Thalassotherapy for fibromyalgia: a randomized controlled trial comparing aquatic exercises in sea water and water pool

Nature-based interventions for physical health conditions: A systematic review and meta-analysis

Nature-based interventions (NBIs) are activities, strategies, or programs taking place in natural settings, such as exercising in greenspaces, to improve the health and well-being of people by integrating the benefits of nature exposure with healthy behaviours. Current reviews on NBIs do not report the effects on different groups of physical health conditions. The purpose of this systematic review and meta-analysis was to identify and synthesize the evidence of the effect of NBIs on physical health outcomes and biomarkers of physical health conditions. Overall, 20,201 studies were identified through searching MEDLINE, Embase, CINAHL, SPORTDiscus, and CENTRAL databases up to June 7, 2024. Inclusion criteria were: 1) randomized controlled intervention studies; 2) population with a physical health condition; 3) NBIs vs. different intervention or no intervention; and 4) measuring physical health outcomes and/or biomarkers. Twenty-six studies were included in the review, 15 of which contributed to the meta-analysis. Compared to control groups, NBIs groups showed significant improvements in: diastolic blood pressure (MD -3.73 mmHg [-7.46 to -0.00], I2 = 62%) and heart rate (MD -7.44 bpm [-14.81 to -0.06], I2 = 0%) for cardiovascular conditions, fatigue (SMD -0.50 [-0.82 to -0.18], I2 = 16%) for central nervous system conditions, and body fat percentage (MD -3.61% [-5.05 to -2.17], I2 = 0%) for endocrine conditions. High effect heterogeneity was found in several analyses and the included studies had moderate-to-high risk of bias (RoB). The non-significant outcomes showed a direction of effect in favour of NBI groups for cardiovascular, central nervous system, endocrine, musculoskeletal, and respiratory conditions. This review found some beneficial effects in favour of NBIs for health outcomes in at least three condition groups though RoB and inconsistent effects limited some interpretations. NBIs are promising therapies that healthcare professionals can consider integrating into clinical practice.

Unveiling the Therapeutic Potential and Healthcare Applications of Marine Therapy: A Systematic Review with Meta-Analysis and Meta-Regression

This study was conducted to estimate the effectiveness of marine-derived resources for treating specific diseases, as well as identify the most effective methods for applying such resources in therapeutic applications. Bibliographic databases (PubMed, Embase, and Cochrane) were searched from their inception until May 2023 using Medical Subject Headings terms and text keywords related to seawater, mineral water, or ocean therapy. Fifteen eligible studies were included, involving 1325 participants aged 42.7-63.0 years. In the subgroup analysis based on treatment type, the mean difference was -1.581 (95% CI: -1.889, -1.274) for seawater with sun exposure and -1.210 (95% CI: -1.417, -1.002) for seawater with sun exposure, mud pack application, and sulfur pool therapy. The pooled standardized mean difference was calculated for different outcomes; the results were -1.110 (95% CI: -3.028, 0.806) for osteoarthritis severity, -0.795 (95% CI: -0.982, -0.607) for arthritis pain, -1.623 (95% CI: -2.036, -1.209) for fibromyalgia pain, and -1.498 (95% CI: -1.888, -1.108) for quality of life. Marine therapy is, therefore, promising for treating chronic skin issues, easing musculoskeletal discomfort, and enhancing the quality of life among patients with musculoskeletal pain.

Mechanisms hypothesized for pain-relieving effects of exercise in fibromyalgia: a scoping review

Background

Exercise is one of the most recommended management strategies by treatment guidelines for fibromyalgia (FM); however, the mechanism through which exercise improves pain in FM is still unknown.

Objective

We aimed to summarize the hypothesized theoretical mechanisms for the pain-relieving effects of exercise in people with FM.

Eligibility Criteria

Randomized controlled trials (RCTs) in English reporting mechanisms for pain-relieving effects of exercise in the 'Introduction' and 'Discussion' sections and significant within- group or between-group effects of exercise interventions were included.

Sources of Evidence

We searched the databases Ovid MEDLINE(R), EMBASE, CINAHL, COCHRANE, Sports Discuss, and AMED with the keywords: exercise and fibromyalgia until December 2021.

Charting Methods

Two authors independently performed title/abstract, full-text review, and data abstraction using a data abstraction form. The hypothesized mechanisms from individual studies were grouped into three categories.

Results

The literature search resulted in 2147 studies, out of which 220 studies were considered for full-text review. A total of 50 RCTs proposing 29 unique mechanisms for the pain-relieving effects of exercise were included. These mechanisms were divided into three categories: physical, neuro-physiological, and psychological. The neuro-physiological category was further subdivided into exercise-induced hypoalgesia (EIH), pain sensitization, the autonomic system, the immune system, the endocrine system, and miscellaneous categories. The most frequently hypothesized mechanisms were EIH (n = 15), autonomic modulation (n = 7), improved sleep (n = 6), muscle oxygenation (n = 6), self-efficacy (n = 5), mental health (n = 4), and benefits of the aquatic environment (n = 12). While all exercise interventions involved FM patients, most of the supporting evidence for these mechanisms was cited from previous studies conducted on healthy samples. No studies performed analyses to demonstrate causal associations between the mechanisms and outcomes.

Conclusion

Multiple mechanisms were hypothesized for the positive influence of exercise in people with FM. Future studies using causal analyses, such as mediation analysis, are recommended to validate these mechanisms.

Therapeutic Patient Education for Fibromyalgia during Spa Therapy: The FiETT Randomized Controlled Trial

Spa therapy is known to improve quality of life and diminish pain. We assessed the efficacy (Fibromyalgia Impact Questionnaire-FIQ) and safety at 6 months of a fibromyalgia-specific therapeutic patient education (TPE) program added to fibromyalgia-specific standardized spa therapy (SST), compared to SST alone, in a controlled randomized trial. We enrolled 157 patients, mostly women, attending spa centers in Southwest France in 2015–2016, and randomized them to SST + TPE (79) or SST (78). The intention-to-treat with “missing as failure” analysis showed a tendency toward a higher, though non-significant, benefit with TPE than without for FIQ (−9 vs. −3; p = 0.053) or pain intensity (−0.9 vs. −1.1; p = 0.58). In addition, pain relief (+3.2 vs. +4.3; p = 0.03) and fatigue (−1.6 vs. −3.7; p = 0.02) were significantly improved, and 87% patients in the SST + TPE arm still regularly practiced the physical exercises taught to them at 6 months. We suspect significant and lasting improvement from spa therapy, as well as our already well-informed and well-managed participants, to have prevented the demonstration of a significant benefit of TPE on FIQ.

[Climate-therapy at seaside resorts in modern medical and wellness practice]

A scientific review is devoted to the study of the coastal climate in the resort treatment role of patients with chronic diseases and its impact on the health and life quality of the population of the seacoasts. The sources were the Cochrane Library, PubMed MEDLINE, MedlinePlus, PedRO, Google Scholar, British Medical Journal, Elsevier, The Global Wellness Institute, eLIBRARY.ru. The review includes 40 publications including 22 domestic and 18 foreign ones on clinical and surrogate outcomes of climate-therapy at seaside resorts in the structure of spa treatment in patients with chronic diseases. The health problems among the population of the seacoasts are considered. The features of conducting evidence-based studies in assessing the effects of climate procedures are noted. The analysis of the therapeutic and health-improving effect results of the seaside climate and the associated forms of thalassotherapy - terrenkur, swimming, aqua gymnastics, sea bathing, heliotherapy, landscape therapy, and the use of maricultureis carried out. The article presents statistically reliable data on the favorable outcomes of treatment of chronic forms of musculoskeletal, skin, pulmonary and cardiac pathology under the influence of thalassotherapy methods. It was found that the effectiveness of climate-therapy in oncological practice, the treatment of pollinosis, the use of algae and other maricultures has been insufficiently proven: the possibility of percutaneous permeability to seawater and its components. The risk of developing negative meteorological reactions during climate-therapy was noted.

Balneotherapy for Fibromyalgia Syndrome: A Systematic Review and Meta-Analysis

(1) Background: The efficiency of balneotherapy (BT) for fibromyalgia syndrome (FMS) remains elusive. (2) Methods: Cochrane Library, EMBASE, MEDLINE, PubMed, Clinicaltrials.gov, and PsycINFO were searched from inception to 31 May 2020. Randomized controlled trials (RCTs) with at least one indicator were included, i.e., pain, Fibromyalgia Impact Questionnaire (FIQ), Tender Points Count (TPC), and Beck’s Depression Index (BDI). The outcome was reported as a standardized mean difference (SMD), 95% confidence intervals (CIs), and I² for heterogeneity at three observational time points. GRADE was used to evaluate the strength of evidence. (3) Results: Amongst 884 citations, 11 RCTs were included (n = 672). Various BT regimens were reported (water types, duration, temperature, and ingredients). BT can benefit FMS with statistically significant improvement at different time points (pain of two weeks, three and six months: SMD = −0.92, −0.45, −0.70; 95% CI (−1.31 to −0.53, −0.73 to −0.16, −1.34 to −0.05); I² = 54%, 51%, 87%; GRADE: very low, moderate, low; FIQ: SMD = −1.04, −0.64, −0.94; 95% CI (−1.51 to −0.57, −0.95 to −0.33, −1.55 to −0.34); I² = 76%, 62%, 85%; GRADE: low, low, very low; TPC at two weeks and three months: SMD = −0.94, −0.47; 95% CI (−1.69 to −0.18, −0.71 to −0.22); I² = 81%, 0; GRADE: very low, moderate; BDI at six months: SMD = −0.45; 95% CI (−0.73 to −0.17); I² = 0; GRADE: moderate). There was no statistically significant effect for the TPC and BDI at the remaining time points (TPC at six months: SMD = −0.89; 95% CI (−1.85 to 0.07); I² = 91%; GRADE: very low; BDI at two weeks and three months: SMD = −0.35, −0.23; 95% CI (−0.73 to 0.04, −0.64 to 0.17); I² = 24%, 60%; GRADE: moderate, low). (4) Conclusions: Very low to moderate evidence indicates that BT can benefit FMS in pain and quality-of-life improvement, whereas tenderness and depression improvement varies at time phases. Established BT regimens with a large sample size and longer observation are needed.

Pool-based exercise for amelioration of pain in adults with fibromyalgia syndrome: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effects of pool-based exercises on pain symptomatology among adults with fibromyalgia syndrome.

METHODS

A systematic review and meta-analysis were carried out using PRISMA guidelines. Database search was conducted by two independent reviewers. For meta-analysis, the visual analogue scale (VAS) score for pain was used as the primary outcome and the Fibromyalgia Impact Questionnaire (FIQ) score was utilized as the secondary outcome.

RESULTS

A total of 42 out of 292 potentially eligible studies were selected for being read in full by reviewers, 14 of which were included in meta-analysis, being 10 of them used in sensitivity analysis of either the primary or secondary outcome. Data pooled from 10 randomized controlled trials (n = 508) revealed that patients who underwent pool-based exercises exhibited a significantly lower mean in VAS score as compared to controls (SMD = -0.27, 95% CI: -0.45 to -0.09). Regarding FIQ scores, data from 10 randomized controlled trials were pooled (n = 578) and a lower mean score was also shown in the group that underwent a pool-based exercise program (SMD = -0.29, 95% CI: -0.49 to -0.09). Limitations of this study include the small sample size and moderate dropout rates in currently available clinical trials.

CONCLUSION

Pool-based exercise may provide some additional benefit for pain relief in adults with fibromyalgia as compared to either land-based or no physical exercise.

IMPLICATIONS OF KEY FINDINGS

Collectively, these findings suggest that pool-based exercise deserves further attention as a potential adjuvant therapeutic option for adults with fibromyalgia. PROSPERO registration number: CRD42019136755.

[Therapeutic effects of climototherapy: scientomatrical analysis of evidence-based studies]

OBJECTIVE

Scientometrical analysis of studies the use of climatotherapy methods and formulation of guidelines based on the evidence obtained during the analysis.

MATERIAL AND METHODS

The article presents the data of scientometrical analysis of 40 publications on the use of climatotherapy in spa practice.

RESULTS

Clinical effects and proposed mechanisms of action of the proven efficacy climatotherapy methods - aerotherapy, heliotherapy and thalassotherapy for the patients with various chronic diseases are presented. The clinical directions for the using of climatotherapy methods in climatic resorts are highlighted.

CONCLUSIONS

Regular generalization and analysis of existing evidence-based studies is required, as well as the implementation of new high-quality randomized controlled clinical trials to study the effects of climate therapy on a wide range of patients with common socially significant diseases.

Thalassotherapy today

Introduction. Thalassotherapy has many aspects in common with thermalism or balneotherapy but also some distinctive characteristics. Balneology has a long European and Asian tradition and Romania can be the cornerstone of international bridges in this area due to its geographical position, legendary tradition and extraordinary natural resources of all kind. Each Balneary Resort begins its story with the discovery of natural factors whose therapeutical value has been clinically and experimentally proven by scientific personalities of that time. (1). Material and method. This article is a systematic and summarizing review of all published articles related to the thalassotherapy and thermal medicine subject found in Web of Science Core Collection. The methodological work is focused on the development of a bibliometric study of the literature generated regarding “thalassotherapy” therm. The analysis process followed integrates the use of descriptive-quantitative statistical techniques, which constitute a series of bibiliometric indicators that allow explore the research dynamics followed so far by the scientific community. These bibliometric indicators are numerical data that enable the analysis of diverse features of the scientific activity, linked both to the production and consumption of information and are based on the so-called “bibliometric laws”. Results and discussions. Analyzing an article database can be of real impact on the development of the field of Thalassotherapy but also can drive the future implications in the scientific arena. Conclusions. In balneary tourism, the importance of researching natural resources is essential for the development of a balneary resort promotion plan, thus providing information on the therapeutic properties of natural factors, their contribution to our health and the biological mechanisms by which they act on our body.

Impact of water therapy on pain management in patients with fibromyalgia: current perspectives

Exercise-related interventions have been recommended as one of the main components in the management of fibromyalgia syndrome (FMS). Water therapy, which combines water's physical properties and exercise benefits, has proven effective in improving the clinical symptoms of FMS, especially pain, considered the hallmark of this syndrome. However, to our knowledge, the mechanisms underlying water therapy effects on pain are still scarcely explored in the literature. Therefore, this narrative review aimed to present the current perspectives on water therapy and the physiological basis for the mechanisms supporting its use for pain management in patients with FMS. Furthermore, the effects of water therapy on the musculoskeletal, neuromuscular, cardiovascular, respiratory, and neuroendocrine systems and inflammation are also addressed. Taking into account the aspects reviewed herein, water therapy is recommended as a nonpharmacologic therapeutic approach in the management of FMS patients, improving pain, fatigue, and quality of life. Future studies should focus on clarifying whether mechanisms and long-lasting effects are superior to other types of nonpharmacological interventions, as well as the economic and societal impacts that this intervention may present.

Mixed exercise training for adults with fibromyalgia

BACKGROUND

Exercise training is commonly recommended for individuals with fibromyalgia. This review is one of a series of reviews about exercise training for fibromyalgia that will replace the review titled "Exercise for treating fibromyalgia syndrome", which was first published in 2002.

OBJECTIVES

To evaluate the benefits and harms of mixed exercise training protocols that include two or more types of exercise (aerobic, resistance, flexibility) for adults with fibromyalgia against control (treatment as usual, wait list control), non exercise (e.g. biofeedback), or other exercise (e.g. mixed versus flexibility) interventions.Specific comparisons involving mixed exercise versus other exercises (e.g. resistance, aquatic, aerobic, flexibility, and whole body vibration exercises) were not assessed.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Thesis and Dissertations Abstracts, the Allied and Complementary Medicine Database (AMED), the Physiotherapy Evidence Databese (PEDro), Current Controlled Trials (to 2013), WHO ICTRP, and ClinicalTrials.gov up to December 2017, unrestricted by language, to identify all potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in adults with a diagnosis of fibromyalgia that compared mixed exercise interventions with other or no exercise interventions. Major outcomes were health-related quality of life (HRQL), pain, stiffness, fatigue, physical function, withdrawals, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, and assessed risk of bias and the quality of evidence for major outcomes using the GRADE approach.

MAIN RESULTS

We included 29 RCTs (2088 participants; 98% female; average age 51 years) that compared mixed exercise interventions (including at least two of the following: aerobic or cardiorespiratory, resistance or muscle strengthening exercise, and flexibility exercise) versus control (e.g. wait list), non-exercise (e.g. biofeedback), and other exercise interventions. Design flaws across studies led to selection, performance, detection, and selective reporting biases. We prioritised the findings of mixed exercise compared to control and present them fully here.Twenty-one trials (1253 participants) provided moderate-quality evidence for all major outcomes but stiffness (low quality). With the exception of withdrawals and adverse events, major outcome measures were self-reported and expressed on a 0 to 100 scale (lower values are best, negative mean differences (MDs) indicate improvement; we used a clinically important difference between groups of 15% relative difference). Results for mixed exercise versus control show that mean HRQL was 56 and 49 in the control and exercise groups, respectively (13 studies; 610 participants) with absolute improvement of 7% (3% better to 11% better) and relative improvement of 12% (6% better to 18% better). Mean pain was 58.6 and 53 in the control and exercise groups, respectively (15 studies; 832 participants) with absolute improvement of 5% (1% better to 9% better) and relative improvement of 9% (3% better to 15% better). Mean fatigue was 72 and 59 points in the control and exercise groups, respectively (1 study; 493 participants) with absolute improvement of 13% (8% better to 18% better) and relative improvement of 18% (11% better to 24% better). Mean stiffness was 68 and 61 in the control and exercise groups, respectively (5 studies; 261 participants) with absolute improvement of 7% (1% better to 12% better) and relative improvement of 9% (1% better to 17% better). Mean physical function was 49 and 38 in the control and exercise groups, respectively (9 studies; 477 participants) with absolute improvement of 11% (7% better to 15% better) and relative improvement of 22% (14% better to 30% better). Pooled analysis resulted in a moderate-quality risk ratio for all-cause withdrawals with similar rates across groups (11 per 100 and 12 per 100 in the control and intervention groups, respectively) (19 studies; 1065 participants; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.69 to 1.51) with an absolute change of 1% (3% fewer to 5% more) and a relative change of 11% (28% fewer to 47% more). Across all 21 studies, no injuries or other adverse events were reported; however some participants experienced increased fibromyalgia symptoms (pain, soreness, or tiredness) during or after exercise. However due to low event rates, we are uncertain of the precise risks with exercise. Mixed exercise may improve HRQL and physical function and may decrease pain and fatigue; all-cause withdrawal was similar across groups, and mixed exercises may slightly reduce stiffness. For fatigue, physical function, HRQL, and stiffness, we cannot rule in or out a clinically relevant change, as the confidence intervals include both clinically important and unimportant effects.We found very low-quality evidence on long-term effects. In eight trials, HRQL, fatigue, and physical function improvement persisted at 6 to 52 or more weeks post intervention but improvements in stiffness and pain did not persist. Withdrawals and adverse events were not measured.It is uncertain whether mixed versus other non-exercise or other exercise interventions improve HRQL and physical function or decrease symptoms because the quality of evidence was very low. The interventions were heterogeneous, and results were often based on small single studies. Adverse events with these interventions were not measured, and thus uncertainty surrounds the risk of adverse events.

AUTHORS' CONCLUSIONS

Compared to control, moderate-quality evidence indicates that mixed exercise probably improves HRQL, physical function, and fatigue, but this improvement may be small and clinically unimportant for some participants; physical function shows improvement in all participants. Withdrawal was similar across groups. Low-quality evidence suggests that mixed exercise may slightly improve stiffness. Very low-quality evidence indicates that we are 'uncertain' whether the long-term effects of mixed exercise are maintained for all outcomes; all-cause withdrawals and adverse events were not measured. Compared to other exercise or non-exercise interventions, we are uncertain about the effects of mixed exercise because we found only very low-quality evidence obtained from small, very heterogeneous trials. Although mixed exercise appears to be well tolerated (similar withdrawal rates across groups), evidence on adverse events is scarce, so we are uncertain about its safety. We downgraded the evidence from these trials due to imprecision (small trials), selection bias (e.g. allocation), blinding of participants and care providers or outcome assessors, and selective reporting.

Land- and pool-based intervention in female fibromyalgia patients: A randomized-controlled trial

OBJECTIVES

The aim of this study was to assess the effect of a standard physical rehabilitation intervention (SPRI) program, in pool-based (SPRI-P) and land-based (SPRI-L) environments, applied to female fibromyalgia (FM) patients with mild-to-moderate symptoms during a period of 20 weeks.

PATIENTS AND METHODS

Between September 2016 and September 2017, a total of 73 female FM patients (mean age 48.2±6.8 years; range, 30 to 59 years) who suffered from FM were included in this study on a voluntary basis. The SPRI program was applied to the patients for 20 weeks. The severity of FM was assessed using the Fibromyalgia Impact Questionnaire. The dependent variables including self- perceived pain, perceived fatigue, aerobic capacity, depressive symptoms, and the overall impact of FM were evaluated.

RESULTS

Self-perceived pain, perceived fatigue, overall impact of FM (p<0.05) and depressive symptoms (p<0.001) of the participants in the SPRI-P program decreased in the post-test values, compared to the pre-test values. Using the SPRI-L program, a significant improvement in the aerobic capacity (maximum consumption of relative oxygen and distance in meters), overall impact of FM (p<0.05), and depressive symptoms (p<0.01) was observed.

CONCLUSION

Our study results indicated that the SPRI-P program yielded improvements in patients with FM in self-perceived pain, perceived fatigue, depressive symptoms, and overall impact, as well as improving the aerobic capacity. In addition, in the SPRI-L program, the participants increased their capacities, self-perceived pain, and overall impact of FM.

Therapeutic validity of exercise interventions in the management of fibromyalgia

BACKGROUND

This study aimed to evaluate the therapeutic validity of exercise interventions included in a previous umbrella systematic review of high-quality randomized controlled trials (RCTs) in the management of fibromyalgia and to explore whether exercise interventions with high therapeutic validity and that meet the 2013 American College of Sports Medicine (ACSM) guidelines are positively associated with greater pain relief.

METHODS

Therapeutic validity was evaluated based on the CONsensus on Therapeutic Exercise and Training (CONTENT) Scale, in high methodological quality RCTs found in the nine systematic reviews of a previous umbrella review on exercise interventions in the management of fibromyalgia. Additionally, adherence to the 2013 ACSM exercise recommendations for fibromyalgia was analyzed. The effect size for pain relief after the exercise programs was also considered.

RESULTS

The CONTENT mean total score was 4.42 out of 9, demonstrating generally low therapeutic validity of the 28 included RCTs. There was poor concordance between therapeutic validity and pain relief (Kappa values ranging between -0.6 to 0.57). Kappa statistic results showed poor concordance (k=0.01) between statistically significant (P<0.05) pain relief values and adherence to the 2013 ACSM exercise recommendations.

CONCLUSIONS

The therapeutic validity of exercise intervention programs in fibromyalgia is low. This is mainly due to incomplete descriptions of exercise interventions and adherence. Poor concordance is found between high therapeutic validity and adherence to the ACSM exercise recommendations with pain relief. Improved standardized reporting is recommended to identify optimal exercise prescription for fibromyalgia.

Salt water and skin interactions: new lines of evidence

In Health Resort Medicine, both balneotherapy and thalassotherapy, salt waters and their peloids, or mud products are mainly used to treat rheumatic and skin disorders. These therapeutic agents act jointly via numerous mechanical, thermal, and chemical mechanisms. In this review, we examine a new mechanism of action specific to saline waters. When topically administered, this water rich in sodium and chloride penetrates the skin where it is able to modify cellular osmotic pressure and stimulate nerve receptors in the skin via cell membrane ion channels known as "Piezo" proteins. We describe several models of cutaneous adsorption/desorption and penetration of dissolved ions in mineral waters through the skin (osmosis and cell volume mechanisms in keratinocytes) and examine the role of these resources in stimulating cutaneous nerve receptors. The actions of salt mineral waters are mediated by a mechanism conditioned by the concentration and quality of their salts involving cellular osmosis-mediated activation/inhibition of cell apoptotic or necrotic processes. In turn, this osmotic mechanism modulates the recently described mechanosensitive piezoelectric channels.

Whole body vibration exercise training for fibromyalgia

BACKGROUND

Exercise training is commonly recommended for adults with fibromyalgia. We defined whole body vibration (WBV) exercise as use of a vertical or rotary oscillating platform as an exercise stimulus while the individual engages in sustained static positioning or dynamic movements. The individual stands on the platform, and oscillations result in vibrations transmitted to the subject through the legs. This review is one of a series of reviews that replaces the first review published in 2002.

OBJECTIVES

To evaluate benefits and harms of WBV exercise training in adults with fibromyalgia.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, CINAHL, PEDro, Thesis and Dissertation Abstracts, AMED, WHO ICTRP, and ClinicalTrials.gov up to December 2016, unrestricted by language, to identify potentially relevant trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in adults with the diagnosis of fibromyalgia based on published criteria including a WBV intervention versus control or another intervention. Major outcomes were health-related quality of life (HRQL), pain intensity, stiffness, fatigue, physical function, withdrawals, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, performed risk of bias assessments, and assessed the quality of evidence for major outcomes using the GRADE approach. We used a 15% threshold for calculation of clinically relevant differences.

MAIN RESULTS

We included four studies involving 150 middle-aged female participants from one country. Two studies had two treatment arms (71 participants) that compared WBV plus mixed exercise plus relaxation versus mixed exercise plus relaxation and placebo WBV versus control, and WBV plus mixed exercise versus mixed exercise and control; two studies had three treatment arms (79 participants) that compared WBV plus mixed exercise versus control and mixed relaxation placebo WBV. We judged the overall risk of bias as low for selection (random sequence generation), detection (objectively measured outcomes), attrition, and other biases; as unclear for selection bias (allocation concealment); and as high for performance, detection (self-report outcomes), and selective reporting biases.The WBV versus control comparison reported on three major outcomes assessed at 12 weeks post intervention based on the Fibromyalgia Impact Questionnaire (FIQ) (0 to 100 scale, lower score is better). Results for HRQL in the control group at end of treatment (59.13) showed a mean difference (MD) of -3.73 (95% confidence interval [CI] -10.81 to 3.35) for absolute HRQL, or improvement of 4% (11% better to 3% worse) and relative improvement of 6.7% (19.6% better to 6.1% worse). Results for withdrawals indicate that 14 per 100 and 10 per 100 in the intervention and control groups, respectively, withdrew from the intervention (RR 1.43, 95% CI 0.27 to 7.67; absolute change 4%, 95% CI 16% fewer to 24% more; relative change 43% more, 95% CI 73% fewer to 667% more). The only adverse event reported was acute pain in the legs, for which one participant dropped out of the program. We judged the quality of evidence for all outcomes as very low. This study did not measure pain intensity, fatigue, stiffness, or physical function. No outcomes in this comparison met the 15% threshold for clinical relevance.The WBV plus mixed exercise (aerobic, strength, flexibility, and relaxation) versus control study (N = 21) evaluated symptoms at six weeks post intervention using the FIQ. Results for HRQL at end of treatment (59.64) showed an MD of -16.02 (95% CI -31.57 to -0.47) for absolute HRQL, with improvement of 16% (0.5% to 32%) and relative change in HRQL of 24% (0.7% to 47%). Data showed a pain intensity MD of -28.22 (95% CI -43.26 to -13.18) for an absolute difference of 28% (13% to 43%) and a relative change of 39% improvement (18% to 60%); as well as a fatigue MD of -33 (95% CI -49 to -16) for an absolute difference of 33% (16% to 49%) and relative difference of 47% (95% CI 23% to 60%); and a stiffness MD of -26.27 (95% CI -42.96 to -9.58) for an absolute difference of 26% (10% to 43%) and a relative difference of 36.5% (23% to 60%). All-cause withdrawals occurred in 8 per 100 and 33 per 100 withdrawals in the intervention and control groups, respectively (two studies, N = 46; RR 0.25, 95% CI 0.06 to 1.12) for an absolute risk difference of 24% (3% to 51%). One participant exhibited a mild anxiety attack at the first session of WBV. No studies in this comparison reported on physical function. Several outcomes (based on the findings of one study) in this comparison met the 15% threshold for clinical relevance: HRQL, pain intensity, fatigue, and stiffness, which improved by 16%, 39%, 46%, and 36%, respectively. We found evidence of very low quality for all outcomes.The WBV plus mixed exercise versus other exercise provided very low quality evidence for all outcomes. Investigators evaluated outcomes on a 0 to 100 scale (lower score is better) for pain intensity (one study, N = 23; MD -16.36, 95% CI -29.49 to -3.23), HRQL (two studies, N = 49; MD -6.67, 95% CI -14.65 to 1.31), fatigue (one study, N = 23; MD -14.41, 95% CI -29.47 to 0.65), stiffness (one study, N = 23; MD -12.72, 95% CI -26.90 to 1.46), and all-cause withdrawal (three studies, N = 77; RR 0.72, 95% CI -0.17 to 3.11). Adverse events reported for the three studies included one anxiety attack at the first session of WBV and one dropout from the comparison group ("other exercise group") due to an injury that was not related to the program. No studies reported on physical function.

AUTHORS' CONCLUSIONS

Whether WBV or WBV in addition to mixed exercise is superior to control or another intervention for women with fibromyalgia remains uncertain. The quality of evidence is very low owing to imprecision (few study participants and wide confidence intervals) and issues related to risk of bias. These trials did not measure major outcomes such as pain intensity, stiffness, fatigue, and physical function. Overall, studies were few and were very small, which prevented meaningful estimates of harms and definitive conclusions about WBV safety.

Aerobic exercise training for adults with fibromyalgia

BACKGROUND

Exercise training is commonly recommended for individuals with fibromyalgia. This review is one of a series of reviews about exercise training for people with fibromyalgia that will replace the "Exercise for treating fibromyalgia syndrome" review first published in 2002.

OBJECTIVES

• To evaluate the benefits and harms of aerobic exercise training for adults with fibromyalgia• To assess the following specific comparisons ० Aerobic versus control conditions (eg, treatment as usual, wait list control, physical activity as usual) ० Aerobic versus aerobic interventions (eg, running vs brisk walking) ० Aerobic versus non-exercise interventions (eg, medications, education) We did not assess specific comparisons involving aerobic exercise versus other exercise interventions (eg, resistance exercise, aquatic exercise, flexibility exercise, mixed exercise). Other systematic reviews have examined or will examine these comparisons (Bidonde 2014; Busch 2013).

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Physiotherapy Evidence Database (PEDro), Thesis and Dissertation Abstracts, the Allied and Complementary Medicine Database (AMED), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), and the ClinicalTrials.gov registry up to June 2016, unrestricted by language, and we reviewed the reference lists of retrieved trials to identify potentially relevant trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) in adults with a diagnosis of fibromyalgia that compared aerobic training interventions (dynamic physical activity that increases breathing and heart rate to submaximal levels for a prolonged period) versus no exercise or another intervention. Major outcomes were health-related quality of life (HRQL), pain intensity, stiffness, fatigue, physical function, withdrawals, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, performed a risk of bias assessment, and assessed the quality of the body of evidence for major outcomes using the GRADE approach. We used a 15% threshold for calculation of clinically relevant differences between groups.

MAIN RESULTS

We included 13 RCTs (839 people). Studies were at risk of selection, performance, and detection bias (owing to lack of blinding for self-reported outcomes) and had low risk of attrition and reporting bias. We prioritized the findings when aerobic exercise was compared with no exercise control and present them fully here.Eight trials (with 456 participants) provided low-quality evidence for pain intensity, fatigue, stiffness, and physical function; and moderate-quality evidence for withdrawals and HRQL at completion of the intervention (6 to 24 weeks). With the exception of withdrawals and adverse events, major outcome measures were self-reported and were expressed on a 0 to 100 scale (lower values are best, negative mean differences (MDs)/standardized mean differences (SMDs) indicate improvement). Effects for aerobic exercise versus control were as follows: HRQL: mean 56.08; five studies; N = 372; MD -7.89, 95% CI -13.23 to -2.55; absolute improvement of 8% (3% to 13%) and relative improvement of 15% (5% to 24%); pain intensity: mean 65.31; six studies; N = 351; MD -11.06, 95% CI -18.34 to -3.77; absolute improvement of 11% (95% CI 4% to 18%) and relative improvement of 18% (7% to 30%); stiffness: mean 69; one study; N = 143; MD -7.96, 95% CI -14.95 to -0.97; absolute difference in improvement of 8% (1% to 15%) and relative change in improvement of 11.4% (21.4% to 1.4%); physical function: mean 38.32; three studies; N = 246; MD -10.16, 95% CI -15.39 to -4.94; absolute change in improvement of 10% (15% to 5%) and relative change in improvement of 21.9% (33% to 11%); and fatigue: mean 68; three studies; N = 286; MD -6.48, 95% CI -14.33 to 1.38; absolute change in improvement of 6% (12% improvement to 0.3% worse) and relative change in improvement of 8% (16% improvement to 0.4% worse). Pooled analysis resulted in a risk ratio (RR) of moderate quality for withdrawals (17 per 100 and 20 per 100 in control and intervention groups, respectively; eight studies; N = 456; RR 1.25, 95%CI 0.89 to 1.77; absolute change of 5% more withdrawals with exercise (3% fewer to 12% more).Three trials provided low-quality evidence on long-term effects (24 to 208 weeks post intervention) and reported that benefits for pain and function persisted but did not for HRQL or fatigue. Withdrawals were similar, and investigators did not assess stiffness and adverse events.We are uncertain about the effects of one aerobic intervention versus another, as the evidence was of low to very low quality and was derived from single trials only, precluding meta-analyses. Similarly, we are uncertain of the effects of aerobic exercise over active controls (ie, education, three studies; stress management training, one study; medication, one study) owing to evidence of low to very low quality provided by single trials. Most studies did not measure adverse events; thus we are uncertain about the risk of adverse events associated with aerobic exercise.

AUTHORS' CONCLUSIONS

When compared with control, moderate-quality evidence indicates that aerobic exercise probably improves HRQL and all-cause withdrawal, and low-quality evidence suggests that aerobic exercise may slightly decrease pain intensity, may slightly improve physical function, and may lead to little difference in fatigue and stiffness. Three of the reported outcomes reached clinical significance (HRQL, physical function, and pain). Long-term effects of aerobic exercise may include little or no difference in pain, physical function, and all-cause withdrawal, and we are uncertain about long-term effects on remaining outcomes. We downgraded the evidence owing to the small number of included trials and participants across trials, and because of issues related to unclear and high risks of bias (performance, selection, and detection biases). Aerobic exercise appears to be well tolerated (similar withdrawal rates across groups), although evidence on adverse events is scarce, so we are uncertain about its safety.

Aquatic exercise training for fibromyalgia

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.

Therapeutic benefit of balneotherapy and hydrotherapy in the management of fibromyalgia syndrome: a qualitative systematic review and meta-analysis of randomized controlled trials

Introduction

In the present systematic review and meta-analysis, we assessed the effectiveness of different forms of balneotherapy (BT) and hydrotherapy (HT) in the management of fibromyalgia syndrome (FMS).

Methods

A systematic literature search was conducted through April 2013 (Medline via Pubmed, Cochrane Central Register of Controlled Trials, EMBASE, and CAMBASE). Standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated using a random-effects model.

Results

Meta-analysis showed moderate-to-strong evidence for a small reduction in pain (SMD −0.42; 95% CI [−0.61, −0.24]; P < 0.00001; I² = 0%) with regard to HT (8 studies, 462 participants; 3 low-risk studies, 223 participants), and moderate-to-strong evidence for a small improvement in health-related quality of life (HRQOL; 7 studies, 398 participants; 3 low-risk studies, 223 participants) at the end of treatment (SMD −0.40; 95% CI [−0.62, −0.18]; P = 0.0004; I² = 15%). No effect was seen at the end of treatment for depressive symptoms and tender point count (TPC).

BT in mineral/thermal water (5 studies, 177 participants; 3 high-risk and 2 unclear risk studies) showed moderate evidence for a medium-to-large size reduction in pain and TPC at the end of treatment: SMD −0.84; 95% CI [−1.36, −0.31]; P = 0.002; I² = 63% and SMD −0.83; 95% CI [−1.42, −0.24]; P = 0.006; I² = 71%. After sensitivity analysis, and excluding one study, the effect size for pain decreased: SMD −0.58; 95% CI [−0.91, −0.26], P = 0.0004; I² = 0. Moderate evidence is given for a medium improvement of HRQOL (SMD −0.78; 95% CI [−1.13, −0.43]; P < 0.0001; I² = 0%). A significant effect on depressive symptoms was not found. The improvements for pain could be maintained at follow-up with smaller effects.

Conclusions

High-quality studies with larger sample sizes are needed to confirm the therapeutic benefit of BT and HT, with focus on long-term results and maintenance of the beneficial effects.

Resistance exercise training for fibromyalgia

BACKGROUND

Fibromyalgia is characterized by chronic widespread pain that leads to reduced physical function. Exercise training is commonly recommended as a treatment for management of symptoms. We examined the literature on resistance training for individuals with fibromyalgia. Resistance training is exercise performed against a progressive resistance with the intention of improving muscle strength, muscle endurance, muscle power, or a combination of these.

OBJECTIVES

To evaluate the benefits and harms of resistance exercise training in adults with fibromyalgia. We compared resistance training versus control and versus other types of exercise training.

SEARCH METHODS

We searched nine electronic databases (The Cochrane Library, MEDLINE, EMBASE, CINAHL, PEDro, Dissertation Abstracts, Current Controlled Trials, World Health Organization (WHO) International Clinical Trials Registry Platform, AMED) and other sources for published full-text articles. The date of the last search was 5 March 2013. Two review authors independently screened 1856 citations, 766 abstracts and 156 full-text articles. We included five studies that met our inclusion criteria.

SELECTION CRITERIA

Selection criteria included: a) randomized clinical trial, b) diagnosis of fibromyalgia based on published criteria, c) adult sample, d) full-text publication, and e) inclusion of between-group data comparing resistance training versus a control or other physical activity intervention.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently assessed risk of bias and extracted intervention and outcome data. We resolved disagreements between the two review authors and questions regarding interpretation of study methods by discussion within the pairs or when necessary the issue was taken to the full team of 11 members. We extracted 21 outcomes of which seven were designated as major outcomes: multidimensional function, self reported physical function, pain, tenderness, muscle strength, attrition rates, and adverse effects. We evaluated benefits and harms of the interventions using standardized mean differences (SMD) or mean differences (MD) or risk ratios or Peto odds ratios and 95% confidence intervals (CI). Where two or more studies provided data for an outcome, we carried out a meta-analysis.

MAIN RESULTS

The literature search yielded 1865 citations with five studies meeting the selection criteria. One of the studies that had three arms contributed data for two comparisons. In the included studies, there were 219 women participants with fibromyalgia, 95 of whom were assigned to resistance training programs. Three randomized trials compared 16 to 21 weeks of moderate- to high-intensity resistance training versus a control group. Two studies compared eight weeks of progressive resistance training (intensity as tolerated) using free weights or body weight resistance exercise versus aerobic training (ie, progressive treadmill walking, indoor and outdoor walking), and one study compared 12 weeks of low-intensity resistance training using hand weights (1 to 3 lbs (0.45 to 1.36 kg)) and elastic tubing versus flexibility exercise (static stretches to major muscle groups).Statistically significant differences (MD; 95% CI) favoring the resistance training interventions over control group(s) were found in multidimensional function (Fibromyalgia Impact Questionnaire (FIQ) total decreased 16.75 units on a 100-point scale; 95% CI -23.31 to -10.19), self reported physical function (-6.29 units on a 100-point scale; 95% CI -10.45 to -2.13), pain (-3.3 cm on a 10-cm scale; 95% CI -6.35 to -0.26), tenderness (-1.84 out of 18 tender points; 95% CI -2.6 to -1.08), and muscle strength (27.32 kg force on bilateral concentric leg extension; 95% CI 18.28 to 36.36).Differences between the resistance training group(s) and the aerobic training groups were not statistically significant for multidimensional function (5.48 on a 100-point scale; 95% CI -0.92 to 11.88), self reported physical function (-1.48 units on a 100-point scale; 95% CI -6.69 to 3.74) or tenderness (SMD -0.13; 95% CI -0.55 to 0.30). There was a statistically significant reduction in pain (0.99 cm on a 10-cm scale; 95% CI 0.31 to 1.67) favoring the aerobic groups.Statistically significant differences were found between a resistance training group and a flexibility group favoring the resistance training group for multidimensional function (-6.49 FIQ units on a 100-point scale; 95% CI -12.57 to -0.41) and pain (-0.88 cm on a 10-cm scale; 95% CI -1.57 to -0.19), but not for tenderness (-0.46 out of 18 tender points; 95% CI -1.56 to 0.64) or strength (4.77 foot pounds torque on concentric knee extension; 95% CI -2.40 to 11.94). This evidence was classified low quality due to the low number of studies and risk of bias assessment. There were no statistically significant differences in attrition rates between the interventions. In general, adverse effects were poorly recorded, but no serious adverse effects were reported. Assessment of risk of bias was hampered by poor written descriptions (eg, allocation concealment, blinding of outcome assessors). The lack of a priori protocols and lack of care provider blinding were also identified as methodologic concerns.

AUTHORS' CONCLUSIONS

The evidence (rated as low quality) suggested that moderate- and moderate- to high-intensity resistance training improves multidimensional function, pain, tenderness, and muscle strength in women with fibromyalgia. The evidence (rated as low quality) also suggested that eight weeks of aerobic exercise was superior to moderate-intensity resistance training for improving pain in women with fibromyalgia. There was low-quality evidence that 12 weeks of low-intensity resistance training was superior to flexibility exercise training in women with fibromyalgia for improvements in pain and multidimensional function. There was low-quality evidence that women with fibromyalgia can safely perform moderate- to high-resistance training.

Safety and effectiveness of vibration massage by deep oscillations: a prospective observational study

The objective of this study is to assess the safety of treatment with vibration massage using a deep oscillation device and the effects on symptom severity and quality of life in patients with primary fibromyalgia syndrome (FMS). Outpatients with FMS performed an observational prospective study with visits 2-4 weeks after the last treatment (control) and after further 2 months (follow-up). Patients were treated with 10 sessions of 45 min deep oscillation massage, 2/week. Primary outcome parameters were safety and tolerability (5-level Likert scale (1 = very good)) (after each treatment session and at control visit). Secondary outcome parameters were symptom severity (Fibromyalgia Impact Questionnaire (FIQ), pain) and quality of life (SF-36). Seventy patients (97.1% females) were included. At control visit, 41 patients (58.6%) reported 63 mild and short-lasting adverse events, mainly worsening of prevalent symptoms such as pain and fatigue. Tolerability was rated as 1.8 (95% confidence interval: 1.53; 2.07). Symptoms and quality of life were significantly improved at both control and follow-up visits (at least P < 0.01). In conclusion, deep oscillation massage is safe and well tolerated in patients with FMS and might improve symptoms and quality of life rather sustained.

The effectiveness of aquatic physical therapy in the treatment of fibromyalgia: a systematic review with meta-analysis

Objective:

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.

[Physiotherapy and physical therapies for fibromyalgia syndrome. Systematic review, meta-analysis and guideline]

BACKGROUND

The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011.

MATERIALS AND METHODS

The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies.

RESULTS AND CONCLUSION

Low-to-moderate intensity aerobic exercise and strength training are strongly recommended. Chiropractic, laser therapy, magnetic field therapy, massage and transcranial current stimulation are not recommended. The English full-text version of this article is available at SpringerLink (under "Supplemental").

[Effectiveness of aquatic biodance on sleep quality, anxiety and other symptoms in patients with fibromyalgia]

BACKGROUND AND OBJECTIVE

To analyze the effects of an aquatic biodance based therapy on sleep quality, anxiety, depression, pain and quality of life in fibromyalgia patients.

PATIENTS AND METHOD

Randomized controlled trial with 2 groups. Fifty-nine patients were assigned to 2 groups: experimental group (aquatic biodance) and control group (stretching). The outcome measures were quality of sleep (Pittsburgh questionnaire), anxiety (State Anxiety Inventory), depression (Center for Epidemiologic Studies Depression Scale), pain (visual analogue scale, pressure algometry and McGill) and quality of life (Fibromyalgia Impact Questionnaire) before and after a 12-week therapy.

RESULTS

After treatment, we observed significant differences in the experimental group (P<.05) on sleep quality (49.7%), anxiety (14.1%), impact of fibromyalgia (18.3%), pain (27.9%), McGill (23.7%) and tender points (34.4%).

CONCLUSIONS

Aquatic biodance contributed to improvements in sleep quality, anxiety, pain and other fibromyalgia symptoms.

Aquatic exercise in a chest-high pool for hormone therapy-induced arthralgia in breast cancer survivors: a pragmatic controlled trial

OBJECTIVE

To investigate the impact of aquatic exercise on pressure pain threshold in breast cancer survivors with hormone therapy-associated arthralgia.

DESIGN

Single-blind, controlled trial.

SETTING

Two major metropolitan hospitals and a Sport and Spa Club in Granada, Spain.

SUBJECTS

Forty women aged 29-71 years with stage I-III breast cancer who reported arthralgia.

INTERVENTION

Patients were allocated alternately to either aquatic exercise in a chest-high pool or usual care while on the waiting list; control patients received treatment later. The two-month hydrotherapy intervention consisted of 24 sessions 3 days per week. Each session included 5 minutes of warm-up, 15-20 minutes of aerobic exercise, 15 minutes of mobility exercise and 20 minutes of recovery techniques.

MAIN MEASURES

Pressure pain threshold at neck, shoulder, hand and leg were evaluated as primary outcomes. Cancer-related fatigue, as measured by the Piper Fatigue Scale, body mass index and waist circumference were secondary outcomes. A 2 × 2 repeated-measure ANCOVA was used in this study.

RESULTS

No adverse events or development of worsening of pain was observed. Almost all the participants in the intervention group (89%) adhered to the hydrotherapy programme. Participants experienced a decrease in pressure pain threshold measured in neck, hand, shoulder and leg, as measured by algometry pressure, and waist circumference; all P < 0.05. Cancer-related fatigue (P = 0.06) and body mass index (P = 0.42) did not show significant improvement.

CONCLUSIONS

These data suggest that hydrotherapy in a chest-high pool may reduce the pain threshold and waist circumference in breast cancer survivors with hormone therapy-associated arthralgia.

Efficacy of Biodanza for treating women with fibromyalgia

OBJECTIVE

The objective of this study was to determine the effects of a 3-month Biodanza intervention in women with fibromyalgia (FM).

DESIGN

This was a controlled trial.

SETTING/LOCATION

The study was conducted at a university research laboratory and social center.

SUBJECTS

The study comprised 59 women with FM recruited from a local association of patients with FM. Participants were allocated to the Biodanza intervention group (n = 27) or usual-care group (n = 32).

INTERVENTION

The Biodanza intervention was carried out once a week for 3 months.

OUTCOME MEASURES

The outcome measures included the following: Pain threshold, body composition (body-mass index and estimated body fat percentage), physical fitness (30-second chair stand, handgrip strength, chair sit and reach, back scratch, blind flamingo, 8 feet up and go, and 6-minute walk test) and psychologic outcomes (Fibromyalgia Impact Questionnaire [FIQ], Short-Form Health Survey 36, Vanderbilt Pain Management Inventory, Hospital Anxiety and Depression Scale, General Self-Efficacy Scale, and Rosenberg Self-Esteem Scale).

RESULTS

We observed a significant interaction effect (group*time) for pain threshold of several tender points (left [L] and right [R] side of the anterior cervical and supraspinatus, trapezius L and lateral epicondyle R, algometer score, tender points count), body fat percentage, and FIQ total score. In the intervention group, post hoc analysis revealed a significant improvement in pain threshold of the anterior cervical R and L and supraspinatus R and L tender points (all p < 0.05), algometer score (p = 0.008), tender point count (p = 0.002), body fat percentage (p = 0.001), and FIQ total score (p = 0.003).

CONCLUSIONS

A 3-month (one session per week) Biodanza intervention shows improvements on pain, body composition, and FM impact in female patients.

A proposal for a worldwide definition of health resort medicine, balneology, medical hydrology and climatology

Health Resort Medicine, Balneology, Medical Hydrology and Climatology are not fully recognised as independent medical specialties at a global international level. Analysing the reasons, we can identify both external (from outside the field) and internal (from inside the field) factors. External arguments include, e.g. the lack of scientific evidence, the fact that Balneotherapy and Climatotherapy is not used in all countries, and the fact that Health Resort Medicine, Balneology, Medical Hydrology and Climatology focus only on single methods and do not have a comprehensive concept. Implicit barriers are the lack of international accepted terms in the field, the restriction of being allowed to practice the activities only in specific settings, and the trend to use Balneotherapy mainly for wellness concepts. Especially the implicit barriers should be subject to intense discussions among scientists and specialists. This paper suggests one option to tackle the problem of implicit barriers by making a proposal for a structure and description of the medical field, and to provide some commonly acceptable descriptions of content and terminology. The medical area can be defined as "medicine in health resorts" (or "health resort medicine"). Health resort medicine includes "all medical activities originated and derived in health resorts based on scientific evidence aiming at health promotion, prevention, therapy and rehabilitation". Core elements of health resort interventions in health resorts are balneotherapy, hydrotherapy, and climatotherapy. Health resort medicine can be used for health promotion, prevention, treatment, and rehabilitation. The use of natural mineral waters, gases and peloids in many countries is called balneotherapy, but other (equivalent) terms exist. Substances used for balneotherapy are medical mineral waters, medical peloids, and natural gases (bathing, drinking, inhalation, etc.). The use of plain water (tap water) for therapy is called hydrotherapy, and the use of climatic factors for therapy is called climatotherapy. Reflecting the effects of health resort medicine, it is important to take other environmental factors into account. These can be classified within the framework of the ICF (International Classification of Functioning, Disability and Health). Examples include receiving health care by specialised doctors, being well educated (ICF-domain: e355), having an environment supporting social contacts (family, peer groups) (cf. ICF-domains: d740, d760), facilities for recreation, cultural activities, leisure and sports (cf. ICF-domain: d920), access to a health-promoting atmosphere and an environment close to nature (cf. ICF-domain: e210). The scientific field dealing with health resort medicine is called health resort sciences. It includes the medical sciences, psychology, social sciences, technical sciences, chemistry, physics, geography, jurisprudence, etc. Finally, this paper proposes a systematic international discussion of descriptions in the field of Health Resort Medicine, Balneology, Medical Hydrology and Climatology, and discusses short descriptive terms with the goal of achieving internationally accepted distinct terms. This task should be done via a structured consensus process and is of major importance for the publication of scientific results as well as for systematic reviews and meta-analyses.

Fibromyalgia syndrome: a discussion of the syndrome and pharmacotherapy

Fibromyalgia is a complex condition that is characterized by chronic widespread pain and multiple other symptoms, including fatigue, sleep disturbances, cognitive dysfunction, stiffness, and depressive episodes. Fibromyalgia may coexist and/or overlap with other conditions that may involve central sensitivity, including chronic fatigue syndrome, irritable bowel syndrome, irritable bladder syndrome or interstitial cystitis, and temporomandibular disorder. The pathophysiology of fibromyalgia remains uncertain but is believed to be partly the result of central systems affecting afferent processing as well as impaired endogenous pain-inhibitory systems. Abnormal central nociceptive processing may contribute to fibromyalgia, producing heightened responses to various noxious stimuli with resulting mechanical hyperalgesia. Fibromyalgia remains a clinical diagnosis. There has been a recent paradigm shift away from requiring 11 or more out of 18 tender points and instead focusing on the presence of chronic widespread pain as well as symptoms of fatigue, unrefreshed sleep, and other somatic complaints. Although there is no known cure for fibromyalgia, multidisciplinary team efforts using combined treatment approaches, including patient education, aerobic exercise, cognitive behavioral therapy, and pharmacologic therapies (serotonin norepinephrine reuptake inhibitors [eg, duloxetine, milnacipran] and alpha 2-delta receptor ligands [eg, pregabalin]) may improve symptoms as well as function of patients with fibromyalgia.

Efficacy of different types of aerobic exercise in fibromyalgia syndrome: a systematic review and meta-analysis of randomised controlled trials

Introduction

The efficacy and the optimal type and volume of aerobic exercise (AE) in fibromyalgia syndrome (FMS) are not established. We therefore assessed the efficacy of different types and volumes of AE in FMS.

Methods

The Cochrane Library, EMBASE, MEDLINE, PsychInfo and SPORTDISCUS (through April 2009) and the reference sections of original studies and systematic reviews on AE in FMS were systematically reviewed. Randomised controlled trials (RCTs) of AE compared with controls (treatment as usual, attention placebo, active therapy) and head-to-head comparisons of different types of AE were included. Two authors independently extracted articles using predefined data fields, including study quality indicators.

Results

Twenty-eight RCTs comparing AE with controls and seven RCTs comparing different types of AE with a total of 2,494 patients were reviewed. Effects were summarised using standardised mean differences (95% confidence intervals) by random effect models. AE reduced pain (-0.31 (-0.46, -0.17); P < 0.001), fatigue (-0.22 (-0.38, -0.05); P = 0.009), depressed mood (-0.32 (-0.53, -0.12); P = 0.002) and limitations of health-related quality of life (HRQOL) (-0.40 (-0.60, -0.20); P < 0.001), and improved physical fitness (0.65 (0.38, 0.95); P < 0.001), post treatment. Pain was significantly reduced post treatment by land-based and water-based AE, exercises with slight to moderate intensity and frequency of two or three times per week. Positive effects on depressed mood, HRQOL and physical fitness could be maintained at follow-up. Continuing exercise was associated with positive outcomes at follow-up. Risks of bias analyses did not change the robustness of the results. Few studies reported a detailed exercise protocol, thus limiting subgroup analyses of different types of exercise.

Conclusions

An aerobic exercise programme for FMS patients should consist of land-based or water-based exercises with slight to moderate intensity two or three times per week for at least 4 weeks. The patient should be motivated to continue exercise after participating in an exercise programme.

Components of effective randomized controlled trials of hydrotherapy programs for fibromyalgia syndrome: A systematic review

Aim

Previous systematic reviews have found hydrotherapy to be an effective management strategy for fibromyalgia syndrome (FMS). The aim of this systematic review was to summarize the components of hydrotherapy programs used in randomized controlled trials.

Method

A systematic review of randomized controlled trials was conducted. Only trials that have reported significant FMS-related outcomes were included. Data relating to the components of hydrotherapy programs (exercise type, duration, frequency and intensity, environmental factors, and service delivery) were analyzed.

Results

Eleven randomized controlled trials were included in this review. Overall, the quality of trials was good. Aerobic exercise featured in all 11 trials and the majority of hydrotherapy programs included either a strengthening or flexibility component. Great variability was noted in both the environmental components of hydrotherapy programs and service delivery.

Conclusions

Aerobic exercise, warm up and cool-down periods and relaxation exercises are common features of hydrotherapy programs that report significant FMS-related outcomes. Treatment duration of 60 minutes, frequency of three sessions per week and an intensity equivalent to 60%–80% maximum heart rate were the most commonly reported exercise components. Exercise appears to be the most important component of an effective hydrotherapy program for FMS, particularly when considering mental health-related outcomes.

Exercise interventions in fibromyalgia: clinical applications from the evidence

This article summarizes physiologic obstacles to exercise and reviews exercise interventions in fibromyalgia (FM). In addition, the authors describe the top 10 principles for successfully prescribing exercise in the comprehensive treatment of FM and provide a practical exercise resource table to share with patients. A therapeutic alliance between the provider and patient is enhanced if both understand the risks and benefits of exercise. Such an alliance increases the likelihood of the patient successfully integrating life-long exercise into his or her comprehensive FM treatment plan.

Improvements of muscle strength predicted benefits in HRQOL and postural balance in women with fibromyalgia: an 8-month randomized controlled trial

OBJECTIVE

To evaluate whether changes in muscle strength due to 32 weeks of supervised aquatic training predicted improvements on health-related quality of life (HRQOL).

METHODS

Thirty women with FM aged 50.8 +/- 8.7 years were randomly assigned to an experimental group (n = 15), performing 3 weekly sessions of 60 min of warm-water exercise; or to a control group (n = 15). HRQOL was evaluated using the Short Form 36 Health Survey (SF-36). Maximal unilateral isokinetic strength was measured at 60 degrees/s and 210 degrees/s in the knee extensors and flexors in concentric action and at 60 degrees/s in knee extensors eccentric action. Postural balance was evaluated using the one-leg stance, eyes closed.

RESULTS

After 32 weeks of water exercise therapy, statistically significant improvements occurred in concentric knee flexors and extensors strength at 60 degrees/s, in eccentric knee extensors and in postural balance. The treatment led to additional improvements in physical function, role physical problems, body pain, general health, vitality, role emotional problems and mental health dimensions of SF-36. Gains in the concentric knee flexors strength predicted improvements in role of physical problems, whereas those in concentric knee extensors did the same for mental health and role emotional problems. Gains in eccentric knee extensors strength predicted improvements in postural balance.

CONCLUSIONS

A long-lasting exercise therapy in warm water produced relevant gains in muscle strength at low velocities of movements, some of which predicted improvements in physical problems, emotional problems, mental health and balance.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number ISRCTN53367487, information available in http://www.controlled-trials.com/ISRCTN53367487.