .05). Power and total work values also improved significantly (p
< .05). No significant difference in fatigue measurements for the upper extremities
was found. The results of this investigation indicated that an aquatic exercise
program may induce positive changes in muscular strength, fatigue, work, and
power in patients with multiple sclerosis.
Key Words: Exercise therapy, Multiple sclerosis, Physical therapy, Water.

Multiple sclerosis (MS) is a degenerative neurological dis-
order characterized by the demyelinization of CNS pathways
that may, in part, be responsible for the neuromuscular dys-
function found in persons with the disease. The primary focus
of research in this area has been on determining the etiology
of the disease and development of a cure rather than on trying
to improve the general fitness of the patient. Because the
etiological origin of MS has yet to be determined, treatment
has been limited to the control of symptomatic complications,
such as muscular fatigue, weakness, contracture, and spastic-
ity, through physical therapy and the use of drugs.1-3
Exercise programs directed toward treating certain specific
deficits have been viewed by some as having the most to offer
patients with MS.4 Traditionally, such techniques as active
and passive range of motion, coordination exercises, and
various facilitation techniques to induce voluntary motor
activity or inhibit unwanted motor patterns have been used
Dr. Gehlsen is Professor of Physical Education and Director of the Biome-
chanics Laboratory, Ball State University, Muncie, IN 47306 (USA).
Ms. Grigsby is Assistant Professor, Physical Therapy Program, Department
of Physiology and Health Science, Ball State University, Muncie, IN.
Mr. Winant was a graduate student in the Department of Men's Physical
Education, Ball State University, when this study was conducted. He is currently
a Research Assistant, Department of Rehabilitative Medicine, University Hos-
pital, University of Washington, Seattle, WA 98105.
This article was submitted March 14, 1983; was with the authors for revision
18 weeks; and was accepted December 20, 1983.
to help alleviate or modify neuromuscular complications,
such as ataxia, spasticity, contracture, and disuse atrophy of
the skeletal muscles.5 A more recent trend has favored the use
of dynamic exercise (calisthenics, cycling, and swimming) for
sustaining the physical conditioning response and preventing
neuromuscular complications associated with physical inac-
tivity.5,6 Russell has implied that dynamic exercise creates a
hyperaemic response in the body that results in opening up
circulation to the ischemic regions of the spinal cord and
brain.6 He observed that a rest-exercise program for patients
with MS arrested the pathogenic process by preventing the
fulminating or malignant type or both from developing.
Certain physical activities, such as jogging, may be inappro-
priate for patients with MS because of exposure to harsh
environmental conditions and the requirement for stamina
and balance beyond the patients' capacities. The buoyant
nature of water and the ability to control water temperature
effectively, however, are characteristics that have made a
positive therapeutic response in patients with neuromuscular
disease possible.7
No empirical evidence is available on the benefits of an
aquatic exercise program for the patient with MS. The phys-
ical therapist, therefore, is unable to make any recommenda-
tion (positive or negative) concerning aquatic exercise pro-
grams for patients with MS. The purpose of this study was to
determine the effects of an aquatic exercise program on the

Volume 64 / Number 5, May 1984 653

TABLE 1 The apparatus was a semiaccommodating resistance device
Demographic Data of Subjects with Multiple Sclerosis that could be preset at a regulated speed to provide a constant
amount of velocity in proportion to the force applied by the
Subject Age Height Weight (kg) user. The speed setting(s) were S-0 (0.9 m/sec), S-2 (1.24 m/
Sex
No. (yr) (M) Pretrial Midtrial Posttrial sec), S-4 (1.7 m/sec), S-6 (2.2 m/sec), and S-8 (2.72 m/sec).
1 30 Woman 1.80 59.0 58.0 59.8
The swim bench was designed with a padded incline for a
2 54 Woman 1.68 57.2 55.9 56.0 prone position and with pull paddles for the hands of the
3 61 Woman 1.59 59.1 57.8 60.0 subjects. Each paddle connected to an attached isokinetic
4 23 Woman 1.68 62.2 59.7 60.8 resistance device by one rope that ran over a pulley and
5 51 Woman 1.68 79.8 79.4 79.3 around the geared spool inside. A governor built onto the
6 37 Woman 1.62 54.0 53.8 54.0 spool regulated the rate at which each rope released from the
7 36 Man 1.87 77.6 76.2 75.0 spool. The force generated during each arm pull was deter-
8 35 Man 1.76 69.3 71.5 70.1 mined from a physiograph chart recorder; muscular work was
9 37 Man 1.82 74.0 73.4 73.7 measured with the digital work integrator (a component of
10 38 Man 1.83 78.0 74.8 73.4 the swim bench); time was measured by the length of the
force curve; and muscular power was calculated by dividing
work by the time of the pull.
upper and lower extremity muscular force, torque, fatigue,
work, and power in patients with MS. The study attempted
to quantify the effects of the aquatic program on muscular
strength and endurance of individuals with MS to determine Test Protocol
whether this type of exercise program could be effectively Lower extremities. Before each testing session, the dyna-
used by the clinician to improve overall patient conditioning. mometer, chart recorder, angle channel, and digital work
integrator were calibrated. The subjects underwent a five-
METHOD minute warm-up period consisting of two contractions at the
Subjects designated angular velocities. We minimized extraneous body
movement by restraining each subject with shoulder har-
A total of 13 subjects comprised the initial experimental nesses, a hip belt, a midthigh restraint strap, and an ankle
group, but 3 subjects dropped out of the study before the fifth strap. The level-arm length and the number of back support
week of testing. We collected data on 10 subjects with MS pads remained constant for each subject; we positioned the
(six women and four men) with a mean age of 40.2 years. midpoint of the lever-arm crank next to the lateral femoral
The subjects were recruited from the local Multiple Sclerosis condyle of the knee joint. The testing protocol required that
Association Chapter. We based eligibility on clinical assess- each subject continue at each preset angular velocity until
ment of disease status by attending physicians. Selection peak torque decline was observed. We conducted retests at
criteria required that all subjects be ambulatory and the specified angular velocities to verify peak torque values. After
disease be in a remissive state. We obtained informed consent dynamic torque measurements were obtained, the isometric
as a prerequisite for participating in the laboratory tests and (0°/sec) torque of the knee extensor and flexor muscles was
exercise program. Table 1 lists demographic data. taken at a leg angle of 45 degrees. We gave the subjects five
minutes of rest before total work data were obtained from a
Experimental Design test of 50 (extension) contractions at the preset speed of 180°/
sec. Muscular fatigue values were calculated from the total
We scheduled three testing trials of the upper and lower work data. We considered fatigue values to be the percentage
extremities' muscular torque, force, fatigue, work, and power of peak torque decline (the percentage of difference between
for each of the 10 subjects on two types of isokinetic dyna- the first and final peak torque values) as described by Thor-
mometers. The pretrial tests were administered the week stensson.8
before the start of a 10-week aquatic exercise program; the
midtrial tests were conducted during the fifth week of the
aquatic exercise program; and the posttrial tests were admin- Upper extremities. We familiarized all subjects with the use
istered during the week following the completion of the of the biokinetic swim bench and allowed them a warm-up
aquatic exercise program. of two practice pulls at each speed setting. Peak force meas-
urements were obtained from the best of three trials at speed
Equipment settings S-0, S-2, S-4, S-6, and S-8. After a five-minute rest
period, each subject performed a 45-second muscular total
We used a Cybex®* II isokinetic dynamometer to measure work and fatigue test. The total work and fatigue test was
knee joint flexor and extensor muscle peak torque at angular performed at the high tension speed setting of S-0 (0.9 m/
velocities of 60, 120, 180, 240, and 300°/sec. A digital work sec). The digital work integrator recorded the total work
integrator (a component of the Cybex® II) was used to deter- produced during the test. We measured fatigue as the per-
mine total work. centage of decline of peak force from the average of the first
A biokinetic swim bench† measured peak force, total work, three and last three arm pulls. As stated previously, power
and maximal power at varying upper extremity velocities. was calculated from the results of the work tests and the time
of the pull. We instructed each subject to give a maximal
effort on every muscular contraction. Verbal encouragement
* Cybex, Div of Lumex, 2100 Smithtown Ave, Ronkonkoma, NY 11779.
† Isokinetic. Inc, PO Box 6397, Albany, CA 94706. was given during each test.

654 Physical Therapy

 RESEARCH

TABLE 2
Cybex® II Dynamometer Results: Peak Torque Values of Knee Extensor" and Flexor Muscles at Predetermined Angular Velocities
Difference
Pretrial (Nm) Midtrial (Nm) Posttrial (Nm)
(%)
Angular Velocity Pretrial Midtrial Pretrial
s s s to to to
Midtrial Posttrial Posttrial
0°/sec Flexion 32.4 19.9 42.6 16.9 43.4 18.9 31.8 1.9 33.9
Extension 85.6 25.9 92.1 32.1 90.8 32.4 7.6 -1.4 6.0
60°/sec Flexion 37.0 30.1 47.5 31.5 46.0 27.5 28.2 -3.2 24.3
Extension 70.5 34.2 87.5 40.8 79.5 32.7 24.0 -9.1 12.7
120°/sec Flexion 28.7 26.9 36.1 26.6 34.9 22.4 25.5 -3.3 21.6
Extension 45.4 28.2 57.4 32.4 54.2 26.4 26.3 -5.6 19.4
180°/sec Flexion 19.9 22.1 27.3 20.6 26.4 19.1 36.7 -3.3 32.7
Extension 30.9 23.0 42.9 25.5 37.1 17.8 39.8 -13.5 20.1
240°/sec Flexion 16.1 18.2 24.8 20.5 22.6 16.7 53.8 -8.9 40.3
Extension 22.8 19.2 34.4 23.2 27.4 15.3 51.2 -20.3 20.1
300°/sec Flexion 13.4 16.4 24.4 21.4 19.1 14.8 81.8 -21.7 42.5
Extension 14.2 15.3 27.1 20.5 21.0 14.2 90.5 -22.5 47.8
a
All extension pretrial to midtrial values except 0°/sec significant (p < .05).

Aquatic Exercise Program Data Analysis

All subjects participated in a 10-week exercise program
consisting of freestyle swimming and shallow water calisthen-
ics, as outlined by the President's Council on Physical Fitness
and Sports7 and Getchell and Anderson.9 The program site
was a 25-m by 15-m instructional facility. We regulated water
temperature within a range of 25° to 27.5°C (77°-81.5°F).
Exercise prescription was based on the guidelines recom-
mended by the American College of Sports Medicine.10 The
frequency of exercise was set at 3 one-hour exercise sessions
each week; training intensity was established at 60 to 75
percent of the subject's estimated maximal heart rate. We
based progression of exercise intensity and duration on sub-
maximal heart rate; subjective feelings of fatigue; periodic
clinical assessment by attending physicians; and monitoring
of resting, recovery, and maximal training heart-rate re-
sponses.
We used a two-way analysis of variance (SPSS computer
program) to test for significance of effects for the following
variables: muscular torque, force, work, and power at selected
movement speeds. The percentage of change was computed
for the torque, work, and fatigue variables by the following
formula:
(1)
RESULTS
Torque and Force
Table 2 presents the mean peak torque data from the
dynamometer testing for knee flexion and extension. Peak
torque measurements for the knee extensor muscles indicated
significant improvement (p < .05) from pretrial to midtrial

TABLE 3
Biokinetic Swim-Bench Results: Mean-Force, Work, and Power Values at Predetermined Speed Settings for Upper Extremities
Pre- Mid- Post- Pre- Mid- Post- Pre- Mid- Post- Pre- Mid- Post- Pre- Mid- Post-
Variable
trial trial trial trial trial trial trial trial trial trial trial trial trial trial trial
S-0 S-2 S-4 S-6 S-8
Forcea (N)
129.2 148.5 189.5 80.3 99.5 128.2 53.8 69.9 87.9 32.3 42.9 58.8 16.0 24.9 29.6
s 57.9 57.6 65.3 61.3 58.1 59.2 46.8 53.7 47.1 32.5 36.1 46.7 24.0 27.0 32.0
Workb (Nm)
89.3 105.6 126.3 42.4 56.6 66.4 25.0 32.6 39.2 15.2 19.6 21.7 4.3 9.8 11.9
s 43.4 38.8 46.3 37.0 35.6 37.2 24.0 28.5 26.4 16.3 18.3 20.0 8.6 12.0 12.7
Powerc
(Nm/sec)
57.8 77.9 92.0 59.6 80.9 95.5 57.2 76.8 97.0 61.5 75.6 81.9 21.7 52.6 66.2
s 43.0 49.6 47.5 55.8 57.0 60.3 54.1 64.6 58.5 55.9 67.1 61.3 43.2 56.8 66.1
a
Significant (p < .05) between trials and speeds.
b
Significant (p < .05) for all trials except S-6.
c
Significant (p < .05) pretrial to posttrial except S-6.

Volume 64 / Number 5, May 1984 655

for all designated angular velocities except for 0%ec. We
found no statistical difference in mean peak torque values for
knee flexor muscles from pretrial to midtrial nor any signifi-
cant differences for each of the respective angular velocities.
All flexor and extensor peak torque values except the knee
flexors at 0°/sec decreased between the midtrial and posttrial.
Peak torque from pretrial to posttrial and midtrial to posttrial
for both the knee extensor and flexor musculature indicated
nonsignificant difference for all of the angular velocities. Table
2 also gives percentage of change between the peak torque
values from the pretrial to midtrial, midtrial to posttrial, and
pretrial to posttrial for the knee flexor and extensor muscles.
Table 3 presents the mean force values for the upper
extremities at the various speed settings for the swim bench.
At all of the speed settings, two-way analysis of variance
revealed a significant difference (p < .05) in peak force values
for the three testing periods and a significant difference (p <
.05) between the speeds of movement. Mean force output was
greatest at the high tension speed settings of S-0 and S-2; the
force output progressively declined at the lower tension speed
setting of S-4, S-6, and S-8, respectively. The percentage of
increase in mean force values from pretrial to posttrial ranged
from 46.7 to 85.0 percent.
Muscular Work and Fatigue
Table 4 outlines group means for total muscular work and
fatigue (percent decrement in peak torque) for the Cybex®.
The total work of the knee extensor muscles increased by 192
percent from pretrial to midtrial and 330 percent from the
pretrial to posttrial. The total work improvement was statis-
tically significant (p < .05). The lower extremities' fatigue
values (percentage of decline in peak torque) showed a statis-
tically significant (p < .05) decrease. The absolute differences
in the fatigue values were 12.84 and 14.14 percent for the
pretrial to midtrial and pretrial to posttrial, respectively.
As determined by significance testing (p < .05), work for
the upper extremities improved at all of the speed settings,
with the exception of S-6. As was characteristic of force, work
progressively decreased as the speed setting (velocity) in-
creased. Table 3 presents mean data for work. The total work
as measured during the 45-second, swim-bench test increased
significantly (p < .05) from pretrial to posttrial. The percent-
age of increase from pretrial to midtrial was 39 percent, and
the increase in total work from the pretrial to posttrial was 82
percent (Tab. 4). As for the swim-bench fatigue values, no
statistically significant difference could be found between
trials. The data showed that the fatigue value increased (14%)
from the prefatigue to postfatigue test trial.
Power
At the .05 level of significance, mean power of the upper
extremities improved (pretrial to posttrial) at all the speed
settings other than S-6. Peak power was recorded at S-4
posttrial (97.0 Nm/sec); at S-8 pretrial (21.7 Nm/sec), power
output was lower than at all other speed settings. Mean power
values can be found in Table 3.
DISCUSSION
The results of this investigation indicated that individuals
with MS who participated in a program of aquatic exercise
were able to overcome some of the neuromuscular deficits
characteristic of the disease process. Factors that may have
influenced the outcome of the muscular force, torque, work,
and fatigue measurements included 1) the specificity of train-
ing principle, 2) neuropathological influences of MS on skel-
etal muscle, 3) physical inactivity, and 4) diurnal physiological
alterations.
Isokinetic dynamometry data revealed that maximal peak
torque for the knee extensor muscles was recorded at the
isometric setting (0°/sec). No statistical differences were ob-
tained, however, for the three trial sessions at the isometric
setting. Similar results were obtained by Larsson, who
strength-trained previously sedentary adult men.11 Larsson
found that although maximum peak torque was produced at
the isometric setting, no statistical significance could be found
when comparing the results of pretrial, midtrial, and posttrial.
The insignificant results for isometric peak torque may indi-

TABLE 4
Total Work Production" and Fatigueb for Upper and Lower Extremities

Pretrial Period Midtrial Period Posttrial Period Difference

(%)
Test Equipment Pretrial Midtrial Pretrial
s s s to to to
Midtrial Posttrial Posttrial
Cybex® II
total work (Nm) 1078.90 817.80 3151.70 1780.50 4641.40 1084.40 192.1 47.3 330.2
fatigue (% decline 55.15 11.02 42.31 12.57 41.01 14.97 -23.3 -3.1 -25.6
in force)
Swim bench
total work (Nm) 1093.40 658.60 1522.00 294.20 1990.80 1091.70 39.2 30.8 82.1c
fatigue (% decline 29.78 15.26 31.57 14.09 33.95 18.93 6.0 7.5 14.0
in force)
a
Significant (p < .05) between trials.
b
Significant (p < .05) between trials.
c
Significant (p < .05) pretrial to posttrial.

656 Physical Therapy


cate the lack of training specificity between dynamic and
static exercise. Investigations by Osternig and associates12 and
Wolf13 have shown that isometric peak torque demonstrated
a low correlation with dynamic peak torque, and the patterns
of motor unit recruitment varied depending on whether the
nature of muscular contraction was static or dynamic. Al-
though dynamic peak torque values for the knee extensors
showed a significant increase from pretrial to midtrial dyna-
mometer measurements in our study, the results failed to
indicate any improvement in dynamic peak torque for the
knee flexor muscles. The lack of muscular torque gains for
the knee flexors may be related to the general muscular
weakness and contracture problems faced by patients with
MS.5, 14 The extent of pyramidal pathway involvement may
have also compromised the ability of the knee flexor muscu-
lature to improve with exercise. Birch et al stated that training
cannot influence irrevocable CNS damage.15
The general trend for the swim-bench data indicated a
significant improvement in the components of strength (force,
work, and power) for all three experimental trials. The reason
why the strength components gains were most evident for the
upper extremities and not for the lower extremities may be
related to discrepancies in testing protocols for the dynamom-
eter and swim bench. Specificity of training may have also
been a key factor influencing the outcome of the force and
torque measurements. Costill and associates have stated that
devices that measure strength must duplicate the actual bio-
mechanical patterns of a particular skill.16
Swim-bench measurements revealed that at the high ten-
sion settings of S-0 and S-2 and medium tension setting of S-
4, force, work, and power showed significant gains; however,
at the low tension settings of S-6 and S-8, significant improve-
ments in force, work, and power were not quite so dramatic.
The somewhat variable findings at the faster velocities may
be related to the duration and intensity of the aerobically-
oriented exercise. Elliott stated that muscles that are trained
at fast velocities become capable of improving strength at
both fast and slow speeds; however, if training takes place
under conditions of high resistance or slow velocities or both,
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Volume 64 / Number 5, May 1984
RESEARCH
quickness and power are sacrificed.17 The inability to produce
peak torque at the faster velocities may also be because of the
demyelinating-denervating process so characteristic of MS.
Edstrom hypothesized that in upper motor neuron lesions
(with paresis and spasticity), there may be selective disuse of
high threshold motor units, which innervate fast twitch (FT)
fibers, and overuse of low threshold motor units/which in-
nervate slow twitch (ST) musclefibers.18This situation would
then result in atrophy of the high threshold motor units and
FTfibersand in hypertrophy of the low threshold motor units
and ST fibers. The predominance of ST muscle fibers in
upper motor neuron lesions may indicate that in patients with
MS, muscle function may be compromised.
Perhaps, the most universal symptom encountered by per-
sons with MS is fatigue. Typically, patients with MS follow a
diurnal cycle in which they awaken in the morning fairly
rested, progressively fatigue throughout the day, and recover
in the evening.19 The results of this investigation indicated
that muscular work and muscular fatigability can be dramat-
ically improved in patients with MS. The results indicated an
82 percent increase in the total work measurement for the
upper extremities and a 330 percent increase in the total work
measurement for the lower extremities. The percent decline
in peak torque (fatigue measure) for the lower extremities
decreased from 55 percent to 41 percent; a significant im-
provement in the ability of the muscles to maintain peak
torque.
CONCLUSION
In light of the mentioned factors that may have influenced
the results of this investigation, we concluded that an aquatic
exercise program is not harmful to the muscular strength and
endurance of patients with MS. The results, although mixed,
did indicate that some positive changes in muscular strength
(force and torque), fatigue, work, and power can be expected
from an aquatic exercise program. The small sample group
and mixed results of this study would indicate the need for
further research in this particular area.
11. Larsson L: Physical training effects on muscle morphology in sedentary
males at different ages. Med Sci Sports Exerc, 14:203-206, 1982
12. Osternig LR, Bates BT, James SL: Isokinetic and isometric torque force
relationships. Arch Phys Med Rehabil 58:254-257, 1977
13. Wolf SL: The morphological and functional basis of therapeutic exercise.
In Basmajian JV (ed): Therapeutic Exercise. Baltimore, MD, Williams &
Wilkins, 1980, p 63
14. Rusk HA: Rehabilitation Medicine. St. Louis, MO, CV Mosby Co, 1977, p
460
15. Birch HG, Proctor F, Bortner M, et al: Perception in hemiplegia: I. Judgment
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41:19-27,1960
16. Costill DL, Sharp RL, Troup J: Muscle strength: Contributions to sprint
swimming. In Flavell ER (ed): Biokinetic Strength Training. Albany, CA,
Isokinetics, Inc, 1981, p 216
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1978
18. Edstrom L: Selective changes in the size of red and white muscle fibers in
upper motor lesions and parkinsonism. J Neurol Sci 11:537-550, 1970
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and Treatment Procedures. Philadelphia, PA, F.A. Davis Co, 1981, pp
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657