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Meta-Analysis
. 2014 Oct 28;2014(10):CD011336.
doi: 10.1002/14651858.CD011336.

Aquatic exercise training for fibromyalgia

Julia Bidonde  1 , Angela J Busch, Sandra C Webber, Candice L Schachter, Adrienne Danyliw, Tom J Overend, Rachel S Richards, Tamara Rader
Affiliations
Meta-Analysis

Aquatic exercise training for fibromyalgia

Julia Bidonde et al. Cochrane Database Syst Rev. .

Abstract

Background: Exercise training is commonly recommended for individuals with fibromyalgia. This review examined the effects of supervised group aquatic training programs (led by an instructor). We defined aquatic training as exercising in a pool while standing at waist, chest, or shoulder depth. This review is part of the update of the 'Exercise for treating fibromyalgia syndrome' review first published in 2002, and previously updated in 2007.

Objectives: The objective of this systematic review was to evaluate the benefits and harms of aquatic exercise training in adults with fibromyalgia.

Search methods: We searched The Cochrane Library 2013, Issue 2 (Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, NHS Economic Evaluation Database), MEDLINE, EMBASE, CINAHL, PEDro, Dissertation Abstracts, WHO international Clinical Trials Registry Platform, and AMED, as well as other sources (i.e., reference lists from key journals, identified articles, meta-analyses, and reviews of all types of treatment for fibromyalgia) from inception to October 2013. Using Cochrane methods, we screened citations, abstracts, and full-text articles. Subsequently, we identified aquatic exercise training studies.

Selection criteria: Selection criteria were: a) full-text publication of a randomized controlled trial (RCT) in adults diagnosed with fibromyalgia based on published criteria, and b) between-group data for an aquatic intervention and a control or other intervention. We excluded studies if exercise in water was less than 50% of the full intervention.

Data collection and analysis: We independently assessed risk of bias and extracted data (24 outcomes), of which we designated seven as major outcomes: multidimensional function, self reported physical function, pain, stiffness, muscle strength, submaximal cardiorespiratory function, withdrawal rates and adverse effects. We resolved discordance through discussion. We evaluated interventions using mean differences (MD) or standardized mean differences (SMD) and 95% confidence intervals (95% CI). Where two or more studies provided data for an outcome, we carried out meta-analysis. In addition, we set and used a 15% threshold for calculation of clinically relevant differences.

Main results: We included 16 aquatic exercise training studies (N = 881; 866 women and 15 men). Nine studies compared aquatic exercise to control, five studies compared aquatic to land-based exercise, and two compared aquatic exercise to a different aquatic exercise program.We rated the risk of bias related to random sequence generation (selection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias), blinding of outcome assessors (detection bias), and other bias as low. We rated blinding of participants and personnel (selection and performance bias) and allocation concealment (selection bias) as low risk and unclear. The assessment of the evidence showed limitations related to imprecision, high statistical heterogeneity, and wide confidence intervals. Aquatic versus controlWe found statistically significant improvements (P value < 0.05) in all of the major outcomes. Based on a 100-point scale, multidimensional function improved by six units (MD -5.97, 95% CI -9.06 to -2.88; number needed to treat (NNT) 5, 95% CI 3 to 9), self reported physical function by four units (MD -4.35, 95% CI -7.77 to -0.94; NNT 6, 95% CI 3 to 22), pain by seven units (MD -6.59, 95% CI -10.71 to -2.48; NNT 5, 95% CI 3 to 8), and stiffness by 18 units (MD -18.34, 95% CI -35.75 to -0.93; NNT 3, 95% CI 2 to 24) more in the aquatic than the control groups. The SMD for muscle strength as measured by knee extension and hand grip was 0.63 standard deviations higher compared to the control group (SMD 0.63, 95% CI 0.20 to 1.05; NNT 4, 95% CI 3 to 12) and cardiovascular submaximal function improved by 37 meters on six-minute walk test (95% CI 4.14 to 69.92). Only two major outcomes, stiffness and muscle strength, met the 15% threshold for clinical relevance (improved by 27% and 37% respectively). Withdrawals were similar in the aquatic and control groups and adverse effects were poorly reported, with no serious adverse effects reported. Aquatic versus land-basedThere were no statistically significant differences between interventions for multidimensional function, self reported physical function, pain or stiffness: 0.91 units (95% CI -4.01 to 5.83), -5.85 units (95% CI -12.33 to 0.63), -0.75 units (95% CI -10.72 to 9.23), and two units (95% CI -8.88 to 1.28) respectively (all based on a 100-point scale), or in submaximal cardiorespiratory function (three seconds on a 100-meter walk test, 95% CI -1.77 to 7.77). We found a statistically significant difference between interventions for strength, favoring land-based training (2.40 kilo pascals grip strength, 95% CI 4.52 to 0.28). None of the outcomes in the aquatic versus land comparison reached clinically relevant differences of 15%. Withdrawals were similar in the aquatic and land groups and adverse effects were poorly reported, with no serious adverse effects in either group. Aquatic versus aquatic (Ai Chi versus stretching in the water, exercise in pool water versus exercise in sea water)Among the major outcomes the only statistically significant difference between interventions was for stiffness, favoring Ai Chi (1.00 on a 100-point scale, 95% CI 0.31 to 1.69).

Authors' conclusions: Low to moderate quality evidence relative to control suggests that aquatic training is beneficial for improving wellness, symptoms, and fitness in adults with fibromyalgia. Very low to low quality evidence suggests that there are benefits of aquatic and land-based exercise, except in muscle strength (very low quality evidence favoring land). No serious adverse effects were reported.

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Conflict of interest statement

We confirm that any present or past affiliations or other involvement in any organization or entity with an interest in the review, which might lead me/us to have a real or perceived conflict of interest, are listed below.

  1. Julia Bidonde: none known

  2. Angela J Busch: none known

  3. Sandra C Webber: none known

  4. Candice L Schachter: none known

  5. Adrienne Danyliw: none known

  6. Tom J Overend: none known

  7. Rachel S Richards: none known

  8. Tamara Rader: none known

Figures

1
1
Study flow diagram. aDiscrepancy between the number of articles and studies denotes that multiple papers may have described the same study.
2
2
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
3
3
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
4
4
Aquatic exercise versus control ‐ Follow‐up analysis of wellness and symptom outcomes. Mann = Mannerkorpi, T2 change from baseline to end of intervention, T3 change from baseline to follow‐up assessment.
5
5
Aquatic versus control ‐ Follow‐up fitness outcomes. Mann = Mannerkorpi, T2 change from baseline to end of intervention, T3 change from baseline to follow‐up assessment.
6
6
Summary of aquatic versus control subgroup analysis findings
1.1
1.1. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 1 Multidimensional function.
1.2
1.2. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 2 Self reported physical function.
1.3
1.3. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 3 Pain.
1.4
1.4. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 4 Stiffness.
1.5
1.5. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 5 Muscle strength.
1.6
1.6. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 6 Submaximal cardiorespiratory.
1.7
1.7. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 7 Patient‐rated global.
1.8
1.8. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 8 Mental health.
1.9
1.9. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 9 Clinician‐rated global.
1.10
1.10. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 10 Self efficacy.
1.11
1.11. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 11 Fatigue.
1.12
1.12. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 12 Tenderness.
1.13
1.13. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 13 Depression.
1.14
1.14. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 14 Flexibility.
1.15
1.15. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 15 Sleep.
1.16
1.16. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 16 Anxiety.
1.17
1.17. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 17 Dyscognition.
1.18
1.18. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 18 Maximal cardiorespiratory function.
1.19
1.19. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 19 Muscle endurance.
1.20
1.20. Analysis
Comparison 1 Aquatic versus control (sensitivity analysis), Outcome 20 Withdrawals.
2.1
2.1. Analysis
Comparison 2 Aquatic versus land‐based, Outcome 1 Multidimensional function.
2.2
2.2. Analysis
Comparison 2 Aquatic versus land‐based, Outcome 2 Self Reported Physical Function.
2.3
2.3. Analysis
Comparison 2 Aquatic versus land‐based, Outcome 3 Pain.
2.4
2.4. Analysis
Comparison 2 Aquatic versus land‐based, Outcome 4 Tenderness.
2.5
2.5. Analysis
Comparison 2 Aquatic versus land‐based, Outcome 5 Fatigue.
2.6
2.6. Analysis
Comparison 2 Aquatic versus land‐based, Outcome 6 Stiffness.
2.7
2.7. Analysis
Comparison 2 Aquatic versus land‐based, Outcome 7 Muscle strength.
2.8
2.8. Analysis
Comparison 2 Aquatic versus land‐based, Outcome 8 Muscle endurance.
2.9
2.9. Analysis
Comparison 2 Aquatic versus land‐based, Outcome 9 Maximal cardiorespiratory function.
2.10
2.10. Analysis
Comparison 2 Aquatic versus land‐based, Outcome 10 Submaximal cardiorespiratory function.
2.11
2.11. Analysis
Comparison 2 Aquatic versus land‐based, Outcome 11 Mental health.
2.12
2.12. Analysis
Comparison 2 Aquatic versus land‐based, Outcome 12 Sleep.
2.13
2.13. Analysis
Comparison 2 Aquatic versus land‐based, Outcome 13 Depression.
2.14
2.14. Analysis
Comparison 2 Aquatic versus land‐based, Outcome 14 Anxiety.
2.15
2.15. Analysis
Comparison 2 Aquatic versus land‐based, Outcome 15 Withdrawals.
3.1
3.1. Analysis
Comparison 3 Aquatic versus aquatic, Outcome 1 Multidimensional function.
3.2
3.2. Analysis
Comparison 3 Aquatic versus aquatic, Outcome 2 Self reported physical function.
3.3
3.3. Analysis
Comparison 3 Aquatic versus aquatic, Outcome 3 Pain.
3.4
3.4. Analysis
Comparison 3 Aquatic versus aquatic, Outcome 4 Tenderness.
3.5
3.5. Analysis
Comparison 3 Aquatic versus aquatic, Outcome 5 Fatigue.
3.6
3.6. Analysis
Comparison 3 Aquatic versus aquatic, Outcome 6 Stiffness.
3.7
3.7. Analysis
Comparison 3 Aquatic versus aquatic, Outcome 7 Sleep.
3.8
3.8. Analysis
Comparison 3 Aquatic versus aquatic, Outcome 8 Depression.
3.9
3.9. Analysis
Comparison 3 Aquatic versus aquatic, Outcome 9 Anxiety.
3.10
3.10. Analysis
Comparison 3 Aquatic versus aquatic, Outcome 10 Mental health.
3.11
3.11. Analysis
Comparison 3 Aquatic versus aquatic, Outcome 11 Withdrawals.
4.1
4.1. Analysis
Comparison 4 Subgroup analysis: age ‐ younger versus older, Outcome 1 Multidimensional function (younger versus older).
4.2
4.2. Analysis
Comparison 4 Subgroup analysis: age ‐ younger versus older, Outcome 2 Pain (younger versus older).
4.3
4.3. Analysis
Comparison 4 Subgroup analysis: age ‐ younger versus older, Outcome 3 Strength (younger versus older).
5.1
5.1. Analysis
Comparison 5 Subgroup analysis: disease duration (short versus long), Outcome 1 Multidimensional function (short versus long duration).
5.2
5.2. Analysis
Comparison 5 Subgroup analysis: disease duration (short versus long), Outcome 2 Pain (short versus long duration).
5.3
5.3. Analysis
Comparison 5 Subgroup analysis: disease duration (short versus long), Outcome 3 Strength (short versus long duration).
6.1
6.1. Analysis
Comparison 6 Subgroup analysis: low versus high impact of disease at baseline, Outcome 1 Multidimensional function (low versus high disease impact at baseline.
6.2
6.2. Analysis
Comparison 6 Subgroup analysis: low versus high impact of disease at baseline, Outcome 2 Pain (low versus high baseline impact).
6.3
6.3. Analysis
Comparison 6 Subgroup analysis: low versus high impact of disease at baseline, Outcome 3 Strength (low versus high disease impact at baseline multidimensional function).
7.1
7.1. Analysis
Comparison 7 Subgroup analysis: low versus high baseline pain, Outcome 1 Multidimensional function (low versus high baseline pain).
7.2
7.2. Analysis
Comparison 7 Subgroup analysis: low versus high baseline pain, Outcome 2 Pain (low versus high baseline pain).
7.3
7.3. Analysis
Comparison 7 Subgroup analysis: low versus high baseline pain, Outcome 3 Strength (low versus high baseline pain).
8.1
8.1. Analysis
Comparison 8 Subgroup analysis: length of program, Outcome 1 Multidimensional function (length of program).
8.2
8.2. Analysis
Comparison 8 Subgroup analysis: length of program, Outcome 2 Pain (length of program).
8.3
8.3. Analysis
Comparison 8 Subgroup analysis: length of program, Outcome 3 Strength (length of program).
9.1
9.1. Analysis
Comparison 9 Subgroup analysis: accumulated time in the pool, Outcome 1 Multidimensional function (accumulated time in the pool).
9.2
9.2. Analysis
Comparison 9 Subgroup analysis: accumulated time in the pool, Outcome 2 Pain (accumulated time in the pool).
9.3
9.3. Analysis
Comparison 9 Subgroup analysis: accumulated time in the pool, Outcome 3 Strength (accumulated time in the pool).
10.1
10.1. Analysis
Comparison 10 Subgroup analysis: exercise frequency, Outcome 1 Multidimensional function (exercise frequency).
10.2
10.2. Analysis
Comparison 10 Subgroup analysis: exercise frequency, Outcome 2 Pain (exercise frequency).
10.3
10.3. Analysis
Comparison 10 Subgroup analysis: exercise frequency, Outcome 3 Strength (exercise frequency).
11.1
11.1. Analysis
Comparison 11 Subgroup analysis: exercise intensity, Outcome 1 Multidimensional function (exercise intensity).
11.2
11.2. Analysis
Comparison 11 Subgroup analysis: exercise intensity, Outcome 2 Pain (exercise intensity).
11.3
11.3. Analysis
Comparison 11 Subgroup analysis: exercise intensity, Outcome 3 Strength (exercise intensity).
12.1
12.1. Analysis
Comparison 12 Subgroup analysis: pool temperature ‐ cool, temperate, warm, Outcome 1 Multidimensional function (pool temperature).
12.2
12.2. Analysis
Comparison 12 Subgroup analysis: pool temperature ‐ cool, temperate, warm, Outcome 2 Pain (pool temperature).
12.3
12.3. Analysis
Comparison 12 Subgroup analysis: pool temperature ‐ cool, temperate, warm, Outcome 3 Strength (pool temperature).
See this image and copyright information in PMC

References

References to studies included in this review

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References to studies excluded from this review

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Gowans 2004 {published data only}
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Jones 2011 {published data only}
    1. Jones KD. Nordic walking in fibromyalgia: a means of promoting fitness that is easy for busy clinicians to recommend. Arthritis Research & Therapy 2011;13(1):103. - PMC - PubMed
Kadetoff 2010 {published data only}
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Karper 2001 {published data only}
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Kendall 2000 {published data only}
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Kesiktas 2011 {published data only}
    1. Kesiktas N, Karagülle Z, Erdogan N, Yazıcıoglu K, Yılmaz H, Paker N. The efficacy of balneotherapy and physical modalities on the pulmonary system of patients with fibromyalgia. Journal of Back and Musculoskeletal Rehabilitation 2011;24(1):57. - PubMed
Khalsa 2009 {published data only}
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Kingsley 2005 {published data only}
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Kingsley 2010 {published data only}
    1. Kingsley JD, McMillan V, Figueroa A. The effects of 12 weeks of resistance exercise training on disease severity and autonomic modulation at rest and after acute leg resistance exercise in women with fibromyalgia. Archives of Physical Medicine and Rehabilitation 2010;91(10):1551‐7. - PubMed
Klug 1989 {published data only}
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Lorig 2008 {published data only}
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Mannerkorpi 2002 {published data only}
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Matsumoto 2011 {published data only}
    1. Matsumoto S, Shimodozono M, Etoh S, Miyata R, Kawahira K. Effects of thermal therapy combining sauna therapy and underwater exercise in patients with fibromyalgia. Complementary Therapies in Clinical Practice 2011;17(3):162‐6. - PubMed
McCain 1986 {published data only}
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Meyer 2000 {published data only}
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Mobily 2001 {published data only}
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    1. Mutlu B, Paker N, Bugdayci D, Tekdos D, Kesiktas N. Efficacy of supervised exercise combined with transcutaneous electrical nerve stimulation in women with fibromyalgia: a prospective controlled study. Rheumatology International 2013;33(3):649‐55. - PubMed
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Peters 2002 {published data only}
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Pfeiffer 2003 {published data only}
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Piso 2001 {published data only}
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Rooks 2002 {published data only}
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Suman 2009 {published data only}
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Thieme 2003 {published data only}
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Tiidus 1997 {published data only}
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Vlaeyen 1996 {published data only}
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References to studies awaiting assessment

Amanollahi 2013 {published data only}
    1. Amanollahi A, Naghizadeh J, Khatibi A, Hollisaz MT, Shamseddini AR, Saburi A. Comparison of impacts of friction massage, stretching exercises and analgesics on pain relief in primary fibromyalgia syndrome: a randomized clinical trial. Tehran University Medical Journal 2013;70(10):616‐22.
Aslan 2001 {published data only}
    1. Aslan UB, Yuksel I, Yazici M. A comparison of classical massage and mobilization techniques treatment in primary fibromyalgia [Turkish]. Fizyoterapi Rehabilitasyon 2001;12(2):50‐4.
Ekici 2008 {published data only}
    1. Ekici G, Yakut E, Akbayrak T. Effects of pilates exercises and connective tissue manipulation on pain and depression in females with fibromyalgia: a randomized controlled trial [Turkish]. Fizyoterapi Rehabilitasyon 2008;19(2):47‐54.
Gomes da Silva 2008 {published data only}
    1. Gomes da Silva T, Suda EY, Marçulo CA, Silva Paes FH, Pinheiro GT. Comparison of transcutaneous electrical nerve stimulation and hydrotherapy effects on pain, flexibility and quality of life in patients with fibromyalgia [Comparação dos efeitos da estimulação elétrica nervosa transcutânea e da hidroterapia na dor, flexibilidade e qualidade de vida de pacientes com fibromialgia]. Fisioterapia e Pesquisa 2008;15(2):118‐24.
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