of fibromyalgia: a systematic review with meta-analysis · myalgia, hydrotherapy, clinical trial,...
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Clinical Rehabilitation27(10) 892 –908© The Author(s) 2013Reprints and permissions: sagepub.co.uk/journalsPermissions.navDOI: 10.1177/0269215513484772cre.sagepub.com
CLINICALREHABILITATION
484772 CRE271010.1177/0269215513484772Clinical RehabilitationLima et al.2013
1 PAIFIT Research Group, Universidade Estadual de Londrina, Brazil
2Centro de Oncologia Bucal, Araçatuba, Brazil3 Department of Physical Therapy, Phonoaudiology and Occupational Therapy, Faculdade de Medicina da Universidade de Sao Paulo, Brazil
The effectiveness of aquatic physical therapy in the treatment of fibromyalgia: a systematic review with meta-analysis
Tarcisio Brandão Lima1, Josilainne Marcelino Dias1, Bruno Fles Mazuquin1, Carla Tassiana da Silva1, Regiane Mazzarioli Pereira Nogueira2, Amélia Pasqual Marques3, Edson Lopes Lavado1 and Jefferson Rosa Cardoso1
AbstractObjective: To assess the effectiveness of aquatic physical therapy in the treatment of fibromyalgia.Data sources: The search strategy was undertaken using the following databases, from 1950 to December 2012: MEDLINE, EMBASE, CINAHL, LILACS, SCIELO, WEB OF SCIENCE, SCOPUS, SPORTDiscus, Cochrane Library Controlled Trials Register, Cochrane Disease Group Trials Register, PEDro and DARE.Review methods: The studies were separated into groups: Group I – aquatic physical therapy × no treatment, Group II – aquatic physical therapy × land-based exercises and Group III – aquatic physical therapy × other treatments.Results: Seventy-two abstracts were found, 27 of which met the inclusion criteria. For the functional ability (Fibromyalgia Impact Questionnaire), three studies were considered with a treatment time of more than 20 weeks and a mean difference (MD) of –1.35 [–2.04; –0.67], P = 0.0001 was found in favour of the aquatic physical therapy group versus no treatment. The same results were identified for stiffness and the 6-minute walk test where two studies were pooled with an MD of –1.58 [–2.58; –0.58], P = 0.002 and 43.5 (metres) [3.8; 83.2], P = 0.03, respectively.Conclusion: Three meta-analyses showed statistically significant results in favour of the aquatic physical therapy (Fibromyalgia Impact Questionnaire, stiffness and the 6-minute walk test) during a period of longer than 20 weeks. Due to the low methodological rigor, the results were insufficient to demonstrate statistical and clinical differences in most of the outcomes.
KeywordsFibromyalgia, hydrotherapy, aquatic physical therapy, controlled clinical trial, meta-analysis
Received: 26 July 2012; accepted: 10 March 2013
Article
Corresponding author:Jefferson R Cardoso, Laboratory of Biomechanics and Clinical Epidemiology, PAIFIT Research Group, Universidade Estadual de Londrina, Av. Robert Koch, 60, Londrina-PR, 86038-440, Brazil. Email: [email protected]
Lima et al. 893
Introduction
Fibromyalgia manifests with widespread pain, it is a major cause of disability which worsens the activ-ities of daily life and leads to a large number of patients seeking medical treatment and physiother-apy.1 Several studies have assessed the effective-ness of treatments for fibromyalgia on land.2,3 Aquatic physical therapy, consisting of a pro-gramme in a heated pool, conducted and supervised by a physical therapist and designed for the subject to increase their musculoskeletal function, is often used in patients with fibromyalgia.4
Reviews by Gowans et al. and Perraton et al. have addressed the effects of aquatic exercises, but with a limited search period and a language restric-tion.5,6 Other reviews have addressed balneother-apy, thalassotherapy and spa therapy, but these techniques are not within the scope of this study.7,8 Thus, the aim of this review was to assess the effec-tiveness of aquatic physical therapy on the treat-ment of fibromyalgia.
Method
We undertook a systematic review of randomized controlled trials with meta-analysis according to the criteria of the Cochrane Collaboration and PRISMA Statement.9,10 In this review, only randomized con-trolled trials on the treatment of fibromyalgia with aquatic physical therapy which included patients who had been diagnosed according to the criteria of the American College of Rheumatology were accepted.11 There were no language or age restric-tions. Randomized controlled trials that had as their main intervention balneotherapy, thalassotherapy, spa therapy or any other type of bath and non- randomized controlled trials were not included in the study.
The outcome measures we studied were those proposed by the American College of Rheumatology: musculoskeletal pain, number of tender points, quality of life, fatigue, sleep disturbances, morning stiffness, depression, anxiety, physical function and rate of perceived exertion (RPE).11 Two indepen-dent assessors made the data extraction.
The search strategy was performed by two inde-pendent investigators assisted by a specialist librar-ian in the following databases up to December 2012: MEDLINE (Medlars Online, 1966–2012), EMBASE (Excerpta Medica Database, 1980–2012), CINAHL (Cumulative Index to Nursing and Allied Health Literature, 1982–2012), LILACS (Latin American and Caribbean Health Science, 1982–2012), SCIELO (Scientific Electronic Library Online, 1998–2012), WEB OF SCIENCE (1970–2012), SCOPUS (1996–2012), SPORTDiscus (1985–2012), AMED (Allied and Complementary Medicine Database) (1985–2012), Cochrane Controlled Trials Register Library, Cochrane Disease Group Trials Register, PEDro (Physiotherapy Evidence Database), DARE (Database of Reviews of Effects). The Medline’s search strategy is shown in Appendix 1 (online) and the following MESH terms were used: fibro-myalgia, hydrotherapy, clinical trial, controlled clinical trial and meta-analysis. Other non-MESH terms such as: fibromyalgia syndrome, aquatic exercise, aquatic therapy, aquatic training, aquatic rehabilitation, aquatic physical therapy, swim-ming therapy, controlled study and systematic review, were also used. In addition, the same researchers performed a manual search on jour-nals of the area.
The studies included in this review were classi-fied into three categories according to their com-parisons: aquatic physical therapy × no treatment; aquatic physical therapy × land-based exercises; aquatic physical therapy × other treatments. The intervention period were also divided into 4–8 weeks, 9–20 weeks, more than 20 weeks and, for the category aquatic physical therapy × no treat-ment, six months of follow-up.
To avoid selection bias, the internal validity of the included studies was evaluated by two indepen-dent reviewers. When there was disagreement between the two, a third experienced reviewer was invited to rule on the decision. This assessment fol-lowed the Cochrane Collaboration Handbook rec-ommendations and items such as: randomization, concealment allocation, blinding of assessment and intention-to-treat analysis were used and were clas-sified as: low risk when clearly described, high risk
894 Clinical Rehabilitation 27(10)
when not described and unclear when described as indeterminate in the text.9
The information from the included studies was presented descriptively, using tables. To evaluate the agreement of the results of the risk of bias of the studies analysed between two raters kappa coeffi-cient (κ) was used. The agreement was excellent when (κ) was >0.81, good between 0.61 and 0.80, moderate between 0.41 and 0.60 and poor below 0.40. The confidence interval (CI) of 95% was cal-culated by multiplying 1.96 by the standard error.12
The mean difference (MD) or standardized mean difference (SMD) was used for analysis of continu-ous data with 95% CI. For all analyses, a fixed-effects model was used if the results were homogeneous (P > 0.10), and a random-effects model was used if heterogeneity was present (P ≤ 0.10). For the analysis we used SPSS (Statistical Package for Social Sciences, version 15.0) and for the meta-analysis Review Manager – Revman 5.1.7. Statistical significance was set at 5% (P ≤ 0.05).
Results
Seventy-two abstracts were found and 20 were excluded because they were duplicated in two or more databases. After a brief reading of the abstracts, three studies were excluded. In the end, 49 completed studies were evaluated, 22 were excluded and 27 met the inclusion criteria for the qualitative synthesis. Of these 27, 15 were consid-ered for the meta-analysis (Figure 1).
The studies were separated into groups and arranged as follow: Group I – aquatic physical ther-apy × no treatment (n = 16) (Table 1),13–28 Group II – aquatic physical therapy × land-based exercises (n = 5) (Table 2)29–33 and Group III – aquatic physi-cal therapy × other treatments (n = 6) (Table 3).34–39 The total number of participants was 1265 (680 aquatic physical therapy and 585 control). Regarding gender, 16 studies were composed of female participants,18–22,24–32,35,36 three with both genders33,37,39 and eight did not specify.13–17,23,34,38 The duration of programmes varied from 3 to 32 weeks and between two and five times per week for the aquatic physical therapy groups.
According to the classification of the Cochrane Collaboration,9 for the randomization item, eight studies presented a high risk of bias,24–29,31,38 13 an unclear risk14–18,20–23,30,33,35,39 and only six studies presented a low risk.13,19,32,34,36,37 In the item alloca-tion concealment 21 studies presented a high risk,14–
18,20–28,30,31,33–35,37,39 one presented an unclear risk21 and only five presented a low risk.13,29,32,36,38 In the item blinding of assessment, 15 studies presented a high risk13–15,16–18,20–23,25,26,33,37,39 and 12 presented a low risk.19,24,27–32,34–36,38 For the item intent-to-treat 19 studies presented a high risk13,14,18,20–28,30,31,33,35,36,38,39 and eight studies a low risk15–17,19,29,32,34,37 (Figure 2 online). The intra-rater agreement varied from 0.64 to 0.83 (Table 4). The values for all items were κ = 0.80 95% CI [0.71;0.89], error = 0.05.
Meta-analysis was performed only in group I with 11 studies and 4 analyses and in group II with 4 studies and 1 analysis, using the outcomes estab-lished by the American College of Rheumatology,11 for instance, pain and number of tender points. Then impact, stiffness, fatigue, depression and physical function were analysed. In group III it was not pos-sible to perform meta-analysis because of the diver-sity of comparisons, which impeded the pooling of the studies. Results are presented in accordance with the group and performance of interventions for treatment versus no treatment only for or aquatic versus land-based exercises.
Aquatic physical therapy × no treatment; 4–8 weeksIn this period of treatment pain, depression, the walk test and perceived exertion were analysed. These forest plots combined studies by Gowans et al.14,16 and presented no statistically significant dif-ferences for these outcomes.
Aquatic physical therapy × no treatment; 9–20 weeksIn this second period of comparison: pain, tender points, quality of life and depression were assessed including studies by Gowans et al.,16 Gusi et al.,17 Munguia-Izquierdo et al.,18 Tomás-Carús et al.,20–22 but did not present any differences.
Lima et al. 895
Figure 1. Flow diagram of the search strategy.
Aquatic physical therapy × no treatment; more than 20 weeks
For more than 20 weeks of training, the outcomes assessed were: pain, tender points, quality of life, stiffness, fatigue, depression and the walk test. These forest plots represented the studies by Gowans et al.,16 Mannerkorpi et al.,24 Tomás-Carús et al.25,27 For the outcome quality of life, MD = –1.35 [–2.04; 0.67], P = 0.0001, in favour of the aquatic therapy group (Figure 3). For stiffness, MD = –1.58 [–2.58; –0.58], P = 0.002, also in favour of the
aquatic therapy group (Figure 4). For the outcome physical function, the 6-minute walk test was supe-rior with MD = 43.5 (metres) [3.8; 83.2], P = 0.03, favouring the aquatic therapy group (Figure 5). For the other outcomes there were no significant differences.
Aquatic physical therapy × no treatment; follow-up (six months)Only pain and depression were analysed and included the studies by Cedraschi et al.13 and Gusi
896 Clinical Rehabilitation 27(10)
Tabl
e 1.
Aqu
atic
phy
sical
ther
apy
× no
trea
tmen
t.
Aut
hors
Subj
ects
Tim
e in
terv
entio
n/fo
llow
-up
Inte
rven
tion
prog
ram
me
Out
com
es/m
ater
ials
Con
clus
ions
Ced
rasc
hi
2004
13n
tota
l = 1
64 F
emal
e/m
ale
G1
= aq
uatic
phy
sical
th
erap
y +
exer
cise
pr
ogra
mm
es +
or
ient
atio
nn
= 84
(48.
9 ye
ars)
78
F/6M
G2
= co
ntro
ln
= 80
(49.
8 ye
ars)
74
F/6M
n fin
al =
129
(G1
= 61
; G
2 =
68)
G1
= 90
min
, 2 ×
per
w
eek,
6 w
eeks
G2
= w
aitin
g lis
tFo
llow
-up:
6 m
onth
s
Tem
p =
34°C
Swim
min
g; re
lax
exer
cise
s; lo
w-
impa
ct g
roun
d ex
erci
ses
and
grou
p ex
erci
ses
Qua
lity
of li
fe, a
nxie
ty,
depr
essio
n, g
ener
al h
ealth
, w
elln
ess,
vita
lity
and
self-
cont
rol a
nd v
italit
y. Q
ualit
y of
life
, gen
eral
hea
lth, p
hysic
al
func
tion
(SF-
36),
func
tiona
l co
nseq
uenc
es o
f sym
ptom
s an
d N
TP
Sign
ifica
nt im
prov
emen
ts in
qu
ality
of l
ife a
nd s
atisf
actio
n.
At f
ollo
w-u
p, di
ffere
nces
wer
e m
aint
aine
d to
fatig
ue, d
epre
ssio
n,
anxi
ety
and
vita
lity
Gow
ans
1999
14n
tota
l = 4
5 su
bjec
tsG
1 =
aqua
tic p
hysic
al
ther
apy
+ or
ient
atio
nn
= 23
G2
= co
ntro
ln
= 22
n fin
al =
41
G1
= 20
(44.
3 ye
ars)
G2
= 21
(46.
6 ye
ars)
G1
= 30
min
, 2 ×
per
w
eek,
6 w
eeks
G2
= w
aitin
g lis
t.Fo
llow
-up:
no
30 m
in a
quat
ic p
hysic
al th
erap
y; 20
min
wal
king
, run
ning
and
re
sistiv
e ex
erci
se, 5
min
st
retc
hing
at t
he b
egin
ning
and
en
d; 6
0 m
in g
roup
ori
enta
tion
HR
60–7
5% o
f age
-adj
uste
d m
axim
um
Phys
ical
func
tion
test
(6-m
in
wal
k), p
erce
ived
exe
rtio
n (R
PE),
pain
, fun
ctio
n an
d sy
mpt
oms
(ASE
S), f
unct
iona
l ca
paci
ty, p
ain,
fatig
ue, m
orni
ng
tired
ness
, stif
fnes
s, an
xiet
y an
d de
pres
sion
(FIQ
)
Sign
ifica
nt im
prov
emen
ts in
6-
min
wal
k, w
elln
ess
and
mor
ning
tir
edne
ss
Gow
ans
2004
15n
tota
l = 3
7 Fe
mal
e/m
ale
G1
= aq
uatic
phy
sical
th
erap
yn
= 29
(47.
3 ye
ars)
–
follo
w-u
p
G1
= 30
min
, 3 ×
per
w
eek
Follo
w-u
p: 2
4 an
d 48
w
eeks
Tem
p =
hot w
ater
10 m
in s
tret
chin
g (b
egin
ning
and
en
d), 2
0 m
in a
erob
ic e
xerc
iseH
R 60
–75%
of a
ge-a
djus
ted
max
imum
Dep
ress
ion
(BD
I), p
hysic
al
func
tion
(6-m
in w
alk
test
), pe
rcei
ved
exer
tion
(RPE
), an
xiet
y (S
TAI),
qua
lity
of li
fe
(FIQ
), pa
in, f
unct
ion,
sym
ptom
s (A
SES)
, men
tal h
ealth
(MH
I) an
d N
TP
Phys
ical
func
tion
and
depr
essio
n ca
n be
impr
oved
up
to 1
2 m
onth
s fo
llow
ing
23 w
eeks
of
supe
rvise
d ex
erci
se c
lass
es
Gow
ans
2001
16n
tota
l = 5
1 su
bjec
tsG
1 =
aqua
tic p
hysi
cal
ther
apy
n =
27 (4
4.6
year
s)
24F/
3MG
2 =
cont
rol
n =
24 (4
9.8
year
s)
20F/
3M
G1
= 30
min
, 3 ×
per
w
eeks
, 23
wee
ksTe
mp
= ho
t wat
er10
min
str
etch
ing
(beg
inni
ng a
nd
end)
, 20
min
aer
obic
exe
rcise
CF
60–7
5%H
R 60
–75%
of a
ge-a
djus
ted
max
imum
Dep
ress
ion
(BD
I), p
hysic
al
func
tion
(6-m
in w
alk
test
), pe
rcei
ved
exer
tion
(RPE
), an
xiet
y (S
TAI),
qua
lity
of li
fe
(FIQ
), pa
in, f
unct
ion,
sym
ptom
s (A
SES)
, men
tal h
ealth
(MH
I) an
d N
TP
Exer
cise
can
impr
ove
the
moo
d an
d ph
ysic
al fu
nctio
n of
in
divi
dual
s w
ith fi
brom
yalg
ia
(Con
tinut
ed)
Lima et al. 897
Aut
hors
Subj
ects
Tim
e in
terv
entio
n/fo
llow
-up
Inte
rven
tion
prog
ram
me
Out
com
es/m
ater
ials
Con
clus
ions
Gus
i 200
617
n to
tal =
35
subj
ects
G1
= aq
uatic
phy
sical
th
erap
yn
= 18
G2
= co
ntro
ln
= 17
n fin
al =
34
G1
= 17
(51.
0 ye
ars)
G2
= 17
(51.
9 ±
9.0
age)
G1
= 60
min
, 3 ×
per
w
eek,
12 w
eeks
G2
= us
ual a
ctiv
ities
of
dai
ly li
ving
Follo
w-u
p: 2
4 w
eeks
Tem
p =
33º
C10
min
war
m-u
p, 10
min
aer
obic
ex
erci
se, 2
0 m
in g
ener
al m
obili
ty
and
stre
ngth
of l
ower
and
upp
er
limbs
, 10
min
aer
obic
exe
rcise
an
d 10
min
coo
l-dow
n.H
R 60
–75%
of a
ge-a
djus
ted
max
imum
Isok
inet
ic to
rque
for
knee
fle
xors
and
ext
enso
rs a
nd
shou
lder
s ad
duct
or a
nd
abdu
ctor
mus
cles
, qua
lity
of li
fe
(EQ
-5D
) and
pai
n (V
AS)
The
ther
apy
relie
ved
pain
an
d im
prov
ed q
ualit
y of
life
an
d m
uscl
e st
reng
th in
the
lo
wer
lim
bs a
t lo
w v
eloc
ity in
pa
tient
s w
ith in
itial
low
mus
cle
stre
ngth
and
a h
igh
num
ber
of
tend
er p
oint
s. M
ost
of t
hese
im
prov
emen
ts w
ere
mai
ntai
ned
in th
e lo
ng-t
erm
Mun
guia
-Iz
quie
rdo
2007
18
n to
tal =
60
fem
ale
G1
= aq
uatic
phy
sical
th
erap
yn
= 35
G2
= co
ntro
ln
= 25
n fin
al =
53
(G1
= 29
; G
2 =
24)
G1
= 70
min
, 3 ×
per
w
eek,
16 w
eeks
G2
= us
ual a
ctiv
ities
of
dai
ly li
ving
Follo
w-u
p: 4
8 w
eeks
Tem
p =
32°C
10 m
in w
arm
-up,
10–2
0 m
in
stre
ngth
exe
rcise
, 20–
30 m
in
aero
bic
exer
cise
and
10
min
co
ol-d
own
HR
50–8
0% o
f age
-adj
uste
d m
axim
um
NTP
(cal
ibra
ted
syri
nge)
, pai
n (V
AS)
, sev
erity
of f
ibro
mya
lgia
(F
IQ),
cogn
itive
func
tion
(PA
SAT,
TMT,
CO
WA
, RAV
LT)
and
anxi
ety
(SA
I)
The
exer
cise
gro
up im
prov
ed
signi
fican
tly th
eir
thre
shol
d of
pain
, te
nder
poi
nt c
ount
, sel
f-rep
orte
d, se
verit
y of
fibr
omya
lgia
and
cogn
itive
func
tion,
whe
reas
in th
e co
ntro
l gro
up th
e di
ffere
nces
wer
e no
t sign
ifica
nt
Mun
guia
-Iz
quie
rdo
2008
19
n to
tal =
60
subj
ects
G1
= aq
uatic
phy
sical
th
erap
yn
= 35
G2
= co
ntro
ln
= 25
G1
= 70
min
, 3 ×
per
w
eek,
16 w
eeks
G2
= us
ual a
ctiv
ities
of
dai
ly li
ving
Follo
w-u
p: 4
8 w
eeks
Tem
p =
32°C
10 m
in w
arm
-up,
10–2
0 m
in
stre
ngth
exe
rcise
, 20–
30 m
in
aero
bic
exer
cise
and
10
min
co
ol-d
own
HR
50–8
0% o
f age
-adj
uste
d m
axim
um
NTP
(cal
ibra
ted
syri
nge)
, se
veri
ty o
f fib
rom
yalg
ia
(FIQ
), sle
ep (P
SQI),
phy
sical
as
sess
men
t (st
reng
th,
resis
tanc
e to
low
load
ing
test
), ps
ycho
logi
cal e
valu
atio
n (S
AI)
and
cogn
itive
func
tion
(PA
SAT)
An
exer
cise
the
rapy
3 t
imes
a
wee
k fo
r 16
wee
ks i
n a
war
m p
oo
l co
uld
impr
ove
m
ost
of
the
sym
pto
ms
of
fibro
mya
lgia
and
cau
se a
hi
gh a
dher
ence
to
exe
rcis
e in
unf
it w
om
en w
ith
heig
hten
ed f
ibro
mya
lgia
sy
mpt
om
ato
logy
Tom
ás-C
arús
20
0720
n to
tal =
34
fem
ale
G1
= aq
uatic
phy
sical
th
erap
yn
= 17
(51.
0 ye
ars)
G2
= co
ntro
ln
= 17
(51.
0 ye
ars)
G1
= 60
min
, 3 ×
per
w
eek,
12 w
eeks
of
trai
ning
and
12
wee
ks n
o tr
aini
ngG
2 =
usua
l act
iviti
es
of d
aily
livi
ngFo
llow
-up:
12
wee
ks
Tem
p =
33°C
10 m
in w
arm
-up,
10 m
in a
erob
ic
exer
cise
, 20
min
gen
eral
mob
ility
an
d st
reng
th o
f low
er a
nd u
pper
lim
bs, 1
0 m
in a
erob
ic e
xerc
ise
and
10 m
in c
ool-d
own
HR
60–7
5% o
f age
-adj
uste
d m
axim
um
Qua
lity
of li
fe (S
F-36
e F
IQ),
phys
ical
fitn
ess(
CA
F, ha
ndgr
ip
test
, 10-
met
re w
alk
test
, 10
-sta
ir te
st, b
alan
ce te
st w
ith
1 le
g an
d cl
osed
eye
s) a
nd
flexi
bilit
y (s
it an
d re
ach
test
)
The
wat
er e
xerc
ise
pro
toco
l im
prov
ed s
om
e co
mpo
nent
s o
f H
RQ
OL,
bal
ance
, and
st
air
clim
bing
in
fem
ales
wit
h fib
rom
yalg
ia,
but
regu
lar
exer
cise
and
hi
gher
int
ensi
ties
may
be
requ
ired
to
pre
serv
e m
ost
of
thes
e ga
ins
Tabl
e 1.
(Con
tinue
d)
898 Clinical Rehabilitation 27(10)
Tabl
e 1.
(Con
tinue
d)
Aut
hors
Subj
ects
Tim
e in
terv
entio
n/fo
llow
-up
Inte
rven
tion
prog
ram
me
Out
com
es/m
ater
ials
Con
clus
ions
Tom
ás-C
arús
20
0721
n to
tal =
33
fem
ale
G1
= aq
uatic
phy
sical
th
erap
yn
= 17
G2
= co
ntro
ln
= 16
n fin
al =
30
G1
= 15
(50.
7 ye
ars)
G2
= 15
(50.
9 ye
ars)
G1
= 60
min
, 3 ×
per
w
eek,
8 m
onth
sG
2 =
rem
aine
d ph
ysic
ally
inac
tive
Follo
w-u
p: n
o
Tem
p =
33°C
10 m
in w
arm
-up,
10 m
in a
erob
ic
exer
cise
, 20
min
gen
eral
mob
ility
an
d st
reng
th o
f low
er a
nd u
pper
lim
bs, 1
0 m
in a
erob
ic e
xerc
ise
and
10 m
in c
ool-d
own
HR
60–7
5% o
f age
-adj
uste
d m
axim
um
Pain
(FIQ
Spa
nish
ver
sion
and
VAS)
and
pai
n (S
F-36
) ten
der
poin
ts (p
hysic
al e
xam
inat
ion)
The
aqua
tic th
erap
y gr
oup
achi
eved
impr
ovem
ents
in p
ain
(FIQ
) and
bod
ily p
ain
(SF-
36). T
he
num
ber
of te
nder
poi
nts
did
not
chan
ge s
igni
fican
tly
Tom
ás-C
arús
20
0722
n to
tal =
34
fem
ale
G1
= aq
uatic
phy
sical
th
erap
yn
= 17
(51.
0 ye
ars)
G2
= co
ntro
ln
= 17
(51.
0 ye
ars)
G1
= 60
min
, 3 ×
per
w
eek,
12 w
eeks
Tem
p =
33°C
10 m
in w
arm
-up,
10 m
in a
erob
ic
exer
cise
, 20
min
gen
eral
mob
ility
an
d st
reng
th o
f low
er a
nd u
pper
lim
bs, 1
0 m
in a
erob
ic e
xerc
ise
and
10 m
in c
ool-d
own
HR
60–7
5% o
f age
adj
uste
d m
axim
um
Func
tiona
l cap
acity
(FIQ
)Th
e ph
ysic
al th
erap
y gr
oup
was
ef
fect
ive
in r
educ
ing
the
impa
ct
of th
e di
seas
e, p
hysic
al a
nd
men
tal h
ealth
Gus
i 200
823
n to
tal =
33
subj
ects
G1
= aq
uatic
phy
sical
th
erap
yn
= 17
(50.
7 ye
ars)
G2
= co
ntro
ln
= 16
(50.
9 ye
ars)
G1
= 60
min
, 3 ×
per
w
eeks
, 8 m
onth
sG
2 =
usua
l act
iviti
es
of d
aily
livi
ng F
ollo
w-
up: 1
2 an
d 32
wee
ks
Tem
p= 3
3°C
10 m
in w
arm
-up,
10 m
in a
erob
ic
exer
cise
, 20
min
gen
eral
mob
ility
an
d st
reng
th o
f low
er a
nd u
pper
lim
bs, 1
0 m
in a
erob
ic e
xerc
ise
and
10 m
in c
ool-d
own
HR
60–7
5% o
f age
adj
uste
d m
axim
um
Qua
lity
of li
fe (E
Q-5
D) a
nd
QA
LYs
This
exer
cise
pro
gram
me
is co
st
effe
ctiv
e in
term
s of
bot
h he
alth
an
d so
cial
cos
ts
Man
nerk
orpi
20
0024
n to
tal =
58
fem
ale
G1
= aq
uatic
phy
sical
th
erap
yn
= 28
(45
year
s)G
2 =
orie
ntat
ion
prog
ram
me
n =
30 (4
7 ye
ars)
n fin
al =
57
G1
= 28
G2
= 29
G1
= 35
min
, 1 ×
per
w
eek,
6 m
onth
sG
2 =
60 m
in, 6
se
ssio
nsFo
llow
-up:
no
Resis
tive
exer
cise
s, fle
xibi
lity,
coor
dina
tion
and
rela
xatio
nQ
ualit
y of
life
(FIQ
), qu
ality
of
life
(SF-
36),
pain
per
cept
ion
(MPI
-S),
self-
effic
acy
(ASE
S-S)
, an
xiet
y an
d de
pres
sion
(AIM
S),
and
func
tiona
l tes
ts (6
-min
w
alki
ng te
st, s
tand
and
sea
t ch
air
test
, sho
ulde
r ra
nge
of
mov
emen
t and
end
uran
ce o
f sh
ould
er a
bduc
tion)
Ther
e w
ere
signi
fican
t diff
eren
ces
betw
een
grou
ps fo
r FI
Q, 6
-min
w
alk
test
, phy
sical
func
tion,
st
reng
th p
ress
ure,
sev
erity
of
pain
, soc
ial f
unct
ion,
psy
chol
ogic
al
dist
ress
and
qua
lity
of li
fe in
fa
vour
of t
he a
quat
ic th
erap
y
(Con
tinue
d)
Lima et al. 899
Aut
hors
Subj
ects
Tim
e in
terv
entio
n/fo
llow
-up
Inte
rven
tion
prog
ram
me
Out
com
es/m
ater
ials
Con
clus
ions
Tom
ás-C
arús
20
0725
n to
tal =
35
fem
ale
G1
= aq
uatic
phy
sical
th
erap
yn
= 18
G2
= co
ntro
ln
= 17
n fin
al =
34
G1
= 17
(51.
0 ye
ars)
G2
= 17
(51.
0 ye
ars)
G1
= 60
min
, 3 ×
per
w
eek,
12 w
eeks
G2
= no
rmal
dai
ly
activ
ities
Follo
w-u
p: 2
4 w
eeks
(12
wee
ks p
ost
trea
tmen
t)
Tem
p =
33°C
10 m
in w
arm
-up,
10 m
in a
erob
ic
exer
cise
, 20
min
gen
eral
mob
ility
an
d st
reng
th o
f low
er a
nd u
pper
lim
bs, 1
0 m
in a
erob
ic e
xerc
ise
and
10 m
in c
ool-d
own
HR
60–7
5% o
f age
adj
uste
d m
axim
um
Pain
(FIQ
Spa
nish
ver
sion
and
VAS)
, pai
n (S
F-36
) and
NTP
(m
edic
al e
xam
inat
ion)
Eigh
t mon
ths
of p
hysic
al e
xerc
isein
war
m w
ater
was
an
effe
ctiv
e tr
eatm
ent t
o de
crea
se th
e pa
in
in w
omen
with
fibr
omya
lgia
. H
owev
er, t
he p
hysic
al e
xerc
ise
prog
ram
me
was
not
effe
ctiv
e in
de
crea
sing
the
NTP
Man
nerk
orpi
20
0226
n to
tal =
28
fem
ale
G1
= aq
uatic
phy
sical
th
erap
yFo
llow
-up
Follo
w-u
p: 2
4 w
eeks
– te
st a
fter
trea
tmen
t48
wee
ks: f
irst
fo
llow
-up
n =
2512
0 w
eeks
: sec
ond
follo
w-u
pn
= 26
Resis
tive
exer
cise
s, fle
xibi
lity,
coor
dina
tion
and
rela
xatio
nC
F 70
%
Qua
lity
of li
fe (F
IQ a
nd S
F-36
), ph
ysic
al fu
nctio
n (6
-min
w
alki
ng te
st, V
AS
befo
re w
alk
test
and
RPE
afte
r w
alk
test
an
d gr
ip s
tren
gth
Ther
e w
as im
prov
emen
t in
the
seve
rity
of f
ibro
mya
lgia
sy
mpt
oms,
phys
ical
and
soc
ial
func
tion
afte
r 24
mon
ths
of
follo
w-u
p
Tom
ás-C
arús
20
0827
n to
tal =
30
fem
ale
G1
= aq
uatic
phy
sical
th
erap
yn
= 15
G2
= us
ual a
ctiv
ities
of
daily
livi
ng n
= 1
5
G1
= 60
min
3 ×
per
w
eek,
32 w
eeks
G2
= us
ual a
ctiv
ities
of
dai
ly li
ving
Tem
p =
33°C
10 m
in w
arm
-up,
10 m
in a
erob
ic
exer
cise
, 20
min
gen
eral
mob
ility
an
d st
reng
th o
f low
er a
nd u
pper
lim
bs, 1
0 m
in a
erob
ic e
xerc
ise
and
10 m
in c
ool-d
own
HR
60–7
5% o
f age
adj
uste
d m
axim
um
Qua
lity
of li
fe (F
IQ),
anxi
ety
(STA
I), V
o 2m
ax, h
and
dyna
mom
eter
, fun
ctio
nal
capa
city
(max
spe
ed te
st, s
tair
te
st, c
arry
ing
a ba
g of
5 k
g) a
nd
flexi
bilit
y (s
it an
d re
ach
test
)
Eigh
t mon
ths
of e
xerc
ise le
d to
long
-ter
m im
prov
emen
ts
in p
hysic
al a
nd m
enta
l hea
lth
in p
atie
nts
with
fibr
omya
lgia
in
a s
imila
r m
agni
tude
to th
e pr
ogra
mm
es o
f a s
hort
er
regi
men
Tom
ás-C
arús
20
0928
n to
tal =
30
fem
ale
G1
= aq
uatic
phy
sical
th
erap
yn
= 15
(50.
8 ye
ars)
G2
= us
ual a
ctiv
ities
of
daily
livi
ngn
= 15
G1
= 60
min
, 3 ×
per
w
eek,
32 w
eeks
G2
= us
ual a
ctiv
ities
of
dai
ly li
ving
Tem
p =
33°C
10 m
in w
arm
-up,
10 m
in a
erob
ic
exer
cise
, 20
min
gen
eral
mob
ility
an
d st
reng
th o
f low
er a
nd u
pper
lim
bs, 1
0 m
in a
erob
ic e
xerc
ise
and
10 m
in c
ool-d
own
HR
60–7
5% o
f age
adj
uste
d m
axim
um
Max
imal
isok
inet
ic to
rque
for
knee
flex
ors
and
exte
nsor
s m
uscl
es, p
ostu
ral b
alan
ce
(upr
ight
pos
ture
test
with
1
leg)
and
qua
lity
of li
fe r
elat
ed
to h
ealth
(SF-
36)
Long
-ter
m a
quat
ic e
xerc
ise in
ho
t wat
er p
rodu
ced
signi
fican
t ga
ins
in m
uscl
e st
reng
th a
t low
sp
eeds
of m
ovem
ent,
som
e of
w
hich
pro
vide
s im
prov
emen
ts
in p
hysic
al p
robl
ems,
emot
iona
l pr
oble
ms,
men
tal h
ealth
and
ba
lanc
e
G1,
gro
up 1
; G2,
gro
up 2
; F, f
emal
e; M
, mal
e; te
mp,
tem
pera
ture
; SF-
36, S
hort
For
m 3
6 H
ealth
Sur
vey;
NTP
, num
ber
of te
nder
poi
nts;
RPE,
rat
e of
per
ceiv
ed e
xert
ion;
ASE
S, A
rthr
itis
Self-
Effic
acy
Scal
e; FI
Q, F
ibro
mya
lgia
Impa
ct Q
uest
ionn
aire
; BD
I, Be
ck D
epre
ssio
n In
vent
ory;
STA
I, St
ate-
Trai
t Anx
iety
Inve
ntor
y; M
HI,
Men
tal H
ealth
Inve
ntor
y; EQ
-5D
, EQ
-5D
: hea
lth-r
elat
ed q
ualit
y of
life
; VA
S, vi
sual
ana
logu
e sc
ale;
PASA
T, Pa
ced
Aud
itory
Ser
ial A
dditi
on T
ask;
TMT,
Trai
l Mak
ing T
est;
CO
WA
, Con
trol
led
Ora
l Wor
d A
ssoc
iatio
n Te
st; R
AVLT
, Rey
Aud
itory
Ver
bal L
earn
ing T
est;
SAI,
Stat
e A
nxie
ty In
vent
ory;
PSQ
I, Pi
ttsb
urgh
Sle
ep Q
ualit
y In
dex;
CA
F, C
anad
ian
Aer
obic
Fitn
ess;
QA
LYs,
qual
ity-a
djus
ted
life
year
s; RO
M, r
ange
of m
ovem
ent.
Tabl
e 1.
(Con
tinue
d)
900 Clinical Rehabilitation 27(10)
Tabl
e 2.
Aqu
atic
phy
sical
ther
apy
× la
nd-b
ased
exe
rcise
.
Aut
hors
Subj
ects
Tim
e in
terv
entio
n/fo
llow
-up
Inte
rven
tion
prog
ram
me
Out
com
es/m
ater
ials
Con
clus
ions
Ass
is 20
0629
n to
tal =
60
subj
ects
G1
= aq
uatic
phy
sical
ther
apy
n =
30G
2 =
conv
entio
nal p
hysic
al
ther
apy
n =
30n
final
= 5
2 (G
1 =
26; G
2 =
26)
G1
= 60
min
, 3
× pe
r w
eek,
15
wee
ksG
2 =
60 m
in,
3 ×
per
wee
k, 15
w
eeks
Follo
w-u
p: 8
and
15
wee
ks
Tem
p =
28–3
1°C
10 m
in s
tret
chin
g, ae
robi
c fo
r 40
min
, 10
min
re
laxa
tion
Ana
erob
ic th
resh
old
(HR A
T)
Pain
(VA
S), g
loba
l pa
tient
ass
essm
ent o
f tr
eatm
ent (
PGA
RT),
depr
essio
n (B
DI)
and
qual
ity o
f life
(FIQ
and
SF
-36)
Aer
obic
gai
n w
as s
imila
r in
bot
h gr
oups
, how
ever
, the
aqu
atic
th
erap
y w
as m
ore
effe
ctiv
e in
the
emot
iona
l asp
ects
Hec
ker
2011
30n
tota
l = 2
4 fe
mal
esG
1 =
aqua
tic p
hysic
al th
erap
y n
= 12
(47.
5 ye
ars)
G2
= ki
nesio
ther
apy
n =
12 (4
5.3
year
s)
G1
= 60
min
, 3
× pe
r w
eek,
23
wee
ksG
2 =
60
min
, 3
× pe
r w
eek,
23
wee
ksFo
llow
-up:
no
Tem
p =
32–3
4°C
15 m
in s
tret
chin
g, 15
min
lo
w-in
tens
ity a
erob
ic
exer
cise
, 15
min
act
ive
mov
emen
t with
out l
oad
and
15 m
in s
tret
chin
g
Qua
lity
of li
fe (S
F-36
)Th
ere
was
no
diffe
renc
e be
twee
n gr
oups
for
the
SF-3
6.
In th
e in
trag
roup
ana
lysis
, bot
h th
erap
eutic
mea
sure
s w
ere
effe
ctiv
e
Jent
oft
2001
31n
tota
l = 3
4 w
omen
G1
= aq
uatic
phy
sical
ther
apy
n =
18 (4
2.9
year
s)G
2 =
conv
entio
nal p
hysic
al
ther
apy
n =
16 (3
9.4
year
s)
G1
= 60
min
, 2
× pe
r w
eek,
20
wee
ksG
2 =
60 m
in,
2 ×
per
wee
k, 20
w
eeks
.Fo
llow
-up:
24
wee
ks
Tem
p =
34°C
Body
aw
aren
ess,
ergo
nom
ics,
war
m-u
p, ae
robi
c da
nce,
coo
l-dow
n,
stre
tchi
ng, s
tren
gthe
ning
an
d re
laxa
tion
HR
60–8
0% o
f age
-adj
uste
d m
axim
um
Qua
lity
of li
fe (F
IQ),
pain
(VA
S an
d do
lori
met
er),
NTP
, se
lf-ef
ficac
y (A
SES)
an
d ph
ysic
al fu
nctio
n (c
ardi
ovas
cula
r, bi
ke
exer
cise
, gri
p st
reng
th:
gaug
e, s
houl
der
mus
cles
st
reng
th te
st)
Phys
ical
cap
acity
can
be
incr
ease
d by
exe
rcise
, eve
n w
hen
the
exer
cise
is p
erfo
rmed
in a
war
m-
wat
er p
ool. A
quat
ic th
erap
y pr
ogra
mm
es m
ay h
ave
som
e ad
ditio
nal e
ffect
s on
sym
ptom
s
Vito
rino
20
0632
n to
tal =
50
wom
enG
1 =
aqua
tic p
hysic
al th
erap
yn
= 25
(48.
9 ye
ars)
G2
= co
nven
tiona
l phy
sical
th
erap
yn
= 25
(46.
6 ye
ars)
n fin
al =
46
(G1
= 24
; G2
= 22
)
G1
= 60
min
, 3
× pe
r w
eek,
3 w
eeks
G2
= 60
min
, 3
× pe
r w
eek,
3 w
eeks
Follo
w-u
p: n
o
G1
= 5
min
war
m-u
p, 6
min
str
etch
ing
(at t
he
begi
nnin
g an
d en
d), 3
0 m
in
aero
bic
exer
cise
s an
d 13
min
rel
axat
ion
G2
= 10
min
infr
ared
th
erap
y, 5
min
str
etch
ing
(at t
he b
egin
ning
and
end
), 30
min
aer
obic
exe
rcise
s an
d 10
min
rel
axat
ion
Qua
lity
of li
fe (S
F-36
) an
d Sl
eep
(TST
and
TN
T)
Aqu
atic
ther
apy
and
land
-bas
ed
exer
cise
s ar
e eq
ually
effe
ctiv
e to
impr
ove
qual
ity o
f life
for
FM
patie
nts,
but a
quat
ic th
erap
y is
mor
e ef
fect
ive
than
land
-bas
ed
exer
cise
to im
prov
e TS
T an
d to
de
crea
se T
NT
(Con
tinue
d)
Lima et al. 901
Aut
hors
Subj
ects
Tim
e in
terv
entio
n/fo
llow
-up
Inte
rven
tion
prog
ram
me
Out
com
es/m
ater
ials
Con
clus
ions
Evci
k 20
0833
n to
tal =
63
F/M
G1
= aq
uatic
phy
sical
ther
apy
n =
33 (4
3.8
year
s)/3
1FG
2 =
hom
e ex
erci
ses
n =
30 (4
2.8
year
s) 3
1F/1
Mn
final
= 6
1 (G
1 =
31; G
2 =
30)
G1
= 60
min
, 3
× pe
r w
eek,
5 w
eeks
G2
= 60
min
, 3
× pe
r w
eek,
5 w
eeks
Follo
w-u
p: 1
2 an
d 24
wee
ks
Tem
p =
33°C
G1
= 20
min
war
m-u
p, ac
tive
ROM
and
rel
axat
ion,
35
min
war
m-u
p, ae
robi
c ex
erci
ses,
activ
e RO
M a
nd
5 m
in c
ool-d
own
G2
= 60
min
war
m-u
p, re
laxa
tion,
RO
M, a
erob
ic
exer
cise
, str
etch
ing
and
cool
-dow
n
NTP
, pai
n (V
AS)
, fu
nctio
nal a
bilit
y (F
IQ),
depr
essio
n (B
DI),
fatig
ue, s
tiffn
ess,
inso
mni
a, pa
raes
thes
ia,
irrita
ble
bow
el
synd
rom
e, R
ayna
ud’s
phen
omen
on, d
ryne
ss
sym
ptom
s, he
adac
he
and
blad
der
dysf
unct
ion
Both
trea
tmen
t pro
gram
mes
had
po
sitiv
e re
sults
in F
IQ, N
TP a
nd
BDI,
but i
n th
e pa
in tr
eatm
ent,
only
aqu
atic
ther
apy
seem
s to
ha
ve lo
ng-t
erm
effe
ct
G1,
gro
up 1
; G2,
gro
up 2
; F, f
emal
e; M
, mal
e; te
mp,
tem
pera
ture
; FIQ
, Fib
rom
yalg
ia Im
pact
Que
stio
nnai
re; S
F-36
, Sho
rt F
orm
36
Hea
lth S
urve
y; N
TP, n
umbe
r of
tend
er p
oint
s; A
SES,
Art
hriti
s Se
lf-Ef
ficac
y Sc
ale;
ROM
, ran
ge o
f mot
ion;
TST
, tot
al s
leep
tim
e; TN
T, to
tal n
ap ti
me;
BDI,
Beck
Dep
ress
ion
Inve
ntor
y.
Tabl
e 2.
(Con
tinue
d)et al.17 There were no statistically significant differ-ences for these outcomes.
Aquatic physical therapy × land-based exercises; 3–23 weeksIn these comparisons, only pain and depression were included in the meta-analysis and the interven-tion period division was not used due to the limited number of studies and the large time span. Assis et al.,29 Hecker et al.,30 Jentoft et al.31 and Vitorino et al.32 were included in these meta-analyses but no statistically significant differences were found. Adverse events/reactions or side-effects related to the use of a pool were mentioned in some studies as: muscle pain,29,36,37 tinea pedis,29 chlorine hypersen-sitivity37 and exacerbation of the concomitant illnesses.34
Discussion
According to the meta-analyses of this review, three outcomes showed statistically significant results in favour of the aquatic physical therapy group com-pared to the control group (no treatment), over a period of 20 weeks. The water treatment favoured the improvement of the impact of the disease (or general sense of well-being) and physical function.
Busch’s review showed that aerobic exercises have demonstrated beneficial effects on exercise capacity and symptoms of fibromyalgia.40 There has not been a review that points out, in a systematic manner and without methodological bias, the effects of aquatic exercise. If the chosen treatment is aquatic physical therapy, topics such as fluid mechanics, temperature, type of exercise (intensity, frequency and duration), professional experience and cost must be taken into consideration.
A guideline by the Ottawa Panel selected 16 studies involving fibromyalgia and aerobic pro-grammes (out of 116).41 Of these studies, two were classified as high quality using the Jadad scale and included in one arm of the study on aquatic physical therapy compared with exercise on land.29,31Although classified as high-quality RCTs, Jentoft et al.31 received a grade C+ (>15% of clinical importance,
902 Clinical Rehabilitation 27(10)
Tabl
e 3.
Aqu
atic
phy
sical
ther
apy
× ot
her
trea
tmen
ts.
Aut
hors
Subj
ects
Tim
e in
terv
entio
n/fo
llow
-up
Inte
rven
tion
prog
ram
me
Out
com
es/m
ater
ials
Con
clus
ions
Redo
ndo
2004
34n
tota
l = 4
0 su
bjec
tsG
1 =
aqua
tic p
hysic
al
ther
apy
n =
19G
2 =
beha
viou
ral
tech
niqu
esn
= 21
G1
= 45
min
, 5×
per
wee
k, 8
wee
ksG
2 =
2 h
30 m
in, 1
× pe
r w
eek,
8 w
eeks
Follo
w-u
p: 2
4 an
d 48
w
eeks
G1
= ca
rdio
vasc
ular
fitn
ess,
mus
cula
r en
dura
nce
and
flexi
bilit
yG
2 =
info
rmat
ion
abou
t ch
roni
c pa
in a
nd e
mot
iona
l as
pect
s, in
form
atio
n ab
out
the
natu
re o
f fib
rom
yalg
ia,
lear
ning
rel
axat
ion
tech
niqu
es, c
opin
g w
ith
chro
nic
pain
, act
iviti
es o
f da
ily li
ving
, soc
ial s
kills
, sle
ep a
nd r
est d
istur
banc
e,
rela
pse
prev
entio
n an
d so
lutio
n
NTP
(ten
der
poin
t sco
re),
qual
ity
of li
fe (F
IQ a
nd S
F-36
), an
xiet
y (B
AI),
dep
ress
ion
(BD
I), c
hron
ic
pain
(CPS
S an
d C
PCI),
upp
er
limbs
, low
er li
mbs
and
spi
ne
(phy
sical
act
ivity
of v
erte
bral
co
lum
n an
d up
per
and
low
er
limbs
) and
mea
sure
men
t of
aero
bic
capa
city
Aqu
atic
ther
apy
and
beha
viou
ral t
echn
ique
s im
prov
e cl
inic
al
man
ifest
atio
ns in
pat
ient
s w
ith fi
brom
yalg
ia o
nly
for
shor
t per
iods
of
time.
Impr
ovem
ents
in
self-
effic
acy
and
phys
ical
fit
ness
are
not
ass
ocia
ted
with
impr
ovem
ent i
n cl
inic
al m
anife
stat
ions
Alta
n 20
0435
n to
tal =
50
fem
ale
G1
= aq
uatic
phy
sical
th
erap
yn
= 25
(43.
14 y
ears
)G
2 =
baln
eoth
erap
yn
= 25
(43.
91 y
ears
)n
final
= 4
6 fe
mal
eG
1 =
24 (4
3.1
year
s)G
2 =
22 (4
3.9
year
s)
G1:
35
min
, 3×
per
wee
k, 12
wee
ksG
2: 3
5 m
in, 3
× pe
r w
eek,
12 w
eeks
Follo
w-u
p: 1
2 w
eeks
Tem
p =
37°C
G1
= w
arm
-up,
ROM
, re
laxa
tion
in a
nd o
ut o
f th
e po
ol fo
r 35
min
G2
= di
d no
t per
form
an
y ex
erci
se d
urin
g th
e se
ssio
ns
Pain
(VA
S an
d 5-
poin
t sca
le),
mor
ning
stif
fnes
s (4
-poi
nt s
cale
), fa
tigue
(VA
S an
d 5-
poin
t sca
le),
sleep
(SH
), N
TP (p
ress
ure
algo
met
er a
nd 4
-poi
nt s
cale
), gl
obal
ass
essm
ent o
f pat
ient
(1
0 cm
sca
le),
phys
icia
n’s
glob
al
eval
uatio
n (1
0 cm
sca
le ),
qua
lity
of li
fe (F
IQ),
resis
tanc
e of
the
low
er e
xtre
miti
es (1
min
cha
ir
sittin
g–ri
sing
test
) and
dep
ress
ion
(BD
I)
Aqu
atic
ther
apy
was
be
tter
in a
ll pa
ram
eter
s, ex
cept
for
the
chai
r te
st fo
r bo
th w
eeks
. In
baln
eoth
erap
y th
ere
was
no
impr
ovem
ent i
n th
e ch
air
test
and
dep
ress
ion
And
rade
20
0836
n to
tal =
46
fem
ale
G1
= aq
uatic
phy
sical
th
erap
yn
= 23
(48.
8 ye
ars)
G2
= th
alas
soth
erap
yn
= 23
(48.
3 ye
ars)
n fin
al =
38
(G1
= 19
; G
2 =
19)
G1
= 60
min
, 3×
per
wee
k, 12
wee
ksG
2 =
60 m
in, 3
× pe
r w
eek,
12 w
eeks
, at 1
5 h
in th
e se
a w
hen
the
wat
er is
as
war
m a
s in
a
pool
. Fol
low
-up:
no
Tem
p =
28 a
nd 3
3°C
Both
gro
ups
rece
ived
10
min
of s
tret
chin
g, 40
min
of l
ow-im
pact
ae
robi
c ex
erci
se, 1
0 m
in o
f re
laxa
tion
Rate
of 5
0% a
nd 7
5% o
f Vo
2max
Pain
(VA
S), f
atig
ue (V
AS)
, NTP
(d
igita
l pre
ssur
e), p
hysic
al
func
tiona
l (FI
Q),
qual
ity o
f life
(S
F-36
), sle
ep (P
SQI),
moo
d sw
ings
an
d de
pres
sion
(BD
I)
Both
gro
ups
impr
oved
on
all
vari
able
s, ex
cept
de
pres
sion
(Con
tinue
d)
Lima et al. 903
Aut
hors
Subj
ects
Tim
e in
terv
entio
n/fo
llow
-up
Inte
rven
tion
prog
ram
me
Out
com
es/m
ater
ials
Con
clus
ions
Cal
andr
e 20
0837
n to
tal =
81
fem
ale/
mal
eG
1 =
aqua
tic p
hysic
al
ther
apy
n =
39 (5
1 ye
ars)
34F
/5M
G2
= A
i Chi
n =
42 (4
9 ye
ars)
39F
/3M
G1
= 60
min
, 3×
per
wee
k, 6
wee
ks.
G2
= 60
min
, 3×
per
wee
k, 6
wee
ks.
Follo
w-u
p: 4
and
12
wee
ks
Tem
p =
36°C
10 m
in r
elax
atio
n an
d 40
min
exe
rcise
Qua
lity
of li
fe (F
IQ a
nd S
F-12
), sle
ep (P
SQI),
dep
ress
ion
(BD
I) an
d an
xiet
y (S
TAI)
Ai C
hi s
how
ed
impr
ovem
ent i
n th
e sy
mpt
oms
of fi
brom
yalg
ia
and
sleep
qua
lity.
In
aqua
tic p
hysic
al th
erap
y, th
ere
was
impr
ovem
ent
in h
ealth
sta
tus
Ide
2008
38n
tota
l = 4
0 su
bjec
tsG
1 =
aqua
tic p
hysic
al
ther
apy
n =
20 (4
6,61
yea
rs)
G2
= re
crea
tiona
l act
iviti
esn
= 20
(45.
47 y
ears
)n
final
= 3
5 (G
1 =
18;
G2
= 17
)
G1
= 60
min
, 4×
per
wee
k, 4
wee
ksG
2 =
6 m
in, 1
× pe
r w
eek,
4 w
eeks
Follo
w-u
p: 4
wee
ks
Tem
p =
32°C
War
m-u
p, br
eath
ing
patt
erns
and
rel
axat
ion
exer
cise
s
Qua
lity
of li
fe (S
F-36
), fu
nctio
nal
abili
ty (F
IQ),
anxi
ety
(HA
S), s
leep
(P
SQI),
NTP
and
pai
n (V
AS)
The
shor
t-te
rm a
quat
ic
resp
irat
ory
exer
cise
-ba
sed
prog
ram
me
impr
oved
pai
n, q
ualit
y of
lif
e, fu
nctio
nal c
apac
ity,
anxi
ety
and
qual
ity o
f sle
ep
Silv
a 20
0839
n to
tal =
10
fem
ale
G1
= aq
uatic
phy
sical
th
erap
yn
= 5
(47.
0 ±
5.6
age)
5W
G2
= TE
NS
n =
5 (5
0.6
± 13
.4 a
ge)
4W/1
M
G1
= 40
min
, 3×
per
wee
kG
2 =
40
min
, 3×
per
wee
k, 10
ses
sions
Follo
w-u
p: n
o
G1
= 5
min
war
m-
up, 2
0 m
in s
tret
chin
g (3
× 2
0 s)
, 15
min
aer
obic
ex
erci
ses
G2
= pu
lse r
ate
15 H
z, pu
lse ti
me
150
µs
NTP
, fle
xibi
lity
(fing
ertip
-to-
grou
nd),
pain
(VA
S), q
ualit
y of
life
(S
F-36
), en
ergy
leve
l, em
otio
nal
reac
tions
, sle
ep d
istur
banc
es,
soci
al is
olat
ion
and
phys
ical
abi
lity
(NH
P), d
epre
ssio
n (B
DI)
Both
trea
tmen
ts w
ere
effic
ient
in im
prov
ing
phys
ical
func
tioni
ng, b
ut
TEN
S pr
oduc
ed b
ette
r re
sults
in r
elie
ving
pai
n an
d in
a g
reat
er n
umbe
r of
var
iabl
es
G1,
gro
up 1
; G2,
gro
up 2
; W, w
omen
; M, m
en; t
emp,
tem
pera
ture
; NTP
, num
ber
of te
nder
poi
nts;
BAI,
Beck
Anx
iety
Inve
ntor
y; BD
I, Be
ck D
epre
ssio
n In
vent
ory;
CPS
S, C
hron
ic
Pain
Sel
f-Effi
cacy
Sca
le; C
PCI,
Chr
onic
Pai
n C
opin
g In
vent
ory;
VAS,
visu
al a
nalo
gue
scal
e; FI
Q, F
ibro
mya
lgia
Impa
ct Q
uest
ionn
aire
; SF-
36, S
hort
For
m 3
6 H
ealth
Sur
vey;
PSQ
I, Pi
ttsb
urgh
Sle
ep Q
ualit
y In
dex;
SF-
12: S
hort
For
m 1
2 H
ealth
Sur
vey;
STA
I, St
ate-
Trai
t Anx
iety
Inve
ntor
y; H
AS,
HA
MIL
TON
AN
XIE
TY S
CA
LE; N
HP,
Not
tingh
am H
ealth
Pro
file.
Tabl
e 3.
(Con
tinue
d)
904 Clinical Rehabilitation 27(10)
Table 4. Kappa coefficient (κ) results.
Components of the assessment of risk of bias
κ CI 95%
Randomization 0.64 0.39–0.89Concealment allocation 0.88 0.67–1Blinding of assessment 0.77 0.54–1Intention-to-treat analysis 0.83 0.62–1
CI, confidence interval.
but without statistical significance) for both local exercise on the quality of life and pain relief as well as endurance in favour of aquatic exercise and Assis et al.29 for quality of life and depression. Hauser et al.2 selected 35 studies in a review of 2010 and the results showed no difference between aquatic versus land-based exercises for pain and depression.
In this review, there was concern about the included studies that were separated according to the comparisons aquatic exercises versus no treat-ment and versus land-based exercises and time in weeks, which did not occur in the two reviews cited above (Brosseau et al. and Hauser et al.).2,41 Yet, the assessment of risk of bias pointed out, unlike the study by the Ottawa Panel,41 a high risk of bias for these two studies, and when the meta-analysis was performed, no statistically significant differences were found in quality of life and depression. Another difficulty in comparing the Ottawa Panel41 and the review by Hauser et al.2 with the present study is the number of studies related to aquatic exercise. The Ottawa Panel included 16 studies, of which only five were about aquatic physical therapy; Hauser included 35 studies, 10 of which related to aquatic therapy. In this review there were 27 stud-ies, all of which included aquatic physical therapy.
In relation to this quantity, it is worth mentioning the high risk of bias that the studies had, from the first randomized controlled trial published in 1999 by Gowans et al.14 to the most recent in 2011 by Hecker et al.30 According to the classification of the Cochrane Collaboration,9 eight studies were assessed as having a high risk of bias and only six as low risk for randomization. The studies showed flaws in the allocation concealment, blinding of the assessor and intention-to-treat analysis. More than
half of the studies had a high risk in two or more items, which showed the poor quality of the ran-domized controlled trials.
Because of the lack of standardization and the diversity of the outcome measures, variation of exercise programmes, time of follow-up and some incomplete descriptions of the results, it was hard to pool the studies, which made higher accuracy in the analysis difficult. Although several meta-analyses were performed in this review only three showed statistically significant results. These results cor-roborated with the review published in 2008 by Busch et al.42 but were not confirmed by Brosseau et al.,41 published in 2008 and Hauser et al.2 in 2010, which cited aquatic therapy as a possible treatment.
The authors included in the meta-analyses of this review performed exercises with aerobic compo-nents. Two studies16,27 performed 10 and 20 min-utes, respectively, three times per week, as suggested by the American College of Sports Medicine.43 One study24 did not describe the working time for this type of exercise and stipulated only one session per week. The total training time ranged from 23 to 32 weeks. Through these results (improvement in the impact of the disease and physical function), one can observe that the control group had unchanged or worsened final values when compared to their ini-tial results, which proves the effectiveness of aquatic therapy for these outcomes compared with the no-treatment group. For the comparison between aquatic therapy versus land-based exercises improvement was found for both groups in the impact of the disease, but there were no significant differences between groups.29–33
Another review, concerned with exercises in water,5 presented no meta-analysis, although it included the studies by Gowans et al.16 and Mannerkorpi et al.24 A methodological comparison of this review with those by Gowans et al.5 and Busch et al.42 shows that Gowan et al. included eight randomized controlled trials, but did not make clear in the method which search strategy was used for the selection of trials and did not carry out assessment of the risk of bias. In the review by Busch et al., the authors clearly described their search strategy, but it was performed in only six databases. In this review a broad search strategy
Lima et al. 905
Figure 3. Meta-analysis of studies assessing quality of life with the Fibromyalgia Impact Questionnaire (aquatic physical therapy × no treatment; more than 20 weeks). Mean difference and fixed effect.
Figure 4. Meta-analysis of studies assessing stiffness with the Fibromyalgia Impact Questionnaire (aquatic physical therapy × no treatment; more than 20 weeks). Mean difference and fixed effect.
Figure 5. Meta-analysis of studies assessing the physical function with 6-minute walk (m) test (aquatic physical therapy × no treatment; more than 20 weeks). Mean difference and fixed effect.
was adopted and 13 databases were used, plus a manual search in journals of interest to the theme.
Because of the recent publication of new classi-fication criteria for fibromyalgia,44 only one study could have been used (because of publication year), however the authors did not apply this. With the results presented in meta-analysis in favour of aquatic therapy, individuals could no longer be clas-sified as having fibromyalgia after the end of treat-ment. Furthermore, it was not possible to perform a meta-analysis with follow-ups of the studies included that showed statistically significant results, to verify the benefits of exercise in the long term.
For aquatic exercise programmes, some points should be taken into account, such as temperature and water resistance. In only one study29 were exer-cises performed at a temperature between 28°C and 31°C; in the remaining, they were performed at temperatures above 32°C. The main form of transformation of energy by the body is exercise, which leads to a large production of heat.45 The elevation of body temperature affects brain func-tion, decreases motor command and may lead to the interruption of exercise.46
The increase in body temperature can also decrease the motivation to exercise, assessed by the
906 Clinical Rehabilitation 27(10)
increase in RPE.47 In this review, a meta-analysis with the outcome RPE was carried out in two stud-ies,14,16 but no statistically significant difference was found. However, these two studies did not report the water temperature and the results for this outcome were maintained practically unchanged. Thus we cannot conclude that the temperature of the water influenced these outcomes or not, although it is known that aerobic exercises in water should be practised at a temperature between 28 and 30°C.48,49 The problem is that for the patient with fibromyal-gia, the aerobic component will last about 20 min-utes43 and the other exercises, such as stretching, mobility and strength, should not be performed at less than 32°C.
Some weaknesses of this review were the diffi-culty in identifying all relevant studies because of the variation in terminology used, and the complex-ity in comparing studies because of the wide range of outcome measures. Although the meta-analysis showed studies with the same outcome and the anal-ysis with fixed effects, it is worth noting the diver-sity of interventions described as aquatic physical therapy, a fact that must be taken into consideration during its interpretation.
Considerations for clinical practiceNo studies have tested negative for the aquatic ther-apy group, so this technique can be considered as a resource in the treatment of patients with fibromyal-gia. The aerobic exercises should be included as a main intervention, such as running (height of the blade in xiphoid process or without touching the land – deep running), subaquatic cycling or adapted swimming, with a frequency of three or more times per week, with sessions lasting at least 20 minutes, according to the recommendations of the American College of Sports Medicine43 and US Centers for Disease Control (CDC) guidelines for physical activity.50 The temperature should be taken into consideration and should not exceed 30°C48,49 for aerobic component and should be performed for a minimum of 20 weeks. Other programme compo-nents, such as stretching, mobility and strength, should be performed at temperatures between 31.5 and 33°C.
Implications for future studies
Some outcomes showed no statistically significant results and may have been influenced by the low methodological rigor of the studies included in the meta-analyses. New randomized controlled trials should be conducted, but according to the rules of the CONSORT Statement.51 It is suggested that an randomized controlled trial should compare two groups: aquatic physical therapy versus land-based exercises. The primary endpoints should be pain, physical function and quality of life. It is recom-mended that the sample should have a total of 180 patients, 90 in each group,52 considering a power of 80% and a type I error of 5% to detect a 20% differ-ence in the improvement of the quality of life (Fibromyalgia Impact Questionnaire) of patients with fibromyalgia who performed aquatic physical therapy (50% improvement) versus those who underwent land-based exercises (improvement of 30%), lasting at least 20 weeks, three times week. It is also suggested that during the randomized con-trolled trial the new classification criteria for fibro-myalgia should be used, according to the American College of Rheumatology.44
Clinical messages
● Aquatic physical therapy caused an improvement in quality of life, physical function and stiffness when compared with no treatment after 20 weeks.
● There is currently insufficient evi-dence to say that aquatic physical ther-apy is beneficial to all patients with fibromyalgia.
Conflict of interest
The author declares that there is no conflict of interest.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Lima et al. 907
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