Exercise as it relates to Disease/Aquatic exercise as a therapy in the management in fibromyalgia symptoms

This is a critique of the original research: Effectiveness of aquatic therapy in the treatment of fibromyalgia syndrome: a randomized controlled open study. Open study

What is the background to this research?
When treating people with Fibromyalgia Syndrome (FMS), research showed that positive effects came from physical therapy.

In the treatment of Fibromyalgia symptoms, many studies have focused on proving the effectiveness of regular physical activities. For example, aerobic and land-based exercise programs. https://www.healthdirect.gov.au/fibromyalgia

It was found that, low-to-moderate-intensity aerobic exercises brought beneficial effects to the participants’ level of: The benefits observed in FMS, during the aerobic and land-based exercise programs, have served as the basics to develop other regimes such as group exercises in a pool or on land.
 * Pain management;
 * Psychological distress;
 * Sleep;
 * Physical capacity; and
 * Emotional wellbeing.

In clinical practice, it was observed that, when patients diagnosed with FMS were exposed to aquatic therapy, they experienced beneficial effects in:
 * physiological distress;
 * intensity of pain;
 * functional capacity; and
 * general wellbeing.

Some additional studies have shown greater benefits from aquatic aerobics when compared to home-based exercises.

The aim of this study was to investigate the positive effects of supervised aquatic therapy with non-supervised home-based exercises, and then compare, which had the greater benefits. Some evidence suggested that home-base exercise prescriptions are usually inadequate. This is because most exercises are based on methods designed for persons without FMS. Therefore, there can be a lack of consideration of the needs of each individual. Not all exercises are suitable for everybody. The participants’ incapacities to complete the exercises could distort the results of the research.

Where is the research from?
In Turkey’s capital city of Ankara, this research was undertaken in collaboration with both Kocatepe and Ufuk Universities’, Departments of Physical Rehabilitation Medicine, in 2008. The head author, Professor Deniz Evcik, works at the Ankara University, Department of Physical Medicine and Rehabilitation (Turkey), and in Guven Hospital’s Department of Physical Medicine and Rehabilitation. She has participated in 104 international medical publications, all of them in the fields of her expertise. These include:


 * Rheumatic Diseases and Rehabilitation;
 * Aquatic Therapy; and
 * Neuropathic pain.

No conflicts of interest were found between University authors.

What kind of research was this?
It was designed as a prospective, randomised, controlled open study (RCT).

Many forms of Fibromyalgia-related exercise-training has been studied through the use of high-quality RCTs. These have included, aquatic and land-based regimes that involve aerobic, strength, flexibility, and mixed format exercise interventions.

Over the past decade, there has also been further growth in the number of review articles, using RCT methodology. It has proven to be a tried and tested methodology to use in this area of research.

The absence of a placebo group and double-blind design were limitations of this investigation. Could this have an impact on the way the results are interpreted, particularly since cause and effect was determined between each of the groups?

What did the research involve?
This prospective study enrolled 63 FMS patients, mainly women and one male subject.

The criteria excluded patients who had:
 * Unstable Hypertension;
 * Severe CVD;
 * Cancer;
 * Osteoarthritis;
 * Medications – antidepressants, non-steroidal anti-inflammatory drugs
 * Habituated exercisers;
 * Heat intolerance; and
 * Pregnancy.

Two groups (mean age 43.4) were formed. Group I (n=33), received a supervised aquatic exercise program and Group II (n=30) received an unsupervised home-based exercise program. Programs consisted of 15 sessions of 60 minutes (i.e. five weeks of three sessions per week).

Patients were initially evaluated for:
 * Pain using the visual analogue scale (VAS);
 * Depression, using Beck depression inventory (BDI),
 * Number of tender points (NTP); and
 * Functional capacity, using the Fibromyalgia Impact Questionare (FIQ).

All markers were retaken in Weeks 4,12 and 24.

Patients in Group I received aquatic sessions in a 33-degree pool. The program consisted of 20 minutes of pool-side exercises, including warm-up, active-range-of-movement, and relaxation. It followed with 35 minutes of pool exercises, forward/backward walking warm-ups, jumping, jogging and active range of aerobic-conditioning-movements, stretches-of-extremities, supine-position-floating for relaxation and 5 minutes for cooling down. Group II received a home-based-exercise program, (warm-up, range-of-movement, aerobics, relaxation and cooling down) explained by a physiotherapist once. Written routines were provided.

Land-based and aquatic program, were being compared in their effectiveness in treating FMS; however, in reality, the aquatic program has a significant combination of both land and water, where one-third of the time allocation is pool-side, on land. Does this compromise the validity of the percentage-results in those who were in the aquatic-based program?

Another methodology concern is the trust ambiguity that is created with the unsupervised Group II. This too can warp this groups results because of the amount of trust there is, that the participant will be able to follow the exercises and intensity properly. FMS can have flare-ups and improvements at any given time. What if modifications are required? It was presumed that they did what they have said they would do. Group II may have bias.

What were the basic results?
Results showed:
 * For both groups, significant improvements in all markers (pain, depression, tender-points, and functional capacity), over the different time-checkpoints;
 * Greater score improvements for Group 1 (Aquatic), when compared with Group II (Land-based);
 * Levels of pain reduced by 40% in Group I and 21% in Group II.
 * Significant statistical improvements were maintained into week 12 for both groups; however, at Week 24’s follow-up, those improvements remained significant only for Group I.

I believe the presumptions about the aquatic group’s long-term results are limited in nature because there may be other variables at play. We do not know what other factors are at play in the lifestyles of the participants.
 * Did they continue the new routines? Did they stop? Was there a cessation of a flare-up? Were there new medications introduced? None of these factors were mentioned. Did they remain sedentary or engage in another physical activity or did another medical condition develop?
 * There is too much ambiguity about the circumstances of the participants, to make their presumptions. Did this cause bias to the results of Week 24 that seem to indicate that the improvements will automatically continue?

What conclusions can we take from this research?
Study results indicated greater scores for FBS patients exercising in water. However, there are concerns that scores may not be purely because of the aquatic exercises, given that some of the time was pool-side and their participants were in a supervised group.

It appears that the improvements made in water, continued after the twenty-four weeks were completed; however, there are some limitations to these presumptions as other factors may be at play.

Practical advice
Supervised, aquatic pain management therapy, facilitates long-term improvements being sustained.

Patients may benefit from those results, practitioners could pursue ‘Further Resources’, which also confirms these positive results.

Further information/resources
For further clarification of this topic, I advise further reading of this meta-analysis (2010).Open Meta-analysis

Other resources include:

https://www.healthdirect.gov.au/linking-to-us

https://painhealth.csse.uwa.edu.au/pain-module/fibromyalgia/

https://arthritisaustralia.com.au/types-of-arthritis/fibromyalgia/