February 2016: Fibromyalgia



Content courtesy of the National Swimming Pool Foundation

Aquatic exercise and therapy programs are truly a “custom-fit” for patients suffering from wide-spread conditions like fibromyalgia. Historically, it has been difficult for therapists working with the chronic pain population to find a good mechanism to treat the whole person and not just chase each symptom as it appears (Salzman, 2013). Amazingly, pool-based treatment fits the bill in almost every way. So many of the big goals which are present with this population (decreasing stress, improving sleep quality, dampening pain reactions, elevating motivation, decreasing fatigue, and improving physical conditioning) are easily tackled at the water’s edge.

Currently, best practice guidelines suggest that physical exercise (especially aquatic exercise) and cognitive-behavioral therapy should be seen as front-line treatments (Angel Garcia, 2015). Both systematic reviews and meta-analyses have consistently demonstrated moderate-level evidence that aquatic exercise works for what ails patients with chronic pain conditions such as Fibromyalgia Syndrome (FMS) (Barker, 2014; Bidonde, 2014; Cerrilo-Urbina, 2015; Naumann, 2014). 

Both 1:1 treatments and group aquatic classes have been shown to be beneficial, although they have not been directly compared to determine which is more effective. Vertical aquatic exercise has been shown to be more effective than multiple kinds of land-based treatments (Sevimli, 2015); swimming has also been shown to be of benefit (Fernades, 2016). Both strengthening exercises and aerobic conditioning are considered very beneficial for the fibromyalgia patient, although aerobic exercise seems to be overall more beneficial for patients with FMS than strengthening exercises (Sevimli, 2015). Studies have shown that the frequency of treatment sessions can occur either two or three times per week, although there is obvious cost-benefits to holding frequencies down (Cuesta-Vargas, 2014). Therapists interested in making a case for the medical necessity of aquatics for the patient with fibromyalga are directed to Salzman (2013).

In short, exercise in a therapeutic pool environment provides a safe and gentle means of addressing the multifaceted therapeutic concerns of patients with fibromyalgia. Recent publications, such as those provided below, can help us better understand the role aquatics can (and should) play.


Ángel García ET Al 2015
This review identifies current practice guidelines for patients with fibromyalgia. Among the recommended treatments are physical exercise (including aquatic exercise) and cognitive-behavioral therapy as front-line treatments. Amitriptyline is recommended as the medication of choice, to be used for short periods of time to control pain. The paper fleshes out best practices for this population.

This systematic review examines the effects of aquatic exercise on all musculoskeletal conditions, including chronic pain syndromes, such as fibromyalgia. The researchers found that aquatics produced moderate beneficial effects, especially notable for pain, quality of life and physical function. These findings are consistent with findings for land-based exercise for many of the conditions examined. 

This systematic review examined the effects of supervised group aquatic classes as led by an instructor. The researchers defined aquatic training as exercising in a pool while standing at waist, chest, or shoulder depth. Their review found low-to-moderate quality evidence which suggests that aquatic training is beneficial for improving wellness, symptoms, and fitness in adults with fibromyalgia. In addition, aquatic exercise produced no serious adverse effects.

Cerrillo-Urbina ET Al 2015
This systematic review and meta-analysis was designed to examine the effects of exercise on fibromyalgia. In general, exercise was found to be beneficial for women with fibromyalgia in their peri-menopausal period. The meta-analysis indicates that programs based on combined exercise and aquatic exercises have a moderate and small effect on functional global well-being. 

Cuesta-Vargas 2014
This study was designed to help therapists determine the optimal aquatic treatment frequency for patients with chronic musculoskeletal pain conditions. Their findings suggest that 2x/week sessions produce similar results to 3x/week sessions and should be considered as a way to manage cost-effectiveness of therapy. 

Fernandes ET Al 2016
This study compares the benefits of walking and swimming for the patient with fibromyalgia syndrome. Patients in both study groups showed pain improvement after a 3 month program. There was no significant difference in the pain relief provided between the two exercise environments. 

Naumann ET Al 2014
This systematic review and meta-analysis was designed to complain the effectiveness of balneotherapy (immersion plus exercise in mineral waters) and hydrotherapy (immersion plus exercise in plain water) on fibromyalgia. The meta-analysis showed moderate-to-strong evidence for both pain reduction and an improvement in health-related quality of life with hydrotherapy. There was no effect noted for reduction of depression or tender point count. 

Sevimli ET Al 2015
The researchers who created this study wished to compare the effects of aquatic, aerobic and isometric strength-stretching exercises on the physical and psychological parameters of patients with fibromyalgia. Three groups were compared: a home-based group, a gym-based group and a pool-based group. The results show that the pool-based (aquatic) group produced the most effective treatment, although all 3 groups showed significant improvements in almost all variables.

This practical online article details how to make a case for medical necessity of aquatic therapy when working with the fibromyalgia population. It walks therapists through how to document or argue for the benefits of aquatic therapy.

Zamunér ET Al 2015
In this controlled study, researchers wished to determine how aquatic exercise altered symptoms, aerobic conditioning and heart rate variability in women with fibromyalgia syndrome. They determined that a 16 week aquatic program was effective in addressing pain and improving cardiac variables in this population.


Andrade, C., & Zamunér, A. (2015). Effects of a hydrotherapy program on baroreflex sensitivity in women with fibromyalgia syndrome. Autonomic Neuroscience: Basic & Clinical, 192, 86. Retrieved from http://www.autonomicneuroscience.com/article/S1566-0702(15)00167-8/abstract

Ángel García, D., Martínez Nicolás, I., & Saturno Hernández, P. J. (2016). Clinical Approach to Fibromyalgia: Synthesis of Evidence-based Recommendations, a Systematic Review. Reumatología Clínica (English Edition), In press. doi:10.1016/j.reumae.2015.06.002. Retrieved from http://www.reumatologiaclinica.org/en/clinical-approach-fibromyalgia-syn...

Bağdatlı, A. O., Donmez, A., Eröksüz, R., Bahadır, G., Turan, M., & Erdoğan, N. (2015). Does addition of “mud-pack and hot pool treatment” to patient education make a difference in fibromyalgia patients? A randomized controlled single blind study. International Journal of Biometeorology, 59, 12: 1905-11. doi:10.1007/s00484-015-0997-7. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25917265

Barker, A., Talevski, J., & Morello, R. (2014). Effectiveness of aquatic exercise for musculoskeletal conditions: a meta-analysis. Archives of Physical Medicine and Rehabilitation, 95(9), 1776–86. Retrieved from http://www.sciencedirect.com/science/article/pii/S0003999314002883 

Bidonde, J., Busch, A. J., Webber, S. C., Schachter, C. L., Danyliw, A., Overend, T. J., … Rader, T. (2014). Aquatic exercise training for fibromyalgia. The Cochrane Database of Systematic Reviews, 10, CD011336. doi:10.1002/14651858.CD011336 Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25350761

Cerrillo-Urbina, A. J., García-Hermoso, A., Sánchez-López, M., & Martínez-Vizcaíno, V. (2015). Effect of Exercise Programs on Symptoms of Fibromyalgia in Peri-Menopausal Age Women: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Journal of Musculoskeletal Pain. Online version. Retrieved from http://www.scopus.com/inward/record.url?eid=2-s2.0-84941255190&partnerID...

Cuesta-Vargas, A. (2014). The optimal frequency of aquatic physiotherapy for individuals with chronic musculoskeletal pain: a randomised controlled trial. Disability & Rehabilitation, 37(4), 311–8. Retrieved from http://informahealthcare.com/doi/abs/10.3109/09638288.2014.918191

Fernandes, G., Jennings, F., Nery Cabral, M. V., Buosi, A. L. P., & Natour, J. (2016). Swimming Improves Pain and Functional Capacity of Patients with Fibromyalgia: A Randomized Controlled Trial. Epub ahead of print. Archives of Physical Medicine and Rehabilitation. doi:10.1016/j.apmr.2016.01.026. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/26903145

Forte, M., Butler, M., & Andrade, K. (2015). Treatments for Fibromyalgia in Adult Subgroups. AHRQ Comparative Effectiveness Reviews. Rockville, MD. Report No.: 15-EHC006-EF.Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK274474/

Latorre Román, P. Á., Santos E Campos, M. P., & García-Pinillos, F. (2015). Effects of functional training on pain, leg strength and balance in women with fibromyalgia. Modern Rheumatology / the Japan Rheumatism Association, 25(6), 943–7. doi:10.3109/14397595.2015.1040614. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25867230

Macías-Hernández, S. I. S., Vázquez-Torres, L., Morones-Alba, J. D., Coronado-Zarco, R., de Los Angeles Soria-Bastida, M., Cruz-Medina, E., & Nava-Bringas, T. I. (2015). Water-based Tai Chi: theoretical benefits in musculoskeletal diseases. Current evidence. Journal of Exercise Rehabilitation, 11(3), 120–4. doi:10.12965/jer.150207. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4492420/

Naumann, J., & Sadaghiani, C. (2014). Therapeutic benefit of balneotherapy and hydrotherapy in the management of fibromyalgia syndrome: a qualitative systematic review and meta-analysis of randomized controlled trials. Arthritis Research & Therapy, 16(4), R141. doi:10.1186/ar4603. Retrieved from http://www.biomedcentral.com/content/pdf/ar4603.pdf

Salzman, A. Fibromyalgia Is (Or Should Be) All Wet: Proving medical necessity for aquatic therapy. (2013). Advance for Physical Therapy & Rehab Medicine. Retrieved from http://physical-therapy.advanceweb.com/Columns/Water-Wisdom/Fibromyalgia...

Sevimli, D., Kozanoglu, E., Guzel, R., & Doganay, A. (2015). The effects of aquatic, isometric strength-stretching and aerobic exercise on physical and psychological parameters of female patients with fibromyalgia syndrome. Journal of Physical Therapy Science, 27(6), 1781–6. doi:10.1589/jpts.27.1781. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4499983/

Zamunér, A. R., Andrade, C. P., Forti, M., Marchi, A., Milan, J., Avila, M. A., … Silva, E. (2015). Effects of a hydrotherapy programme on symbolic and complexity dynamics of heart rate variability and aerobic capacity in fibromyalgia patients. Clinical and Experimental Rheumatology, 33(1 Suppl 88), 73–81. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/25786047