Findings on aquatic pilot trial for chronic fatigue syndrome

by Sasha Nimmo

Dr Broadbent provided an update on the Southern Cross University (SCU) pilot trial to see if aquatic therapy improves the self-reported wellness scores of people with diagnosed with ME, chronic fatigue syndrome (CFS), post viral fatigue syndrome, post infectious fatigue syndrome or chronic mononucleosis.

Dr Suzanne Broadbent, Associate Professor of Clinical Exercise Physiology now at the University of the Sunshine Coast, updated ME Australia on the pilot.

The trial involved a small group with no set chronic fatigue syndrome or ME criteria, there was no control group. There were two sessions per week for five weeks and the length of session depended on the participants. Here is the report from the beginning of the trial.

“We have finalised results and will be running statistical analyses as soon as possible. Just a general heads up that we had no adverse findings for the study and that ALL participants improved in physiological outcomes (such as 6 minute walk time) and that the majority of participants had reduced pain and fatigue after the 5 week aqua block,” said Dr Broadbent.

“We were actually astounded that the participants showed such huge improvements. We hope to publish 2 papers on our findings as soon as possible, and I will be applying for further funding to run a bigger project on the Sunshine Coast, Gold Coast and Northern Rivers of NSW. I was also delighted to find that many of our participants formed their own little aqua exercise group and continued with the program!”

Please note that this is not a recommendation for this therapy.

ME Australia readers had thoughtful comments on the original article,  including this from John Muir, who has lived with ME/CFS & FM for than 20 years.

I have already explored this area in practical terms more than a decade ago, and found it had a number of potential pitfalls.

First and foremost is a safety concern, that it might be conducted by an individual in an ‘unsupervised’ way, due to positive recommendations in the research. This possibly could lead to potential drownings.

Hydrotherapy uses water resistance, which a #pwme might not take into account and ‘overdo it.’ Also buoyancy, may ‘disguise’ levels of fatigue. A #pwme may also have trouble leaving the pool, or returning home after an exercise bout, due to increased ‘gravitational effect’ once they leave the water.

Just imagine ‘running out of energy’ in open water or an unattended pool?

These concerns can be accommodated in a supervised environment, and with adequate support systems, but what about unsupervised environments? Often research recommendations and guidelines fail to mention potential dangers and are sometimes adopted by people who don’t have access to qualified staff or supervised treatment.

In sports medicine, you often consider ‘environmental dangers’, which are often overlooked in the medical and exercise physiology literature. Exercise often does not take place in a benign or sterile environment, and there are potential for HARMS if environmental dangers are not taken into account.

Also many #pwme have chemical sensitives. Most hydrotherapy is carried out in chlorinated pools, which some #pwme might not tolerate all that well.

#pwme may also be temperature sensitive, and may find issues with this.

Other potential issues are photophobia, photosensitivity and difficulty coping with complex visual stimuli, which can occur in a group and pool environment. These sensitivities may exacerbate symptoms.

Heated pools may also cause problems for those that have neurally mediated hypotension:http://www.njcfsa.org/wp-content/uploads/2010/08/4-11-Patient-Unofrmationon-Neurally-Mediated-Hypotension-and-its-Treatment.pdf

I know Suzanne points out benefits of hydrotherapy can include improved circulation and venous return, but you can also achieve this with other types of exercise.

You also need specific pool requirements: http://www.eha.sa.gov.au/uploadFiles/documents/codehydrotherapy.pdf

http://almacen-gpc.dynalias.org/publico/Guia%20australiana%20de%20hidroterapia.pdf

I know Dr Broadbent has the best intentions for #pwme, but sometimes having an experiential insight gives you a certain advantage that some researchers who do not have #mecfs, do not have.

Having used hydrotherapy as a rehab modality for clients (don’t like the word patients), I know it’s advantages and limitations. Cost, access to facilities and lack of trained exercise therapists (no specific #mecfs knowledge) are just some of the cons for this therapy for #pwme. Typical community-type classes may not be appropriate for #pwme.

On the study itself. I know it is only a pilot study, but it should be right from the start. GP and self-reported symptoms are not sufficient for saying a person has a formal and accurate diagnosis of #mecfs . Most GPs don’t have the required skill set or experience to diagnosis #mecfs accurately. Self-reported symptoms also could potentially lead to non-#pwme being included in the study, which has the potential to skew data. Given the small sample size, this could be significant. A good reason for being very stringent in your subject selection criteria.

Also exercise response is very specific, Every exercise physiologist knows that if you train on a bike you do ‘better’ on a bicycle ergometer test, rather than a treadmill test. I know the six-minute walk is easy to implement and compare with normal populations, but will it accurately measure training effect gained from hydrotherapy?

Grip strength test? Not so sure, unless they are using hand-resistance paddles in the routine. I would use it in sport for things like judo or sailing, but #mecfs? I would have thought quadricep muscle strength testing is of more value. Maybe ease of testing and cost-efficiency?

The VAS 0 – 10 pain and tiredness scale also requires careful administration, and needs somebody who is thoroughly familiar with it’s implementation, and has a knowledge base of what can confound it’s implementation.

Also skeptical about 4 weeks duration? Is this enough time for physiological adaptations to exercise to take place? For example, measuring muscular strength gains(handgrip) after only 4 weeks, would it be true muscular strength gains, or an increase in neurological efficiency – the way you recruit muscle fibres?

Not trying to sound hypercritical of Suzanne’s intended pilot study. Her intentions are good, and she is well informed about #mecfs. She is also quite aware of the problems with the #PACEtrial.

From my perspective, she is trying to examine an area that really needs further investigation, as to-date, most recommendations for GET have been simplistic and flawed. For that Suzanne deserves due credit.

However, if you want to get down to the nuts-and-bolts of it, the real issue is appropriateness of exercise therapy in #mecfs? Is it appropriate for all #pwme, or just certain sub-groupings of patients? You need to identify those, for whom exercise is appropriate! Another issue, is can you extend exercise training principles extrapolated from healthy populations, and apply them to #pwme? If a #pwme’s physiology responds differently to an exercise stimulus, than that of healthy individuals, wouldn’t it be prudent to study the limitations of exercise in #mecfs, before implementing standard GET principles in exercise programmes for #pwme. If not, it may result in potential HARMS. http://www.meassociation.org.uk/2015/05/23959/

Often Post-exertional Malaise (PEM) is seen as a central issue with #pwme. Do most exercise therapists actually objectively measure recovery, or is it a guesstomate based on patient feedback; which may or may not be accurate? If you don’t objectively measure recovery, you can’t introduce the next exercise stimulus at the right time. Too early, and it can result in overtraining, and physical performance decrements. Not to mention the inevitable ‘crash’ that #pwme suffer when exposed to inappropriate exercise loads. Maybe there should be some exploration of the sports science literature, in how they address optimizing performance and recovery?

What really needs to happen, is that we need to explore the theoretical underpinnings of excise science and whether they are appropriate in #mecfs. It will probably eventually come down to individualizing fitness training principles to accommodate the needs of the individual #pwme, in an effort to minimize deconditioning and hypokinetic conditions. In other words, individualized exercise prescriptions.

To be honest, that is what every good professional exercise therapist strives for. Group settings and approaches are something the public health system implements for cost efficiency. The cost-efficient path may not be what is is best for individual #pwme.