- Warm Water Benefits Fibromyalgia Patients
- Aquatic exercise training for fibromyalgia
- Aquatic Therapy in Baltimore Eases Fibromyalgia Symptoms
- Benefits of Aquatic Therapy in Baltimore
- Warm Water Exercises and Fibromyalgia
- Finding the Right Aquatic Therapy in Baltimore
- Effectiveness of Aquatic Therapy vs Land-based Therapy for Balance and Pain in Women with Fibromyalgia: a study protocol for a randomised controlled trial
- Study design
- Enrollment and eligibility criteria
- Inclusion criteria
- Exclusion criteria
- Outcome measures
- Primary outcomes
- Secondary outcomes
- Aquatic therapy
- Land-based therapy
- Statistical issues
- Statistical analysis
- Water Therapy for Fibromyalgia May Help Pain
- Fibromyalgia and Water Therapy
- Aquatic Therapy for Fibromyalgia
Warm Water Benefits Fibromyalgia Patients
Fibromyalgia is a chronic pain disorder that can include musculoskeletal pain and fatigue along with many other symptoms that can affect every aspect of one’s life. It can be difficult to treat and many patients who suffer from fibromyalgia struggle to lead “normal” lives when the symptoms are so pervasive. According to the Mayo Clinic, fibromyalgia can also be linked to fatigue, sleep problems, headaches, depression and anxiety. The ability to keep these effects at bay is crucial for being able to maintain daily function.
Mary, a fibromyalgia sufferer for years, is one such patient who is now able to enjoy life thanks to the aquatic sessions she attends once a week with Barb Cacia, Wellness Coordinator at Pieters Family Life Center. Once hopeless, getting out of bed some days was nearly impossible. She has now reduced her medications to almost none and is able to maintain a much more “normal” daily life. Mary does multiple things to manage her symptoms. Aquatic therapy is an important piece of this puzzle.
This is one of the things that gives me hope. I would have to be almost dead not to make my water appointment.
Barb uses the water to help stretch and strengthen Mary’s muscles and joints as well as her core without causing pain. Their sessions consist of a warm up to loosen tight joints, aerobic exercise to increase her strength and a cool down to stretch her muscles and strengthen her core. Mary is able to do many more activities in the water than she would be able to tolerate on land. Oftentimes, conditions such as fibromyalgia can eventually cause other problems, such as osteoarthritis. In order to avoid the onset of osteoarthritis in Mary’s hip, Barb has her perform exercises specifically to stretch her outer hip and improve her function. Mary is adamant that she would not be able to do these types of exercises on land. By using the buoyancy of the water and dropping the adjustable floor to 6′, she is able to do some exercises completely weightless. The combination of ankle weights and floatation devices provides the right amount of counteracting forces to open up her joints. From this position, she is also able to perform some important core strengthening exercises.
Mary also walks and works on side shuffling using an underwater treadmill, which helps her to maintain cardiovascular fitness, improve her hip function and build muscle mass.
Watch her full story below:
View more case studies like this in our video library>>
Aquatic exercise training for fibromyalgia
We reviewed studies on the effects of aquatic exercise training for people with fibromyalgia on wellness, symptoms, fitness, and adverse effects.
Background: what is fibromyalgia and what is aquatic training?
People with fibromyalgia have persistent, widespread body pain and often experience symptoms such as fatigue, stiffness, depression, and difficulty sleeping.
Aquatic training is exercising in a pool while standing at waist, chest, or shoulder depth. This review examined the effects of supervised group aquatic training programs (led by an instructor).
We searched the literature up to October 2013 and found 16 studies with 866 women and 15 men with fibromyalgia; 439 were assigned to aquatic training programs.
Nine studies compared aquatic exercise to no exercise; five studies compared aquatic exercise to land-based exercise, and two studies compared aquatic training to a different aquatic training.
Key results: for those who took part in aquatic exercise training compared to people who did not exercise
Overall well-being (multidimensional function) on a scale of 0 to 100 units
Those who did aquatic exercise rated their overall well-being six units better at the end of the study than those who did not exercise.
Physical function (ability to do normal activities) on a scale of 0 to 100 units
Those who did aquatic exercise rated their ability to function four units better at the end of the study than those who did not exercise.
Pain on a scale of 0 to 100 units
Those who did aquatic exercise rated their pain seven units better at the end of the study than those who did not exercise.
Stiffness on a scale of 0 to 100 units
Those who did aquatic exercise rated their stiffness 18 units better at the end of the study than those who did not exercise.
People who did aquatic training improved their muscle strength by 37% more than those who did not do aquatic training.
Cardiovascular fitness estimated by meters walked in six minutes
Those who did aquatic exercise walked 37 meters further at the end of the study than those who did not exercise.
Dropping out of the studies
Two more participants out of 100 in the aquatic training groups dropped out of the studies (15 aquatic exercisers dropped out while 13 non-exercisers dropped out).
Quality of evidence – aquatic versus control
Further research on overall well being and ability to function is likely to have an important impact on our confidence in these results and may change the results.
Further research on pain, stiffness, muscle strength, and cardiovascular fitness is very likely to have an important impact on our confidence in these results and is likely to change the results.
Key results: for those who did aquatic training compared to people who did land-based exercise
People who did both programs had similar results for overall well-being, physical function, pain, and stiffness. However, people who exercise on land improved their muscle strength by 9% more than those who did aquatic training. About the same number of people from both groups dropped out.
Quality of evidence – aquatic versus land-based
As so few studies have been done so far, we are very uncertain about the results.
Key results: for those who did one kind of aquatic training compared to a different kind of aquatic training
There were two studies in this comparison: one compared Ai Chi (Tai Chi in the water) to stretching in the water, and the other compared aquatic training in a pool to aquatic training in sea water. The only important difference found was for stiffness, favoring the Ai Chi aquatic training.
Quality of evidence – aquatic versus aquatic programs
As so few studies have been done so far, further research is likely to change this result.
The authors declare no conflicts of interest in this work.
4. Doron Y, Peleg R, Peleg A, Neumann L, Buskila D. The clinical and economic burden of fibromyalgia compared with diabetes mellitus and hypertension among Bedouin women in the Negev. Fam Pract. 2004;21(4):415–419. doi:10.1093/fampra/cmh411
7. Silverman S, Dukes EM, Johnston SS, Brandenburg NA, Sadosky A, Huse DM. The economic burden of fibromyalgia: comparative analysis with rheumatoid arthritis. Curr Med Res Opin. 2009;25(4):829–840. doi:10.1185/03007990902728456
8. Berger A, Dukes E, Martin S, Edelsberg J, Oster G. Characteristics and healthcare costs of patients with fibromyalgia syndrome. Int J Clin Pract. 2007;61(9):1498–1508.
9. Annemans L, Le Lay K, Taïeb C. Societal and patient burden of fibromyalgia syndrome. PharmacoEconomics. 2009;27(7):547–559.
10. Boonen A, van Den Heuvel R, van Tubergen A, et al. Large differences in cost of illness and wellbeing between patients with fibromyalgia, chronic low back pain, or ankylosing spondylitis. Ann Rheum Dis. 2005;64(3):396–402. doi:10.1136/ard.2003.019711
19. Bidonde J, Busch AJ, Schachter CL, et al. Aerobic exercise training for adults with fibromyalgia. Cochrane Database Syst Rev. 2017;6:CD012700.
21. Eller-Smith OC, Nicol AL, Christianson JA. Potential mechanisms underlying centralized pain and emerging therapeutic interventions. Front Cell Neurosci. 2018;12. doi:10.3389/fncel.2018.00035
22. Lauche R, Cramer H, Hauser W, Dobos G, Langhorst J. A systematic overview of reviews for complementary and alternative therapies in the treatment of the fibromyalgia syndrome. Evid Based Complement Alternat Med. 2015;2015:610615. doi:10.1155/2015/610615
24. Demir-Göçmen D, Altan L, Korkmaz N, Arabaci R. Effect of supervised exercise program including balance exercises on the balance status and clinical signs in patients with fibromyalgia. Rheumatol Int. 2013;33(3):743–750. doi:10.1007/s00296-012-2444-y
25. Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;4:CD011279. doi:10.1002/14651858.CD011279.pub3
29. Carbonell-Baeza A, Aparicio VA, Chillón P, Femia P, Delgado-Fernandez M, Ruiz JR. Effectiveness of multidisciplinary therapy on symptomatology and quality of life in women with fibromyalgia. Clin Exp Rheumatol. 2012;29(6 Suppl 69):S97–S103.
30. Latorre PÁ, Santos MA, Heredia-Jiménez JM, et al. Effect of a 24-week physical training programme (in water and on land) on pain, functional capacity, body composition and quality of life in women with fibromyalgia. Clin Exp Rheumatol. 2013;31(6 Suppl 79):S72–S80.
32. Zamunér AR, Andrade CP, Forti M, et al. Effects of a hydrotherapy programme on symbolic and complexity dynamics of heart rate variability and aerobic capacity in fibromyalgia patients. Clin Exp Rheumatol. 2015;33(1 Suppl 88):S73–S81.
34. Charter of Physiotherapists. The definition of aquatic physiotherapy. Aqualines. 2009;21(2):6.
43. Avelar NCP, Bastone AC, Alcântara MA, Gomes WF. Effectiveness of aquatic and non-aquatic lower limb muscle endurance training in the static and dynamic balance of elderly people. Braz J Phys Ther. 2010;14(3):229–236.
44. Furnari A, Calabrò RS, Gervasi G, et al. Is hydrokinesitherapy effective on gait and balance in patients with stroke? A clinical and baropodometric investigation. Brain Inj. 2014;28(8):1109–1114. doi:10.3109/02699052.2014.910700
45. Volpe D, Giantin MG, Maestri R, Frazzitta G. Comparing the effects of hydrotherapy and land-based therapy on balance in patients with Parkinson’s disease: a randomized controlled pilot study. Clin Rehabil. 2014;28(12):1210–1217. doi:10.1177/0269215514536060
47. Pöyhönen T, Keskinen KL, Hautala A, Mälkiä E. Determination of hydrodynamic drag forces and drag coefficients on human leg/foot model during knee exercise. Clin Biomech (Bristol, Avon). 2000;15(4):256–260.
49. Batterham SI, Heywood S, Keating JL. Systematic review and meta-analysis comparing land and aquatic exercise for people with hip or knee arthritis on function, mobility and other health outcomes. BMC Musculoskelet Disord. 2011;12:123. doi:10.1186/1471-2474-12-181
50. Gibson AJ, Shields N. Effects of aquatic therapy and land-based therapy versus land-based therapy alone on range of motion, edema, and function after hip or knee replacement: a systematic review and meta-analysis. Physiother Can. 2015;67(2):133–141. doi:10.3138/ptc.2014-01
52. Rivas Neira S, Pasqual Marques A, Pegito Perez I, Fernandez Cervantes R, Vivas Costa J. Effectiveness of aquatic therapy vs land-based therapy for balance and pain in women with fibromyalgia: a study protocol for a randomised controlled trial. BMC Musculoskelet Disord. 2017;18(1):22. doi:10.1186/s12891-017-1624-z
56. Assis MR, Silva LE, Alves AM, et al. A randomized controlled trial of deep water running: clinical effectiveness of aquatic exercise to treat fibromyalgia. Arthritis Rheum. 2006;55(1):57–65. doi:10.1002/art.21693
58. Bote ME, Garcia JJ, Hinchado MD, Ortega E. An exploratory study of the effect of regular aquatic exercise on the function of neutrophils from women with fibromyalgia: role of IL-8 and noradrenaline. Brain Behav Immun. 2014;39:107–112. doi:10.1016/j.bbi.2013.11.009
59. Calandre EP, Rodriguez-Claro ML, Rico-Villademoros F, Vilchez JS, Hidalgo J, Delgado-Rodriguez A. Effects of pool-based exercise in fibromyalgia symptomatology and sleep quality: a prospective randomised comparison between stretching and Ai Chi. Clin Exp Rheumatol. 2009;27(5 Suppl 56):S21–S28.
62. de Andrade SC, de Carvalho RF, Soares AS, de Abreu Freitas RP, de Medeiros Guerra LM, Vilar MJ. Thalassotherapy for fibromyalgia: a randomized controlled trial comparing aquatic exercises in sea water and water pool. Rheumatol Int. 2008;29(2):147–152. doi:10.1007/s00296-008-0644-2
64. Fernandes G, Jennings F, Nery Cabral MV, Pirozzi Buosi AL, Natour J. Swimming improves pain and functional capacity of patients with fibromyalgia: a randomized controlled trial. Arch Phys Med Rehabil. 2016;97(8):1269–1275.
65. Gowans SE, deHueck A, Voss S, Silaj A, Abbey SE, Reynolds WJ. Effect of a randomized, controlled trial of exercise on mood and physical function in individuals with fibromyalgia. Arthritis Rheum. 2001;45(6):519–529.
66. Gusi N, Tomas-Carus P, Häkkinen A, Häkkinen K, Ortega-Alonso A. Exercise in waist-high warm water decreases pain and improves health-related quality of Life and strength in the lower extremities in women with fibromyalgia. Arthritis Rheum. 2006;55(1):66–73. doi: 10.1002/art.21718
67. Hecker CD, Melo C, Tomazoni S, Martins RÁBL, Leal Junior ECP. Análise dos efeitos da cinesioterapia e da hidrocinesioterapia sobre a qualidade de vida de pacientes com fibromialgia: um ensaio clínico randomizado. Fisioter Mov. 2011;24:57–64. doi:10.1590/S0103-51502011000100007
70. Kesiktas N, Karagulle Z, Erdogan N, Yazicioglu K, Yilmaz H, Paker N. The efficacy of balneotherapy and physical modalities on the pulmonary system of patients with fibromyalgia. J Back Musculoskelet Rehabil. 2011;24(1):57–65.
71. Latorre Roman PA, Santos ECMA, Garcia-Pinillos F. Effects of functional training on pain, leg strength, and balance in women with fibromyalgia. Mod Rheumatol. 2015;25(6):943–947.
72. Letieri RV, Furtado GE, Letieri M, et al. Dor, qualidade de vida, autopercepção de saúde e depressão de pacientes com fibromialgia, tratados com hidrocinesioterapia. Rev Bras Reumatol. 2013;53:494–500.
73. Lopez-Rodriguez MM, Fernandez-Martinez M, Mataran-Penarrocha GA, Rodriguez-Ferrer ME, Granados Gamez G, Aguilar Ferrandiz E. . Med Clin. 2013;141(11):471–478.
74. Mannerkorpi K, Nyberg B, Ahlmen M, Ekdahl C. Pool exercise combined with an education program for patients with fibromyalgia syndrome. A prospective, randomized study. J Rheumatol. 2000;27(10):2473–2481.
75. Mannerkorpi K, Nordeman L, Ericsson A, Arndorw M; Group GAUS. Pool exercise for patients with fibromyalgia or chronic widespread pain: a randomized controlled trial and subgroup analyses. J Rehabil Med. 2009;41(9):751–760.
76. Munguia-Izquierdo D, Legaz-Arrese A. Exercise in warm water decreases pain and improves cognitive function in middle-aged women with fibromyalgia. Clin Exp Rheumatol. 2007;25(6):823–830.
77. Munguia-Izquierdo D, Legaz-Arrese A. Assessment of the effects of aquatic therapy on global symptomatology in patients with fibromyalgia syndrome: a randomized controlled trial. Arch Phys Med Rehabil. 2008;89(12):2250–2257.
78. Perez de la Cruz S, Lambeck J. A new approach to the improvement of quality of life in fibromyalgia: a pilot study on the effects of an aquatic Ai Chi program. Int J Rheum Dis. 2018;21(8):1525–1532. doi:10.1111/1756-185X.12930.
79. Segura-Jimenez V, Carbonell-Baeza A, Aparicio VA, et al. A warm water pool-based exercise program decreases immediate pain in female fibromyalgia patients: uncontrolled clinical trial. Int J Sports Med. 2013;34(7):600–605.
80. Sevimli D, Kozanoglu E, Guzel R, Doganay A. The effects of aquatic, isometric strength-stretching and aerobic exercise on physical and psychological parameters of female patients with fibromyalgia syndrome. J Phys Ther Sci. 2015;27(6):1781–1786.
82. Tomas-Carus P, Gusi N, Hakkinen A, Hakkinen K, Raimundo A, Ortega-Alonso A. Improvements of muscle strength predicted benefits in HRQOL and postural balance in women with fibromyalgia: an 8-month randomized controlled trial. Rheumatology. 2009;48(9):1147–1151.
85. Clauw DJ. Fibromyalgia. JAMA. 2014;311(15):1547–1547.
86. Hauser W, Ablin J, Fitzcharles MA, et al. Fibromyalgia. Nat Rev Dis Primers. 2015;1:15022.
87. Wingenfeld K, Heim C, Schmidt I, Wagner D, Meinlschmidt G, Hellhammer DH. HPA axis reactivity and lymphocyte glucocorticoid sensitivity in fibromyalgia syndrome and chronic pelvic pain. Psychosom Med. 2008;70(1):65–72.
88. Naugle KM, Riley JL. Self-reported physical activity predicts pain inhibitory and facilitatory function. Med Sci Sports Exerc. 2014;46(3):622–629.
89. Geytenbeek J. Evidence for effective hydrotherapy. Physiotherapy. 2002;88(9):514–529.
90. Perraton L, Machotka Z, Kumar S. Components of effective randomized controlled trials of hydrotherapy programs for fibromyalgia syndrome: A systematic review. J Pain Res. 2009;2:165–173.
91. Mooventhan A, Nivethitha L. Scientific evidence-based effects of hydrotherapy on various systems of the body. N Am J Med Sci. 2014;6(5):199–209.
93. Hall J, Swinkels A, Briddon J, McCabe CS. Does aquatic exercise relieve pain in adults with neurologic or musculoskeletal disease? A systematic review and meta-analysis of randomized controlled trials. Arch Phys Med Rehabil. 2008;89(5):873–883.
95. Mense S. Algesic agents exciting muscle nociceptors. Exp Brain Res. 2009;196(1):89–100.
96. Harris RE, Sundgren PC, Craig AD, et al. Elevated insular glutamate in fibromyalgia is associated with experimental pain. Arthritis Rheum. 2009;60(10):3146–3152.
97. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150(3699):971–979.
99. Pöyhönen T, Sipilä S, Keskinen KL, Hautala A, Savolainen J, Mälkiä E. Effects of aquatic resistance training on neuromuscular performance in healthy women. Med Sci Sports Exerc. 2002;34(12):2103–2109.
100. Forti M, Zamuner AR, Andrade CP, Silva E. Lung function, respiratory muscle strength, and thoracoabdominal mobility in women with fibromyalgia syndrome. Respir Care. 2016;61(10):1384–1390.
101. Furlan R, Colombo S, Perego F, et al. Abnormalities of cardiovascular neural control and reduced orthostatic tolerance in patients with primary fibromyalgia. J Rheumatol. 2005;32(9):1787–1793.
104. Zamunér AR, Barbic F, Dipaola F, et al. Relationship between sympathetic activity and pain intensity in fibromyalgia. Clin Exp Rheumatol. 2015;33(1 Suppl 88):S53–S57.
105. Bou-Holaigah I, Calkins H, Flynn JA, et al. Provocation of hypotension and pain during upright tilt table testing in adults with fibromyalgia. Clin Exp Rheumatol. 1997;15(3):239–246.
106. Aicher SA, Randich A. Antinociception and cardiovascular responses produced by electrical stimulation in the nucleus tractus solitarius, nucleus reticularis ventralis, and the caudal medulla. Pain. 1990;42(1):103–119.
107. Bruehl S, Chung OY. Interactions between the cardiovascular and pain regulatory systems: an updated review of mechanisms and possible alterations in chronic pain. Neurosci Biobehav Rev. 2004;28(4):395–414. doi:10.1016/j.neubiorev.2004.06.004
108. Bruehl S, Chung OY, Jirjis JN, Biridepalli S. Prevalence of clinical hypertension in patients with chronic pain compared to nonpain general medical patients. Clin J Pain. 2005;21(2):147–153.
109. Andrade A, Vilarino GT, Serafim TT, Junior AAP, de Souza CA, Sieczkowska SM. Modulation of autonomic function by physical exercise in patients with fibromyalgia syndrome: A systematic review. PM&R. 2019. doi:10.1002/pmrj.12158
110. Hall J, Grant J, Blake D, Taylor G, Garbutt G. Cardiorespiratory responses to aquatic treadmill walking in patients with rheumatoid arthritis. Physiother Res Int. 2004;9(2):59–73.
111. Valim V, Oliveira L, Suda A, et al. Aerobic fitness effects in fibromyalgia. J Rheumatol. 2003;30(5):1060–1069.
112. Langhorst J, Musial F, Klose P, Hauser W. Efficacy of hydrotherapy in fibromyalgia syndrome–a meta-analysis of randomized controlled clinical trials. Rheumatology. 2009;48(9):1155–1159. doi:10.1093/rheumatology/kep182
114. Cazzola M, Atzeni F, Salaffi F, Stisi S, Cassisi G, Sarzi-Puttini P. Which kind of exercise is best in fibromyalgia therapeutic programmes? A practical review. Clin Exp Rheumatol. 2010;28(6 Suppl 63):S117–S124.
115. Hauser W, Arnold B, Eich W, et al. Management of fibromyalgia syndrome–an interdisciplinary evidence-based guideline. German Med Sci. 2008;6:Doc14.
116. Arca EA, Martinelli B, Martin LC, Waisberg CB, Franco RJ. Aquatic exercise is as effective as dry land training to blood pressure reduction in postmenopausal hypertensive women. Physiother Res Int. 2014;19(2):93–98. doi:10.1002/pri.1565
117. Asa C, Maria S, Katharina SS, Bert A. Aquatic exercise is effective in improving exercise performance in patients with heart failure and type 2 diabetes mellitus. Evid Based Complement Alternat Med. 2012;2012:349209. doi:10.1155/2012/349209
118. Benfield RD, Hortobagyi T, Tanner CJ, Swanson M, Heitkemper MM, Newton ER. The effects of hydrotherapy on anxiety, pain, neuroendocrine responses, and contraction dynamics during labor. Biol Res Nurs. 2010;12(1):28–36. doi:10.1177/1099800410361535
120. Crofford LJ. The hypothalamic-pituitary-adrenal stress axis in fibromyalgia and chronic fatigue syndrome. Z Rheumatol. 1998;57(Suppl 2):67–71.
121. Crofford LJ. Neuroendocrine abnormalities in fibromyalgia and related disorders. Am J Med Sci. 1998;315(6):359–366.
122. Griep EN, Boersma JW, de Kloet ER. Altered reactivity of the hypothalamic-pituitary-adrenal axis in the primary fibromyalgia syndrome. J Rheumatol. 1993;20(3):469–474.
123. Cuatrecasas G, Riudavets C, Guell MA, Nadal A. Growth hormone as concomitant treatment in severe fibromyalgia associated with low IGF-1 serum levels. A pilot study. BMC Musculoskelet Disord. 2007;8:119. doi:10.1186/1471-2474-8-119
127. Totsch SK, Sorge RE. Immune system involvement in specific pain conditions. Mol Pain. 2017;13:1744806917724559. doi:10.1177/1744806917724559
129. Imamura M, Targino RA, Hsing WT, et al. Concentration of cytokines in patients with osteoarthritis of the knee and fibromyalgia. Clin Interv Aging. 2014;9:939–944. doi:10.2147/CIA.S60330
132. Kosek E, Altawil R, Kadetoff D, et al. Evidence of different mediators of central inflammation in dysfunctional and inflammatory pain — interleukin-8 in fibromyalgia and interleukin-1 β in rheumatoid arthritis. J Neuroimmunol. 2015;280:49–55. doi:10.1016/j.jneuroim.2015.02.002
133. Ortega E, Garcia JJ, Bote ME, et al. Exercise in fibromyalgia and related inflammatory disorders: known effects and unknown chances. Exerc Immunol Rev. 2009;15:42–65.
139. Sramek P, Simeckova M, Jansky L, Savlikova J, Vybiral S. Human physiological responses to immersion into water of different temperatures. Eur J Appl Physiol. 2000;81(5):436–442. doi:10.1007/s004210050065
141. Naumann J, Sadaghiani C. Therapeutic benefit of balneotherapy and hydrotherapy in the management of fibromyalgia syndrome: a qualitative systematic review and meta-analysis of randomized controlled trials. Arthritis Res Ther. 2014;16(4):R141. doi:10.1186/ar4603
Aquatic Therapy in Baltimore Eases Fibromyalgia Symptoms
A low impact form of exercise called aquatic therapy can be tailored to your tolerance level and help improve your day-to-day symptoms. Now is the time to look into aquatic therapy in Baltimore at Comprehensive Spine and Sports Center. Our programs use warm water exercises and help improve some of the symptoms of fibromyalgia.
Benefits of Aquatic Therapy in Baltimore
Studies show that warm-water exercise has the potential to offer some benefits for people with fibromyalgia. For instance, it can improve pain threshold to help make symptoms of fibromyalgia more manageable and can reduce tender-point counts. Additionally, regular aquatic therapy can help improve mental health and cognitive function. Plus, it can also help decrease body fat which in turn will reduce the effect of fibromyalgia on the body.
Warm Water Exercises and Fibromyalgia
The reason that aquatic therapy helps those with fibromyalgia is because it is a low impact form of exercise. Vigorous exercise will pull on joints and ligaments that already ache from fibromyalgia, but the buoyancy of the water relieves pressure from your joints and ligaments as you work out. The warm water itself also soothes the body, which makes exercise less likely to trigger any painful episodes. In fact, most people leave aquatic therapy feeling refreshed and relaxed.
Finding the Right Aquatic Therapy in Baltimore
In order to get the best results from therapy, you need to work with a trained therapist who has experience treating fibromyalgia with aquatic therapy. Comprehensive Spine & Sports Center is a premier rehabilitation center with specialized expertise in aquatic therapy in Baltimore. Dr. Neil Cohen and the staff at Comprehensive Spine & Sports Center create personalized therapy routines meant to ease your symptoms. Reach out today for more information.
Effectiveness of Aquatic Therapy vs Land-based Therapy for Balance and Pain in Women with Fibromyalgia: a study protocol for a randomised controlled trial
The study will be a single-blind randomised controlled trial.
Enrollment and eligibility criteria
The sample will consist of 40 women, members of the “Fibromyalgia, Chronic Fatigue Syndrome and Multiple Chemical Sensitiviy Association” (ACOFIFA), in A Coruña (Spain).
Age range between 35 and 64 years .
FM diagnosis according to the ACR criteria: 1990 and 2010 .
Mark ≥ 4 on “Visual Analogue Scale” (VAS) for pain.
Mark ≥ 5 on EVA for balance, included in the “Revised Fibromyalgia Impact Questionnaire” (FIQR).
Medical history of severe trauma.
Severe psychiatric diseases.
Peripheral nerve entrapment.
Inflammatory rheumatic diseases.
People who suffered traumatic injuries in the past 6 months.
Anxiety conditions related to water.
Severe cardiovascular disease.
Patients who do exercise regularly.
Significant changes in pharmacological treatment during the study period.
The assessments will take place at the Faculty of Physiotherapy of the University of A Coruña (Spain). Three assessment blocks will be established to carry out the measurements. A group of blinded trained assessors will be in charge of each block. In the first block, sociodemographic data (years since FM diagnosis, marital status, employment status, education level, smoking, number of falls in the last 6 months and medication) and anthropometric data (age, weight, height and body-mass index) will be registered. Pain intensity, fatigue, sleep quality, quality of life and self-confidence in balance will also be assessed. The second block will focus on measuring the pain threshold for the 18 tender points and functional independence in performing activities of daily life. Finally, the third block will assess physical ability and static/dynamic balance. Patients will be evaluated at three different moments: At baseline, immediately after the end of treatment and at 6-weeks follow-up.
Once the patients have read and signed the informed consent, those who have met the inclusion criteria, will be randomly assigned to one of the two intervention groups:
Active Control Group: Land-based exercise program (CG n = 20).
Experimental Group: Water exercise program (EG n = 20).
The randomisation will be carried out in a 1:1 manner via a computer-based scheme. The allocation will be concealed using sealed and opaque envelopes, numbered consecutively . An independent researcher who will not participate in other study procedures will perform the randomisation process. The flow diagram of the study is summarised in Fig. 1.
Flow diagram of the study
All assessment instruments will be used in their validated Spanish versions, except for the Berg scale which is not validated in Spanish and will have to be applied in a translated version.
Static balance will be assessed with the Romberg’s test and dynamic balance with both the Timed Up & Go (TUG) test and a gait test.
In order to quantify and increase the objetivity of balance assessment, all tests will be filmed. Mechanical parameters of the movement will subsequently be analysed with the Computer Vision Mobility (CvMob) software ; the analysis is shown in Fig. 2. Patients will be instructed to attend the study wearing a form fitting top and shorts, or swim suits and to take off their shoes during all tests. The CvMob is an open source tool for movement analysis, created with the OpenCv and Qt libraries . The software uses computing vision techniques, pattern recognition and optical flow to make object tracking possible, generating data of trajectory, speed, acceleration, and angular movement . The equipment consists of a digital camera and CvMob program. The camera, a “Casio Exilim EX-ZR1000” model, with a resolution of 16.1 megapixels and 120 frames/s, will be used to record videos. The camera will be attached to a tripod and will be positioned at a distance of 2.27 m from the patient during the Romberg’s test and at 3.15 m for the gait test. For a proper analysis, the CvMob should always be calibrated at the begginning of each video. Calibration consists of providing a reference measurement to the software, which will be used to do all of the calculations. For the Romberg’s test, the instrument used to calibrate the system consists of a brown cardboard marked with two yellow points placed at a 20 cm interval distance. A mark painted on the floor of 21.5 cm in length will be used for the gait test. A series of markers will be placed on certain bony landmarks to facilitate registration of different motion parameters and further analysis. For static balance, the total speed, mean, standard deviation and amplitude of oscillation around the medio-lateral (ML) and anterior-posterior (AP) axes will be studied. The results that CvMob provides for these parameters are equal to those given by a conventional force platform. The gait speed and the length/height of step will be studied for dynamic balance. All of these parameters are explained in Table 1.
Analysis and data extraction for the oscillation around the AP axis in Romberg’s test
Table 1 Outcomes analysed with the CvMob software
A recent study of validity and reliability has shown that CvMob is a reliable tool for two-dimensional analysis of human gait. The results have revealed a strong correlation between CvMob and “Vicon Motion System” , a three-dimensional capture motion system with a high technological precision for movement analysis. In addition, a strong correlation has also been observed in both inter and intra-rater analysis. This demonstrates that CvMob results are reproducible by different researchers and by the same person, at different times .
This test assesses the integrity of proprioception. Central postural control depends on three systems: Visual, vestibular and proprioceptive . If the patient has a loss of proprioception, balance is maintained through activation of the visual and vestibular systems. However, if the patient is also deprived of eyesight, any proprioceptive disorder compensated by this system, will be detected and balance will be lost.
In order to increase test sensitivity, the Romberg’s test will also be performed with feet in the tandem position . Therefore, 4 tests will be carried out, with a single attempt for each one and with a 10-s pause between each test:
Test 1: Feet together, arms along the body and eyes open. Hold this position for 30 s.
Test 2: Feet together, arms along the body and eyes closed. Hold this position for 30 s.
Test 3: Feet in tandem position (the heel of the dominant must be placed inmediately in front of the non-dominant foot), arms crossed over the chest and eyes open. Hold this position for 30 s.
Test 4: Feet in tandem position, arms crossed over the chest and eyes closed. Hold this position for 30 s.
The test is positive when the oscillation significantly worsens with the eyes closed .
Timed Up & Go Test:
This test is a functional mobility test whose purpose is to assess balance in the sitting position, transfers from a sitting position to a standing position and vice versa. It also evaluates stability during ambulation and direction changes while in gait without using compensatory strategies. The test consists of standing up from a chair with armrests and walking, at a normal speed, for 3 m, turning 180° and walking back to the chair. It will be practised once in order to insure that methodology is clear. At the time of assessment, only one single attempt will be registered. The test is measured in seconds and quantifies the time that the patient takes to complete the walk. A time of 10 s or less is considered normal and a time longer than 14 s is indicative of impaired balance and a high risk of falls .
The patient will have to walk, at a normal speed, for 8 m. The test will be practised once. As a limitation of optical range of the camera, only 3–4 gait cycles will be captured. Therefore, the 3 central meters of the walk should be used in the analysis of gait parameters.
It will be measured with the EVA, a 10 cm long line with the value 0 on the left indicating “no pain” and the value 10 on the right indicating the “worst imaginable pain” . The distance along the line indicated by the patient will correlate with their average pain intensity in the last week. Scores between 0 cm and 3 cm are classified as “mild pain”; between 4 cm and 7 cm “moderate pain” and between 8 cm and 10 cm “severe pain”.
Pressure Pain threshold (PPT)
This is defined as the minimum pressure that triggers a painful response. An electronic algometer (Commander™ Algometer de JTECH Medical) will be used to measure the PPT on the 18 tender points, according to the ACR criteria . The unit of pressure measurement will be kg/cm2, and the assessments will be done bilaterally, always beginning from the point located on the right. To avoid the risk of temporal summation , each tender point will be assessed only once. A 1 cm2 rubber tip will be used to centralise the pressure, the 18 tender points are:
Occiput: Suboccipital muscle insertion.
Supraspinatus muscle: Supraspinatus tendon, above medial scapular spine.
Trapezius: Midpoint of the upper border.
Greater trochanter: Posterior to the greater trochanter of the femur.
Gluteus maximus: Upper outer quadrant of the buttocks in the anterior muscle fold.
Lower cervical: Anterior C5-C7 intertransverse space.
Second intercostal space: At the second costochondral junction.
Lateral epicondyle: 2 cm distal to the lateral epicondyle.
Medial knee: Medial fat pad of the knee, proximal to the joint line.
The procedure will be explained to the patients and demonstrated by performing a measurement on a non-included point. The rubber tip of the algometer will be placed perpendicularly to the skin and patients will have to say “stop” when the pressure begins to be painful.
This will be assessed with the “Berg Scale” , a 14-item scale that evaluates the static, dynamic and functional balance during the activities of daily living (ADL’s). Each item is scored from 0 to 4, where 0 means the inability to perform the task and 4 means the ability to complete the task without difficulty. The maximum score possible is 56 points and a score lower than 45 is related to risk of fall .
Quality of life
This will be assessed with the FIQR , a tool which tries to address the limitations of the Fibromyalgia Impact Questionnaire (FIQ) while at the same time maintaining the basic properties of the FIQ. The FIQR is composed of 21 questions that make reference to the week prior to answering the questionnaire. Each question is based on an 11-point numeric rating scale of 0 to 10, with 10 being “worst”. The questionnaire is divided into three linked domains: Function, overall impact and symptoms. The “symptoms” domain contains four new questions relating to memory, tenderness, balance and environmental sensitivity (to loud noises, bright lights, odours and cold temperatures). The total FIQR score is the sum of the following 3 domain scores that can reach a maximum of 100 points: The “function” score (from 0 to 90) is divided by 3; the “overall impact” score (from 0 to 20) is not changed and the “symptoms” score (from 0 to 100) is divided by 2. Higher values indicate a poorer quality of life.
Quality of sleep
This will be evaluated with the Pittsburgh Sleep Qualitiy Index (PSQI) a retrospective tool for measureing quality of sleep and sleep disorders. The PSQI is a 19-item questionnaire that refers to last month. It contains 7 sleep components: Subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication and daytime dysfunction. The total PSQI is the sum of all component scores that can reach a maximum of 21 points. Higher values indicate a poorer sleep quality.
This will be evaluated by the Multidimensional Fatigue Inventory (MFI) , a 20-item assessment tool with five domains: General fatigue, physical fatigue, mental fatigue, reduced activity and reduced motivation. Each fatigue domain consists of four items and has a potential score ranging from 4 to 20, where higher MFI scores indicate a higher degree of fatigue.
Self-confidence in balance
This will be assessed with the Activities-specific Balance Confidence (ABC) scale , a 16-item questionnaire that measures the self-confidence in balance for performing ADL’s. Each item is based on a 0–100 scale where 0 is “no confidence” and 100 is “total confidence”. The total ABC score is calculated using the sum of all-items (range 0 to 1600) divided by 16. Scores >80% indicate a high level of physical functioning, 50–80% a moderate level, and scores <50% a low level of physical functioning. Scores <67% in older adults are predictive of future falls .
This will be measured with the 6-minute walk test , which determines the maximum distance that a person can walk in 6 minutes along a 20-m corridor. Heart rate (HR) and oxygen saturation will also be assessed with pulse oximetry. Dyspnea and lower limb fatigue will be measured with the modified Borg scale . These parameters will be registered before the start of the test, immediately after and during recovery time (when the patient returns to baseline HR).
The interventions designed in this protocol consist of two similar physiotherapy protocols for people with FM. Both will include 60-min sessions that will be carried out 3 times a week for 3 months by a physiotherapist, in groups of 8–9 people maximum.
Both interventions will be based on: 15 min of warm-up, 25 min of proprioceptive exercises, 8 min of stretching and 12 min of relaxation.
For adequate training of balance and postural control, patients will be required to contract their local musculature (“core stability”) before starting any specific exercise. The transversus abdominis, pelvic floor muscles, internal oblique and multifidus form the local musculature. The most important aspect of achieving core stability will be co-activation of the first two muscles, for which patients will have to place their pelvis in a neutral position. Before starting the interventions, patients will receive anatomy and palpation classes to aid in identification of the involved musculature and how its contraction is perceived.
The protocols have been created by the main researcher based on available scientific evidence. The protocols were designed with the intention of being as similar as possible in order to attribute any statistically significant difference in outcomes between the two groups to the environment where the interventions were performed. Sessions will be pre-programmed with a progression in difficulty over the intervention period: Shorter pauses, higher exercise intensity, eyes closed, etc.
Patients will not be allowed to begin any other activity during the study period. They will have to report any problems, whether event-related or not, as well as any medication changes.
The twenty patients included in the EG will perform aquatic therapy in the Rialta Sports Complex, in A Coruña (Spain). The water temperature is 30 °C, with less than 1 °C of variation, and the environmental temperature is 27.5 °C, with less than 1 °C of variation. Sessions will be given in a swimming-pool of 20 × 6 m, with a 120-cm depth. The aquatic therapy protocol is described in Table 2.
Table 2 Description of aquatic therapy protocol
The twenty patients included in the CG will perform the intervention in one of the laboratories at the Faculty of Physical Therapy. The land-based therapy protocol is described in Table 3.
Table 3 Description of land-based therapy protocol
Sample size calculation
The sample size was calculated to find a difference of ± 2.5 points between intervention groups on the VAS pain intensity scale , with a standard deviation of 2.5 points .
In order to achieve a statistical power of 80% with a significance level of p ≤ 0.05 and assuming a 20% dropout rate, an estimated 20 participants are required in each of the intervention groups. This sample size allows for detecting differences of 2 ± 2 s in the TUG test, with a statistical power of 80% and a significance level of p ≤ 0.05, assuming a 20% dropout rate.
The sample size was defined for a bilateral hypothesis and was carried out by the ENE software.
Analysis will be descriptive of all outcomes included in the study, expressing quantitative outcomes with their mean ± standard deviation and qualitative outcomes with their absolute value, percentage and 95% confidence intervals.
The association between qualitative outcomes will be studied using the Chi-square test. After checking normality with the Kolmogorov-Smirnov test, the Student T test or the Mann–Whitney U test will be used to perform mean comparison. The mean comparison between two or more categories will be studied with the ANOVA test or Kruskal-Wallis test, as appropriate.
The correlation between quantitative outcomes will be analysed with the Pearson or Spearman correlation coefficients, as appropriate.
The mean comparisons for related outcomes in two different moments will be studied with the Wilcoxon test. Friedman test will be used when comparing more than two moments. In addition, the clinical relevance of the intervention will be studied by calculating the relative risk, relative risk reduction, absolute risk reduction and the number needed to treat. All of these measures will be presented with their 95% confidence interval.
A multivariate analysis by multiple linear regression or logistic regression to adjust for the effectiveness of the intervention according to possible confounding factors and to determine what other outcomes might be associated with each result will be carried out. Only the outcomes that show a statistical significance p <0.20 in the bivariate analysis, will be included in the multivariate regression analysis. In addition, a stepwise backward modelling strategy will be carried out.
All analysis will be done by intention to treat , where the total value of randomisation is preserved and control of any counfounders’ effect is insured.
The significance level set for all the analysis will be p ≤0.05. The SPSS statistical software, version 21.0 (SPSS, Chicago, IL) will be used for all analysis.
Water Therapy for Fibromyalgia May Help Pain
Fibromyalgia and Water Therapy
Spring is here — the time of year when life begins to stir again and activities increase as people make their way outdoors.
This can be scary and frustrating for those dealing with fibromyalgia. As much as we want to participate, some days, it takes all one can muster to get moving. Still, moving is exactly what you need to be doing!
If you are suffering from fibromyalgia, at this very moment you are doing something you may not even be aware of — clenching, an involuntary reaction to stress that leads to more pain.
This is why a stressful lifestyle and too much time spent sitting or laying down is like double jeopardy for those suffering with fibromyalgia pain. It is natural for us to avoid activity when we’re in pain, but movement is exactly what we need.
The Value of Exercise in Pain Management
Studies show that if a person can develop a routine of exercising three times a week, even low impact exercises, it will help control fibromyalgia pain and muscle tenderness. Exercise also relieves fatigue and depression, and helps people feel better about themselves and more in charge of their lives. Exercise helps your mood, helps you sleep better and helps your pain.
But it’s easier said than done sometimes isn’t it? I know for me personally as a FM sufferer, exercise is a difficult task on some days. Though once I get moving I feel so much better and can accomplish more after loosening those achy, tense muscles.
If traditional exercise such as walking or stretching or even yoga is too painful, there is another alternative that could be an ideal solution – especially as the warmer weather approaches. That solution is water aerobics, or water therapy as it is sometimes called.
Why Water Therapy?
If you stay extremely stiff or live with a high level of pain each day, traditional exercise is a daunting task, but water therapy is a wonderful place to start for developing an exercise routine. It is also a great alternative for those dealing with obesity in addition to their fibromyalgia.
You May Also Like:Trying Acupuncture for Fibromyalgia Treatment
- Warm water from a shower or bath can be very comforting — it is the same with water therapy in a pool. Water aerobics get blood flow to muscles and tendons without stressing your joints.
- Water offers resistance, which helps muscles get stronger. It actually provides a three-dimensional resistance to movement so muscles develop more equally in all directions.
- Water applies hydrostatic pressure to bodies immersed in it, which reduces swelling and discomfort. So, exercising in water helps improve fitness while treating your pain at the same time.
- The natural buoyancy of water helps you move and allows you to exercise in ways that would otherwise be painful. It eliminates painful tissues and joints and provides an ease of movement that is not possible with routine exercise for those suffering with fibromyalgia.
- You don’t need to know how to swim. Should you sign up for aquatic therapy or a water aerobics class, the instructor will conduct the workout in shallow water and if you are taken to the deeper end of the pool, you bob in deep water with a foam belt, floatation devices or a life jacket.
Whether you choose water aerobics under the care of an instructor, a physical therapist in a heated facility or in your own backyard pool, it is a wonderful way to implement exercise into your weekly routine.
The good news about structured aquatic therapy is that most insurers, workers’ comp and private companies pay for or reimburse the therapy if prescribed by a licensed medical professional.
For those dealing with joint pain (among other pain concerns), any type of fitness program that can create a stronger and more toned body without potential damage is ideal. To find a therapy pool near you, check out your local Arthritis Foundation office, YMCA, YWCA, or fitness and health clubs in your area. Call to see if they offer warm water therapy classes. Call your doctor’s office to see if their physical therapy referrals have any recommendations. Ask for referrals from local chiropractors, massage therapists, or support groups, etc.
Keep in mind that many senior centers also have recommendations for aqua therapy classes. Age may not be a deterrent. Many senior centers encourage participation in their fitness programs from those of any age who have limited mobility issues.
NOTE: If available, look for saltwater pools rather than ones using chemical compounds such as chlorine. Many public pools – and especially therapeutic pools – are now switching to salt water systems for the health and wellness of their members.
Are you ready to take the plunge? The coldest season of the year is the perfect time to try out the warm and soothing benefits that aqua therapy has to offer.
Sue Ingebretson (www.RebuildingWellness.com) is an author, speaker, certified holistic health care practitioner and the director of program development for the Fibromyalgia and Chronic Pain Center at California State University, Fullerton. She is also a Patient Advocate/Fibromyalgia Expert for the Alliance Health website and a Fibromyalgia editor for the ProHealth website community.
Her #1 Amazon best-selling chronic illness book, FibroWHYalgia, details her own journey from chronic illness to chronic wellness. She is also the creator of the FibroFrog™– a therapeutic stress-relieving tool which provides powerful healing benefits with fun and whimsy.
1. “Aquatic Therapy.” Aquahab Physical Therapy.
2. Schachner, J. “Benefits of Aquatic Therapy for the Arthritic Patient.” Athletico Physical Therapy. June 26, 2012.
3. “Aquatic Exercise and Tai Chi Effective Therapy for Osteoarthritis.” Arthritis Foundation.
Aquatic Therapy for Fibromyalgia
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