Fibromyalgia and Aquatic Therapy
Fibromyalgia (FM) is a chronic pain syndrome characterized by widespread non-articular pain, stiffness, multiple tender points and fatigue. Other common symptoms include diminished pain threshold, sleep disturbance, fatigue, headaches, morning stiffness, parasthesias, and anxiety. Nonrestorative sleep is common in FM. About 75% of patients report sleep disturbances, including early middle or late insomnia, hypersomnia and frequent awakening. The organic nature of the abnormal central pain processing in FM has been demonstrated in many studies.
Patients experience that symptoms have a severe impact on their function in everyday life, including such basic activities as walking and upper extremity activities of daily living (ADLs). Patients’ muscular performance is often found to be impaired(6-8).
Initially called fibrositis, the name was changed to fibromyalgia when it became evident that inflammation was not part of this condition. The prevalence of FM is reported to be 3.4% in women and 0.5% in men, affecting women from 7-10 times more than men. Demographic and social characteristics associated with the presence of FM are Western culture, female gender, failing to complete high school, low income status and depression.
The etiology and pathogenesis of FM remain relatively unknown. In different patients, FM has had differing origins. Some patients report having FM symptoms since childhood. Others slowly develop FM in adulthood or become afflicted with FM following a traumatic or stressful incident. Patients have also reported “waking one morning with flu-like aches,” but never getting ill, just staying in pain. Commonly, there is an association with childhood stress or prolonged or severe stress.
Treatment of FM often involves a combination of medication, nutrition, physical therapy (PT) and psychological counseling. PT can be challenging because the overall objective is to increase movement, activity, and function. This can initially exacerbate the symptoms of FM, particularly if too aggressive of an approach is taken. The fine line a PT normally has to take in the progression of an exercise program is even more sensitive for patients with FM.
PTs are aware of the hazards of treating patients with FM, but often find themselves without the tools to effectively treat these patients. Pain modalities and soft tissue mobilization provide short-term relief, but do little to progress the patient towards their goals. Exercise can be intolerable due to pain and many FM patients drop out of their PT program due to the pain and discomfort they experience during or after exercise.
A proven solution to this dilemma for patients with FM is aquatic therapy. The buoyancy of water provides a weightless feeling to patients that often feel “weighed down,” movement is facilitated by the viscosity of water, and a warm pool (90F) all provide relief that FM patients don’t experience elsewhere. There is no risk of dropping a weight on one’s foot, overexertion is improbable and there is minimal risk of gravity forcing a joint into an angle beyond the normal range of motion. These positive attributes all contribute to the safe environment of an aquatic exercise program, helping the patient with FM overcome the roadblocks that lead to the avoidance of exercise, making them more likely to participate.
Munguia-Izquierdo and Legaz-Arrese found that an exercise therapy program with moderate intensity performed 3 times a week for 16 weeks in a chest-high pool of warm water (32C) has no apparent negative effects and improves, pain, sleep quality, and physical and cognitive function, causing a great adherence to exercise in previously unfit women with heightened and long FM symptomatology. This shows that aquatic therapy achieves the major objectives of an FM exercise program – increased function, relief of the predominant symptoms and patient adherence to a program.
With the objective of progressing from gentle movement to increasing velocity and resistance, and eventually to functional activities, aquatic therapy should be a part of every FM patient’s program.