Influence of yoga and aerobics exercise on fatigue, pain and psychosocial status in

patients with multiple sclerosis: A Randomized Trial

ََAli Hassanpour Dehkordi

Department of Nursing and Midwifery, Shahrekord University of Medical Sciences, Shahrekord, I.R. Iran
RUNNING HEAD: Influence yoga and aerobics exercise
Email: [email protected]
Abstract

Background and aim

Multiple sclerosis (MS) is an autoimmune disease that involves brain and spinal cord .weakness cognitive
impairment, pain, depression and fatigue significantly effect in general health in multiple sclerosis (MS)
patients Therefore, this study was aimed to Influence of yoga and aerobic exercise on fatigue, pain, and
psychosocial status in patients with MS.

Material and methods

This study is a clinical trial study with a sample size determined as 90 individuals per statistical advice,
previous studies, and the formula of sample size calculation. The samples were randomly assigned to
three groups of yoga exercises (n: 30), aerobics exercises (n: 30), and control group (n: 30). The exercise
program was performed three sessions a week for 12 weeks. The exercise program included 40 minutes,
including 5-10 minutes for warm-up, 25-30 minutes of exercise (walking), and 5 minutes for cooling
down (Total Body Workout). Also yoga exercises were performed three sessions a week for 12 weeks.
The data, were analyzed using SPSS software through paired t-test, ANOVA, and Tukey’s post hoc

Results

The results of the study indicated that there was no significant difference in fatigue, pain severity and
psychological status among the three groups prior to the study, but after the study, results show in yoga
and exercise groups, fatigue physical function, physical and emotional role which patients play
throughout daily life, social function, energy, mental status and overall hygiene increased, and the pain
and fatigue were relieved in the patients patients.

Conclusions:
Yoga and aerobics exercise decrease some of the MS symptoms and should be decrease in therapeutic
costs, hospital stay, days lost from work, and increase in patients’ efficiency.

Keyword

Yoga, aerobics exercise, fatigue, pain, psychosocial status

Introduction
Multiple sclerosis (MS) is an autoimmune disease that involves brain and spinal cord by
demyelinating the neurons in central nervous system (CNS), and cause symptoms including
visual disturbances, pain, urinary incontinence, weakness, tremor, fatigue, cramps, unintelligible
speech, dysphagia, difficulty thinking and memory performance, dizziness, impaired balance,
optic neuritis, numbness or local tingling, paralysis, cognitive problems, depression, mood
changes, impotence especially in men, loss of balance, speech disorders and mental disorders in
patients .MS is one of the prevalent, costly, and chronic diseases of CNS, which is mainly
developed in the youth and occurs in 20 to 35-year-old individuals; the prevalence is twice
higher in women than in men .
In recent years, the MS prevalence has been increasing globally .By the reports, 2.5 million (30
per 100000) individuals suffer from MS, out of whom 80% will finally face inability and
disability .In addition, World Health Organization states that the prevalence of MS is decreasing
most speedily in Europe, followed by Eastern Mediterranean, Americas, Oceania, Southeastern
Asia, and Africa .

In 2005, Disability Adjusted Life Years was reported 1510 years and is estimated to register 1586
and 1648 years till respectively 2015 and 2030 . Although no reliable data of Iran are available,
according to the figures issued by Iranian MS Society about 40000 individuals have acquired
MS . MS as a chronic disease could affect various aspects of social, physical, mental, and
economic life . and make the patients tackle with numerous challenges in life . the majority of
MS patients complain fatigue, so that fatigue affects the patients’ life negatively leads to
depression, anxiety, and sleep and motor disorders in them .

Although the major cause of fatigue in patients is not clearly known, it may be due to the disease
mechanism and complications (sleep disorders, spasticity, pain, anxiety, etc.) .

Pain is another problem that affecting different aspects of the patients’ life. The results show that
the patients suffer from severe pain due to central and peripheral neuropathies, trigeminal
neurology, painful spasms and regional pain syndrome . The majority of MS patients suffer from
glossopharyngeal neuralgia and myelitis, so that management and control of pain in patients face
many challenges, because drug administration to relieve the pain causes many complications,
therefore non pharmacologic approaches such as massage therapy is a suitable approach to
relieving the pain in MS patients

Economically, MS imposes a large burden on family and community in a way that most patients
abandon treatment because of not being able to afford it . Also, MS adversely affects social and
family relationships in a way that it leads to dependence and loss of independence in the patients.
MS patients suffer from anxiety and depression over time so that they are not able to do their
daily tasks . Many patients need physiotherapy, occupational therapy, speech therapy and
psychological counseling. All these types of therapies are called complementary therapies
because they complement or strengthen pharmacotherapy’s.Although pharmacotherapy’s are
considered as the first choice of treatment for MS, today non pharmacologic therapies like
message therapy, programmed exercises, etc. have been paid large attention as complementary
treatment for MS due to low cost and easy implementation . Dehkordi et al study indicated that
aerobic exercises led to improved quality of life in patients .

Several studies have suggested the role of exercise in improving performance. The results of
studies suggest that exercise leads to movement improvement, especially walking. Aerobic
exercise also increases physical strength and balance, and reduces fatigue in patients . Chronic
diseases have impact on different aspects of patients' quality of life . so that they lead to reduced
physical function, role limitations due to physical problems, role limitations due to emotional
problems, social status, physical pain, energy, vitality, mental status and overall hygiene .

Overall hygiene, well-being, and improvement quality of life are particularly important in
patients with MS . So, many efforts are being made to improve the overall hygiene, well-being,
quality of life, and the factors influencing them. Physical and mental exercises such as yoga, as
non pharmacologic approaches, may promote the overall hygiene, well-being and quality of life
in MS patients through reducing the severity of MS symptoms. However, little research has been
done in this regard. Therefore, this study was aimed to Influence of yoga and aerobic exercise on
fatigue, pain, and psychosocial status in patients with MS.

Materials and methods

This study is a clinical trial study with a sample size determined as 90 individuals per statistical
advice, previous studies, and the formula of sample size calculation. Having referred Special
Diseases Association and been assisted by a neurologist, the researcher specified the patients’ file
at first and the samples were determined by systematic randomization. The samples were
randomly assigned to three groups of yoga exercises (n: 30), aerobics exercises (n: 30), and
control group (n: 30). The exercise program was performed three sessions a week for 12 weeks.
The exercise program included 40 minutes, including 5-10 minutes for warm-up, 25-30 minutes
of exercise (walking), and 5 minutes for cooling down (Total Body Workout). Also yoga
exercises were performed three sessions a week for 12 weeks. All of the exercise sessions were
controlled by the nurse of research team at the hospital under the supervision of a neurologist.
Blood pressure and heart rate were measured before and after exercise
The patients in group three were determined as controls who received no intervention. Yoga and
aerobics exercises were implemented by trained individuals in the Sports Hall of Shahrekord
University of Medical Sciences. The inclusion criteria into the study were: definite diagnosis of
MS, patients agreed to participate in the study, the ability to speak, the ability to move and
perform daily activities. Exclusion criteria were: lack of ability to complete the exercises or
cooperate for any reason. In this study, 20 from case group and nine from control group were
excluded for various reasons.

The questionnaire consisted of three sections: demographic data, Rotten fatigue test, and quality
of life questionnaire of SF-36 to investigate various aspects of quality of life in patients for
physical functioning, role limitations due to physical problems, role limitations due to emotional,
social problems, physical pain, energy, vitality, mental health, and overall hygiene. Validity and
reliability of Persian version of this questionnaire has been already obtained as satisfactory in
previous studies.

The content validity of the questionnaire was confirmed by 10 faculty members of Department of
Nursing and Midwifery. For reliability assessment, the questionnaires were simultaneously
completed and the correlation coefficient was calculated as 0.91.
The questionnaires were filled out by all patients twice: prior to the study and 12 weeks after

completion of the study. Initially, the required approval was obtained from Research and

Technology Deputy of Shahrekord University of Medical Sciences, and to obtain the patients’
consent to participate in the study, we explained the purposes of the study to the patients

completely and then they were asked to fill out the consent form of participation in the study. In

addition, the patients were ensured that all study data are dealt with as confidential and used only

for research purposes. In all research steps, a neurologist monitored the implementation of the

study. The ethical approval (with ethics code of 87-1-2) was obtained from Ethics Committee of

Shahrekord University of Medical Sciences and registration code of RCT2013063013768N2 was

issued by Iranian Registry of Clinical Trials for this study.

The data were analyzed using SPSS software (version 11.5) through paired t-test, ANOVA, and
Tukey’s post hoc. The level of significance was considered < 0.05 in all tests.
Figure 1. Sampling flowchart

Results

In this study, 61 patients with MS participated, out of whom 60 were women. The mean age of
the patients participating in this study was 31.9 years. The majority of investigated units (85%)
were married. The majority of the patients (86%) had diploma and under diploma education. The
majority of investigated units (98%) were covered by insurance. The economic status of most
patients (73%) was moderate.

Figure 2. Normal distribution of data in yoga and exercise groups

The results of the study indicated that there was no significant difference in fatigue severity
among the three groups prior to the study, but after the study, fatigue severity decreased in yoga
and exercise groups, but in the control group, the fatigue severity increased (Table 1).

Also, the results of the test indicated that physical functioning, role limitations due to physical
problems, role limitations due to emotional problems, social status, physical pain, energy,
vitality, mental status and overall hygiene were not significantly different among the three yoga,
exercises and control groups before the study, but after the study, these variables changed,
so that in yoga and exercise groups, physical function, physical and emotional role which
patients play throughout daily life, social function, energy, mental status and overall hygiene
increased, and the pain was relieved in the patients, while in the control group, overall hygiene,
physical function, and physical and emotional role decreased, and the pain intensified in the
patients, and social function, energy and mental status did not change in the patients (Table 2).

Discussion
MS is a chronic and progressive disease of nervous system which has adverse impacts on
physical functioning, emotional and physical roles, social functioning, energy, mental status,
overall hygiene, physical pain, and severity of fatigue in the patients. The findings of several
studies have indicated that the patients with MS develop disorder in functioning and gradual
disability . In addition, MS influences overall hygiene and social functioning of patients in a way
that it leads to the seclusion and depression in the patients
The results of the present study showed that the scheduled yoga exercises can significantly
enhance the overall hygiene of the patients. Velikonja’s study indicated that yoga exercises
influenced overall hygiene and increased motivation for life in MS patients, so that yoga
exercises led to enhanced overall hygiene and well-being .The results of the present study
showed that yoga resulted in reduced fatigue and reserved energy.
Consistent with the findings of the present study, another study investigating the effect of yoga
exercises Cognitive function, fatigue, and mood in patients with MS showed that yoga can
improve cognitive function and mood, and reduce fatigue in the patients .
The findings of another study, consistent with the present study, indicated that yoga exercises not
only led to balance, speed, and resistance in walking, but also causes decline in fatigue and
improvement of quality of life in patients with MS .
Severe depression, fatigue, sleep disorders, bipolar disorder, anxiety and personality changes are
main problems in the patients with MS, which negatively affect Physical function, physical and
emotional roles, social functioning, energy, and mental status, so that over 50% of these patients
are suffering from severe depression and may attempt suicide . One way to prevent the problems
that patients with MS deal with is healthcare, treatment, and doing yoga exercises, so that the
patients practicing yoga exercises have good social relations, develop mental disorders less
frequently, and are able to properly take care of themselves. Also, yoga exercises are easy and
economical, and help MS patients return to community and apt with the existing conditions .
Since thousands of years ago, ancient philosophers have applied yoga for health improvement,
physical fitness, physical and mental relaxation, concentration, and blood pressure and chronic
pain decrease .The cited study results also showed that yoga may help to decrease pain and
mental composure in the MS patients. In view of the findings of the present study, any social
activity and exercise including yoga contribute positively to physical functioning, emotional and
physical roles, social function, energy, mental status, overall hygiene, physical pain, and severity
of fatigue in patients with MS, and leads to increased motivation for life and social interaction.
Exercise is also a low-cost and effective activity on physical functioning, role physical and
emotional roles, social functioning, energy, mental status, general health, bodily pain, and fatigue
intensity .so that the results of this study showed regular aerobic exercise could enhance the
quality of life and overall hygiene, and reduce the severity of fatigue in patients with MS.
The findings of a study also indicated that exercise resulted in improved social function,
increased perception of their own health in patients, increased tendency towards physical
activities, and relief of muscle tension, increased flexibility, and reduced fatigue. Regular
exercise also leads to improved performance, balance, reduced muscle spasms and fatigue in
patients with MS .Other studies have shown that exercise leads to increased lung capacity,
endurance, mobility, and muscle strength, and on the other hand, as much lung capacity and
muscle strength increase, fatigue intensity declines, thus improving the quality of life .Exercise is
a reasonable, practical, applicable, useful and uncomplicated method to adjust the physical,
emotional and mental status of humans .
Conclusion

The findings of the present study indicated that both yoga and aerobic contributed positively to
physical functioning, emotional and physical roles, social functioning, energy, mental status,
overall hygiene, physical pain, and severity of fatigue in patients with MS, in a way that those
patients practicing these two sports suffer from less pain and fatigue, enjoy suitable social
communications, are not afraid of being stigmatized by others, and are less damaged
professionally. Use of the present study findings leads to decrease in therapeutic costs, hospital
stay, and days lost from work, and increase in patients’ efficiency.

Implications
The findings of the present study could be considered in students’ education, in-service training,
research, management, and treatment.

Limitations
Small sample size enrolled in this study limits the generalization of the study findings.
Conflict of interest
The authors of the present work declare no conflict of interest.
Acknowledgement
Hereby, we thank the Research and Technology Deputy of Shahrekord University of Medical
Sciences.
Authors’ contributions:
Study concept and design, Acquisition of data, Analysis and interpretation of data: Drafting of
the manuscript: Critical revision of the manuscript for important intellectual content:; Statistical
analysis:; Administrative, technical, and material support: Ali Hassanpour Dehkordi;
Funding/support:
This study was supported by the Research and Technology Deputy of Shahrekord University of
Medical Sciences.
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