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

Figures & data

Table 1 Summary of water physics principles

Water property	Definition	Properties	Clinical significance
Buoyancy	Upward force that opposes gravity, and has a direct relationship with the immersion depth, movement speed, body composition, and gender^Citation36^Citation37	Archimedes principle states that, as the body submerges, it displaces water, and this displacement creates a floating force (buoyancy) equivalent to the water volume that has been displaced^Citation38	Buoyancy can be used to assist or to resist movements, to provide bodyweight offloading, and to help improve muscle activation and range of movement.^Citation27,Citation35,Citation39 Also, buoyancy may assist in reduction of the perceived fatigue^Citation40
Hydrostatic pressure	Pressure exerted by the fluid on submersed objects	Pressure exerted by water on a submersed object is equal on all surfaces of the object, depending on the submersion depth^Citation40	Fluids are driven from the extremities toward the central cavity,^Citation38 compressthe thorax, and increase respiratory load.^Citation41 This property also provides support during movement performance underwater, improving static and dynamic balance,^Citation42^–^Citation46 including in women with FMS^Citation31
Hydrodynamic drag forces	Force that acts in an opposite direction to the line of the movement,^Citation47 which is affected by the size and shape of the object^Citation41^Citation47	Drag force is a function of the velocity squared, which means that doubling the speed quadruples the drag force^Citation41,Citation47	As the movement speed through water increases, resistance to motion increases^Citation27 If a person stops movement, the resistance drops almost immediately to 0, allowing improved control of exercises considering the patient’s comfort^Citation35,Citation47
Thermal conduction	Water conducts temperature 25 times faster than air and exchanges heat with the submerged object	The aquatic environment is stable to retain cold or heat.^Citation41 The rate of temperature change depends on the mass and specific heat of the object	A submerged body adapts to the aquatic environment, quickly exchanging heat and achieving thermal balance.^Citation41 Temperatures of 26–28 °C (80–84° F) are comfortably cool for exercising, while therapeutic pools are heated to between 30 and 32 °C (86 and 90° F)^Citation27

Abbreviation: FMS, fibromyalgia syndrome.

Table 2 Summary of studies using water therapy for FMS treatment

Author (year)	PEDro score	Design	Primary outcome	Groups (number in each group)	Water therapy protocol	Exercise Intensity	Water temperature	Main results	Effect sizes (reported for pain)	Secondary outcomes	Main results of Secondary outcomes	Effect sizes (reported for pain)
Altan et al (2004)^Citation53	8	RCT	Pain, tender points, fatigue, sleep, stiffness, health-related quality of life, muscle endurance, patient-rated disability, clinician-rated disability, depression	2 groups: Aquatic exercise (n=24) Balneotherapy (n=22)	35 min/session, 3×/week 12 weeks Protocol: Aquatic exercise – warm-up aerobics, muscle activation exercises, stretching, relaxation Balneotherapy – no exercise	Aquatic exercise: not reported Balneotherapy: no exercise	37 °C	Aquatic exercise: significant decrease in pain (VAS and 5-point scale), fatigue (VAS and 5-point scale), morning stiffness, number of tender points, myalgic score, FIQ, sleep disorder, patient’s and physician’s global evaluation, and BDI. Significant increase in algometric score Balneotherapy: significant decrease in pain (VAS and 5-point scale), fatigue (VAS and 5-point scale), number of tender points, myalgic score, patient’s and physician’s global evaluation. Significant increase in algometric score. Significant difference between groups after 12 and 24 weeks for BDI favoring aquatic exercise group	Aquatic exercise after 12 weeks: ain (VAS)=1.06; ain (5-point scale)=0.99; number of tender points=2.11; myalgic score=1.62; FIQ=0.83; algometric score=0.62. Aquatic exercise after 24 weeks: pain (VAS)=1.01; pain (5-point scale)=1.18; number of tender points=1.97; myalgic score=1.32; FIQ=0.74; algometric score=0.78. Balneotherapy after 12 weeks: pain (VAS)=1.08; pain (5-point scale)=1.28; number of tender points=2.15; myalgic score=2.00; FIQ=0.62; algometric score=0.93. Balneotherapy after 24 weeks: pain (VAS)=0.54; pain (5-point scale)=0.82; number of tender points=1.18; myalgic score=0.91; FIQ=0.30; algometric score=0.60.	NA	Aquatic exercises and balneotherapy significantly decreased pain. Aquatic exercises proved longer-lasting effects. There was no superiority of aquatic exercises over balneotherapy	NA
Andrade et al (2018)^Citation54	9	RCT	Peak oxygen uptake, PPT, pain (VAS)	2 groups: Aquatic exercise (n=27) No exercise control (n=27)	45 min/session 2×/week 16 weeks Protocol: warm-up, stretching, aerobic exercises (30 min), resistance exercises of upper limbs using floats (5 min), relaxation (5 min)	Aerobics: three HR percentages reached at VAT. Level 1: lower limb exercises sitting on floats (5 min) at 80% VAT HR; level 2: jumping on a trampoline (10 min) at 110% VAT HR; level 3: exercises in aquatic cycle with resistance adjustment at 100% VAT HR (10 min)	30 °C (±2°C)	Aquatic exercise: significant increase in relative VO2, PPT, VAS well-being, and decrease in VAS pain and FIQ scores. No-exercise control group: did not present any significant improvement	Aquatic exercise: PPT=0.31; VAS pain=−0.20. No-exercise control group: PPT=−0.33; VAS pain=0.43	NA	Aquatic exercise: PPT=0.31; VAS pain=−0.20. No-exercise control group: PPT=−0.33; VAS pain=0.43	Not reported
Arcos-Carmona et al (2011)^Citation55	8	RCT	Sleep, pain, fatigue, health-related quality of life, self-rated physical function, mental health, anxiety, depression	2 groups: Experimental (n=27) Placebo control (n=26)	60 min/session 2×/week 10 weeks Protocol: Experimental –30 min of pool-based aerobic exercises and Jacobson relaxation Placebo control –20 min of sham magnet therapy applied at cervical (10 min) and lumbar (10 min) spine.	Not reported	28 ºC	Experimental group: SF-36 scores were lower after intervention Placebo control group: no significant differences from baseline	Not reported	Not reported	Not reported	Not reported
Assis et al (2006)^Citation56	9	RCT	Pain (VAS)	2 groups: DWR (n=26) land-based exercises (n=26)	60 min/session, 3×/week 15 weeks Protocol: a) stretching warm-up (10 min), DWR aerobic training (40 min), relaxation (10 min); b) land-based exercises – stretching warm-up (10 min), aerobic training on a treadmill (40 min), relaxation (10 min)	DWR: first 2 weeks: low-intensity exercises for adaptation. Then, exercises performed at the anaerobic threshold level controlled by HR Land-based exercises: first 2 weeks: low-intensity exercises for adaptation. Then, exercises performed at the anaerobic threshold level controlled by HR	28–31 °C	DWR: significant improvement in pain (VAS) Land-based exercises: significant improvement in pain (VAS)	Not reported	Patient global assessment of response to therapy on a 5-point scale; SF-36; BDI; and FIQ	NA	NA
Avila et al (2017)^Citation28	5	Single-arm clinical trial	Scapular three-dimensional motion measured with electromagnetic tracking device (Flock of Birds)	1 group: (n = 20)	45 min/session, 2×/week 16 weeks Protocol: stretching, warm-up, aerobics, muscle activation exercises, stretching, relaxation	Patient determined	31 °C (±2 °C)	No significant changes in scapular kinematics	NA	Pain, quality of life, function	Pain significantly decreased (lower NPRS and PPT), function (lower FIQ scores), and quality of life (greater SF-36 scores for most domains) significantly improved	PPT: 041–1.61 NPRS: −1.41 to −1.93
Biezus et al (2006)^Citation57	5	RCT	Pain (VAS)	3 groups: GA – general aquatic exercises (n=5) GB –passive aquatic relaxation (n=5) GC –control (n=6)	60 min/session, 2×/week 8 weeks Protocol: GA – warm-up, strengthening, stretching, and relaxation. Number of exercises in each therapy was approximately 13 GB – passive aquatic relaxation. TheExercises were done slowly and smoothly GC – no physical therapy intervention	Not reported	32 °C	Aquatic exercises and aquatic relaxation significantly decreased pain. However, aquatic exercises provided greater pain decrease than the aquatic relaxation program	GA – general aquatic exercises: d=0.55 GB – passive aquatic relaxation: d=1.26 GC – control group: d=0.20	NA	NA	NA
Bote et al (2014)^Citation58	7	RCT	Neutrophil function	2 groups: Aquatic exercise program (n=10) Control no exercise (n=10)	60 min/session, 2×/week 32 weeks Protocol: stretching out of the water (5 min), aerobic warm-up in the water (5 min), passive stretching of the main muscle groups in the water (5 min), aerobic aquatic choreography (25 min), strength exercises involving the main muscle groups of the upper limbs (15 min), and cool-down (10 min)	Parts (a), (b), (c), and (f) were performed at low exercise intensity (40–50% maximal HR). Part (d) was performed at low-to-moderate intensity (50–60% maximal HR) at the beginning of the program, and with increased intensity at the end of the program (65–75% maximal HR)	32 °C	Aquatic exercise group had lower concentrations of IL-8 and noradrenaline together with reduced chemotaxis of neutrophils compared with the values determined in the same month in the control group of nonexercised FMS women	Not reported	Weight, body mass index, waist-to-hip ratio, body fat, flexibility, grip strength, balance, 6MWT, FIQ	Significant decrease of weight, body mass index, body fat and FIQ. Significant increase in grip strength	Not reported
Calandre et al (2009)^Citation59	7	RCT	FIQ and PSQI	2 groups: Stretching in water (n=39) Ai Chi–water Tai Chi (n=42)	60 min/session, 3×x/week 6 weeks Protocol: stretching performed over muscles of main body areas: cervical, upper, and lower extremities and trunk; Ai Chi: 16 movements which constitute the Tai Chi therapy	Adjusted according to the degree of pain and fatigue Adjusted according to the degree of pain and fatigue	36 °C	Significant reduction in the FIQ and PSQI scores observed in Ai Chi but not in stretching group, with longer effect duration on sleep measures	Stretching in water: FIQ total score (d=0.35), FIQ-VAS (d=0.26), PSQI total scores (d=0.28) Ai Chi–water Tai Chi: FIQ total score (d=0.53), FIQ-VAS (d=0.53), PSQI total scores (d=0.72)	FIQ difficulty at work, fatigue, morning tenderness, stiffness, anxiety, and depression	BDI decreased in stretching but not in Ai Chi group. Trait-anxiety scores decreased in both groups	Stretching in water: FIQ difficulty at work (d=0.26), fatigue (d=0.21), morning tenderness (d=0.26), stiffness (d=0.17), anxiety (d=0.25). and depression (d=0.32) Ai Chi–water Tai Chi: FIQ difficulty at work (d=0.47), fatigue (d=0.64), morning tenderness (d=0.29), stiffness (d=0.58), anxiety (d=0.32), and depression (d=0.43)
Carbonel-Baeza et al (2010)^Citation60	6	RCT	Tender points, blind flamingo test, chair stand test, body composition, chair sit and reach, back scratch, 8 feet up andgo, handgrip strength, and 6MWT	2 groups: Intervention (n=27) Usual care (n=32)	120 min/session, 1×/week 12 weeks Protocol: a) verbal phase (35–45 min); b) moving/dancing according both to the suggestion given by the facilitator and the music played (75–80 min) Usual care: asked not to change their activity levels and medications during the 12-week intervention period	Adjusted according to the degree of pain and fatigue Intervention intensity was controlled by the RPE based on Borg’s conventional (6–20-point) scale. The medium values of RPE were 11±1. These RPE values correspond to a subjective perceived exertion of “fairly light exertion,” that is, low intensity	Not reported	Biodanza intervention reduced pain and FM impact (measured by FIQ). There was significant decrease in body fat percentage. There was no significant improvement in physical fitness tests. The program was well tolerated and did not have any deleterious effects on the patients’ health	Not reported	NA	NA	NA
Cuesta-Vargas et al (2011)^Citation61	5	Nonrandomised pilot clinical trial	FIQ	2 groups: MMPP+DWR (n=22) Control (n=22)	60 min/session, 3×/week 8 weeks Protocol: land-based exercises (stretching of tonic muscle and strengthening of phasic muscles combined with advice and education – 30 min) and DWR (30 min) Control: waiting list (no intervention)	Exercise training at anaerobic threshold determined by a graded treadmill exercise test and DWR test with lactate and HR analyses	28–31 °C	Significant decrease in FIQ	Not reported	SF-12: physical component, mental component, EuroQoL-5D, EuroQoL-VAS	Significant improvement in pain, physical function, sleep, fatigue, morning stiffness, quality of life, and psychological symptoms (depression and anxiety)	Not reported
De Andrade et al (2008)^Citation62	9	RCT	Pain intensity, fatigue, number of tender points, physical functional capacity, general health status, sleep quality and depression	2 groups: Pool-based exercises (n=23) Thalassotherapy (n=23)	60 min/session, 3×/week 12 weeks The program was composed of 10-min stretching, 40 min of various forms of low-impact aerobic exercise according to the desired intensity, and then a 10-min relaxation period	Patients were monitored each for 10 min and were oriented to remain between levels 12 and 13 on BORG scale (from light to moderate). The first 2 weeks were used for familiarization, with light-intensity exercises only (between levels 10 and 11 on BORG scale) and learning the exercises. When pain occurred while they were exercising, patients were taught to decrease the intensity for a short time	Pool-based exercises (28–33 °C) Thalassotherapy (28–33 °C)	There was a statistically significant improvement in pain, fatigue, tender points, FIQ, PSQI, and BDI in both groups. Improvement in BDI was greater in the thalassotherapy group	Not reported	NA	NA	NA
Evcik et al (2008)^Citation63	5	RCT	Number of tender points, pain, depression, and functional capacity	2 groups: Home-based exercise program (n=30) Aquatic exercise program (n=33)	60 min/session 3×/week 5 weeks Protocol.: home-based exercise program: warm-up, ROM, relaxation, aerobic, stretching, and cool-down exercises. Aquatic exercise program: warm-up (20 min), aerobic exercises, active ROM, stretching, relaxation (35 min) and cool-down (5 min)	Not reported	33 °C	Both aquatic therapy and home-based aerobic exercise programs improved well-being, quality of life, and pain parameters in FMS. Aquatic therapy seems to have more advantage in long-term pain management	Not reported	NA	NA	NA
Fernandes et al (2016)^Citation64	9	RCT	Pain (VAS)	2 groups: Swimming (n=39) Walking (n=36)	50 min/session 3×/week 12 weeks Protocol for both groups: warm-up (5 min), exercise (40 min), and cool-down (5 min) Swimming: freestyle swimming without floatation devices Walking: open-air walking	Swimming group: HR was kept at 11 beats below the anaerobic threshold Walking group: HR was kept at the anaerobic threshold	Not reported	Swimming, like walking, is an effective method for reducing pain in patients with FM	Not reported for intragroup comparisons. Effect size=0.168 for between-group comparison	Not reported	Swimming, like walking, is an effective method for improving both functional capacity and quality of life in patients with FM	Not reported
Gowans et al (2001)^Citation65	8	RCT	BDI and 6MWT	2 groups: Supervised exercise (n=15) Control (n=16)	30 min/session 3×/week 23 weeks Protocol: stretching (5 min before and 5 min after exercise) and aerobic exercise (20 min)	The aerobic component of the classes was designed to generate HRs equivalent to 60–75% of age-adjusted maximum HRs (210 – age [years])	Not specified: “a warm therapeutic pool”	There were significant improvements for exercise group subjects in 6MWT distances and BDI	Not reported	Anxiety, general mental health, number of tender points, isokinetic maximal voluntary strength, FIQ, and self-efficacy	There was a significant improvement in anxiety, FIQ, self-efficacy, and mental health	Not reported
Gusi et al (2006)^Citation66	6	RCT	Pain, isokinetic muscle strength, health-related quality of life, spare time and work activities	2 groups: Exercise (n=17) Control (n=17)	60 min/session 3×/week 12 weeks Protocol: exercise – warm-up (10 min), aerobic exercises (10 min), overall mobility and lower-limb strength exercises (20 min), another set of aerobics (10 min), and cool-down (10 min) Control – follow normal daily activities, which did not include any form of exercise related to those in therapy	Aerobic exercises were performed at 65–75% of maximal HR	33 °C	Therapy relieved pain and improved HRQOL and muscle strength in the lower limbs at low velocity	Not reported	NA	NA	NA
Hecker et al (2011)^Citation67	9	RCT	Quality of Life (SF-36)	2 groups: Kinesiotherapy (n=12) Hydrokinesiotherapy (n=12)	60 min/session 1×/week 23 weeks Protocol: muscle stretching exercises (15 min); passive and active movement of the lower limbs, upper limbs, trunk, and neck (30 min); and same stretching exercises performed at beginning of session (15 min)	Not reported objectively (low intensity during the entire protocol)	32–34 °C	No significant differences between groups after the intervention program. Both groups improved physical functioning, pain, social aspects, and mental health. Hydrokinesiotherapy group improved also emotional aspects, while the kinesiotherapy group improved physical aspects	Not reported	NA	NA	NA
Ide et al (2008)^Citation68	6	RCT	PAIN (VAS – 10 cm, number of tender points)	2 groups: ARG (n=18) CG (n=17)	Both groups: 60 min/session, 1×/week, 4 weeks: supervised recreational activities (involved no exercises or health-related issues) ARG: 60 min/session, 4×/week; 4 weeks: warm-up, general exercises targeting specific breath patterns (45 min), and relaxation exercises	Not specified	32 °C	Decrease in pain (lower VAS scores); no difference in tender points count	Not reported	Dyspnea, function, quality of life, anxiety, sleep	Improvement in dyspnea (lower VAS scores), sleep quality (lower PSQI scores), anxiety (lower HAS scores), function (lower FIQ scores), and quality of life (greater SF-36 values)	NA
Jentoft et al (2001)^Citation69	5	RCT	Function (FIQ)	2 groups: PE (n=18) LE (n=16)	60 min/session, 2×/week, 20 weeks. Both groups: body awareness training, ergonomics, warm-up, stretching, strengthening exercises, relaxation. Pool-based exercise group performed adapted protocol in water	60–80% of maximum HR for age (during 40–50% of session)	34 °C	No differences between groups for function; function equally improved for both groups (lower FIQ scores)	NA	Pain (FIQ pain subscore and VAS for local pain), self-efficacy, cardiovascular capacity, grip strength, walking time and endurance time of shoulder muscles	Improved grip strength (hand-held dynamometry) in LE group; within-group improvements in cardiovascular capacity (maximum O2 uptake), and walking time (s/100 m); within-group improvements in the PE group for several FIQ subscales including pain, anxiety, and depression	Not reported
Kesiktas et al (2011)^Citation70	3	Quasi-randomized trial	Pain (tender points count, VAS – 10 cm, and total PPTon tender points)	2 groups: PTM+BT (n=16) PTM (n=20) PTM+HT (n=20)	PTM: 36 min/session, 5×/week, 3 weeks: conventional TENS (15 min), ultrasound (6 min). and infrared (15min); PTM+BT: PTM added to 19 sessions of thermal pool bath (20 min of immersion/session); PTM+HT: PTM added to 20-min sessions of hydrotherapy (protocol not described)	Not specified	Thermal pool bath: 37–38 °C Hydrotherapy: 37 °C	Total PPT was lower for PTM+BT (compared to PTM+HT); improvement in pain symptoms (lower VAS, total PPTs and tender point count) was observed for all groups after treatment and only for PTM+BT and PTM+HT in the follow-up (after 6 months)	Not reported	Depression, pulmonary function	Improvement in depressive symptoms (lower BDI and HDRS scores) for all groups after treatment; only PTM+BT maintained better scores at follow-up; pulmonary function only improved for PTM+BT and PTM+HT groups after treatment, but only PTM+BT maintained improved pulmonary function at follow-up	NA
Latorre et al (2013)^Citation30	5	Nonrandomized clinical trial	Pain (tender point count, VAS – 10 cm, PPT over tender points)	2 groups: EG (n=48) CG (n=37)	CG: no activities or exercises other than usual, and none similar to EG protocol EG: 60 min/session, 3×/week (2×/week pool exercises and 1×/week land exercises), 24 weeks Protocol: warm-up, exercises of muscular strengthening, aerobic exercises, cool-down	Not specified (controlled by Borg scale)	Not reported	EG significantly improved pain symptoms (lower VAS scores, greater PPT and reduced number of tender points)	Not reported	Functional capacity, body composition, and quality of life	EG improved functional capacity (greater hand-held grip dynamometry values, greater maximum O2 uptake, greater agility and balance indexes), quality of life (greater FIQ scores), and body composition (reduced fat percentage)	NA
Latorre Román et al (2015)^Citation71	6	RCT	Pain (tender point count, VAS – 10 cm, PPT over tender points)	2 groups: EG (n=20) CG (n=16)	CG: no activities or exercises other than usual, and none similar to EG protocol EG: 60 min/session, 3×/week (2×/week pool exercises and 1×/week land exercises), 18 weeks Protocol: warm-up, exercises of muscular strengthening and balance, cool-down	Patient determined	30 °C	EG significantly improved pain symptoms (lower VAS scores, greater PPT and reduced number of tender points)	Not reported	Impact of fibromyalgia, strength, and balance	EG significantly improved: lower impact of fibromyalgia (lower FIQ scores), greater strength (leg and handgrip) and balance (agility dynamic and balance)	NA
Letieri et al (2013)^Citation72	6	RCT	Pain (VAS – 10 cm)	2 groups: HG (n=33) CG (n=33)	45 min/session, 2×/week, 15 weeks. Protocol: warm-up, strengthening, balance, coordination and agility exercises, stretching, and relaxation	Moderate according to the perceived effort modified scale	33 °C	Decrease in pain (lower VAS scores)	Not reported	Quality of life, depressive symptoms	Improved quality of life (lower FIQ scores) and depressive symptoms (lower BDI scores)	NA
López-Rodríguez et al (2013)^Citation73	6	RCT	Pain (VAS – 10 cm, MPQ, PPT)	2 groups: ABD (n=29) CG (n=30)	60 min/session, 2×/week; 12 weeks. Protocol: ABD – flexibility and breathing exercises, rhythmic dancing movements, and mild exercises; CG – stretching exercises for different body parts	Not specified	29 °C (preceded by a bath of 33–35 °C)	Decrease in pain (lower VAS and MPQ scores and lower number of active tender points for PPT)	Not reported	Sleep, anxiety, depression, function	Improvement in sleep quality (lower PSQI scores), anxiety (lower SAI scores), function (lower FIQ scores) for ABD	NA
Mannerkorpi et al (2000)^Citation74	4	Quasi-randomized clinical trial	Impact of fibromyalgia (FIQ – total score), physical capacity (6MWT)	2 groups: TG (n=37) CG (n=32)	35 min/session, 1×/week, 24 weeks. Protocol: exercises for endurance, flexibility, coordination, and relaxation along with education sessions (6 sessions, 1 h/session)	Patient determined	Not reported	Decreased fibromyalgia impact (lower FIQ total scores) and improved physical capacity (better scores in the 6MWT)	NA	FIQ subscores (including pain), pain, quality of life, self-efficacy, functional limitations	TG significantly improved physical functioning (lower FIQ subscores), anxiety (lower FIQ and AIMS subscores), depression (lower AIMS subscores), strength (greater grip strength), general health (greater SF-36 scores), social functioning (greater SF-36 scores), and pain (lower scores for pain severity and affective distress for the MPI-S)	Not reported
Mannerkorpi et al (2009)^Citation75	8	RCT	Impact of fibromyalgia (FIQ – total score), physical capacity (6MWT)	2 groups: Ex-Edu (n=81) Edu (n=85)	45 min/session, 1×/week, 20 weeks. Protocol: exercises for endurance, flexibility, coordination, and relaxation along with education sessions (6 sessions, 1 h/session)	48–65% of maximum HR (light to moderate intensity)	33 °C	Decreased fibromyalgia impact (lower FIQ total scores) and improved physical capacity (better scores in the 6MWT)	NA	FIQ subscores (including pain), pain, quality of life, anxiety and depression, leisure-time physical activity, stress, fatigue	Significant improvement for change in pain (lower FIQ pain subscores) and for leisure time (decreased LTPAI scores)	0.69 (0.45 for the intention-to-treat analysis)
Munguía-Izquierdo and Legaz-Arrese (2007)^Citation76	7	RCT	Tender point count, PPT on the tender points, and FIQ pain subscore (VAS – 100 mm)	3 groups: Ex (n=35) CG (n=25) Healthy group (n=25)	60 min/session, 3×/week, 16 weeks Protocol: warm-up with slow walks and mobility exercises, strength exercises, aerobic exercises, and cool-down	50–80% of predicted maximum HR according to age	32 °C	Decreased pain (reduced number of tender points, increased PPT over all tender points, and reduction in FIQ pain subscore) compared to control group	Not reported	Severity of FM and cognitive function	Improvement of FM severity (lower FIQ scores) and in cognitive function (improvement in neuropsychological tests)	NA
Munguía-Izquierdo and Legaz-Arrese (2008)^Citation77	8	RCT	Tender point count, PPT over tender points, health status (FIQ)	3 groups: Ex (n=35) CG (n=25) Healthy group (n=25)	60 min/session, 3×/week, 16 weeks Protocol: warm-up with slow walks and mobility exercises, strength exercises, aerobic exercises, and cool-down	50–80% of predicted maximum HR according to age	32 °C	Decreased pain (reduced number of tender points, increased PPT over all tender points) compared to control group, Improvement in health status (lower FIQ scores)	Not reported	Anxiety, sleep quality, cognitive function, physical function	Improvement in sleep quality (lower PSQI scores), cognitive function (greater PASAT scores) and physical function (increased muscle endurance for upper and lower limbs)	NA
Pérez de la Cruz and Lambeck (2016)^Citation78	3	Pilot study	VAS (10 cm) for pain	1 group: FMS (n=20)	45 min/session, 2/week, 10 weeks Protocol: warm-up, Ai Chi program, cool-down	Not reported	33 °C±0.5 °C	Significant improvement in pain (lower VAS scores)	Not reported	Health-related quality of life	Improved quality of life (increased scores in all domains of SF-36 except role physical and role emotional)	NA
Piso et al (2001)^Citation54	4	Case–control study	PPT over tender points	2 groups: Sauna (n=9) HT (n=9)	30 min/session, 2×/week, 6 weeks. Protocol: bodily awareness exercises, low-impact strength exercises	Patient determined	Sauna: 90 ºC HT: 35 °C	No significant differences comparing groups; significant improvement in PPT only for sauna group	Not reported	Previous treatment	Out of 18, 12 patients consider HT as first-choice treatment	NA
Santana et al (2010)^Citation53	1	Analytical clinical trial	FM impact and pain over tender points	2 groups: Ai Chi (n=5) CG (n=5)	40 min/session, 10 sessions (number of weeks not specified) Protocol: Ai Chi program (sequence of slow and wide movements with upper limbs, lower limbs, and trunk, emphasizing deep breathing during the exercises)	Not reported	34–36 °C	No significant improvement was observed for intervention group compared to CG	Not reported	NA	NA	NA
Segura-Jiménez et al (2013)^Citation79	2	Uncontrolled clinical trial	Tender point count and immediate pain (VAS – 10 cm)	1 group: FMS (n=33)	45 min/session, 2×/week, 12 weeks Protocol: warm-up, general exercises (on Mondays: strength; on Wednesdays: balance), stretching, and relaxation	RPE (Borg): 12±2 points	34 °C	Improvement in immediate pain (decreased VAS scores)	Not reported	Body composition	No differences were observed in body composition	NA
Sevimli et al (2015)^Citation80	5	RCT	Pain (VAS – 100 mm)	3 groups: ISSEP (n=25) AEP (n=25) AAEP (n=25)	ISSEP: 15 min/day (3 months) of home-based stretching and strength exercises AEP and AAEP: 40–50 min/session, 2×/week, 12 weeks Protocol not described for AEP and AAEP	60–80% maximal HR	Not reported	Pain improved for AEP and AAEP (lower VAS after treatment)	Not reported	Health status, endurance, quality of life, depression	Improvement in quality of life (greater SF-36 scores), depression (lower BDI scores), health status (lower FIQ scores) and endurance (greater scores for 6MWT) for AAEP and AEP	NA
Tomas-Carus et al (2007)^Citation81	7	RCT	FM impact (FIQ total score)	2 groups: EG (n=17) CG (n=17)	60 min/session, 3×/week, 12 weeks Protocol: warm-up, mobility exercises, aerobic exercises, lower limb exercises, cool-down exercises, and relaxation	60–65% maximal hear rate	33 °C	Improvement of FM impact (lower FIQ scores)	NA	FIQ subscores (including pain)	Improvement of all FIQ subscores (lower scores for all, including pain)	Not reported
Tomas-Carus et al (2009)^Citation82	7	RCT	FM impact (FIQ total score and subscores, including pain) and anxiety state (STAI)	2 groups: EG (n=15) CG (n=15)	60 min/session, 3×/week, 24 weeks Protocol: warm-up, mobility exercises, aerobic exercises, lower limb exercises, cool-down exercises	60–65% maximal hear rate	33 °C	Significant reduction of FM impact (lower FIQ total scores, and FIQ pain subscores)	Treatment effect of −0.5 (−1.8 to 0.7) for the FIQ pain subscore	Physical fitness	Improvement of physical fitness (increase in maximal oxygen uptake, and increased scores for mobility and balance tests)	NA
Trevisan et al, (2015)^Citation31	1	Single-arm study	Postural control (center of pressure sway)	1 group: FMS (n=17)	45 min/session, 2×/week, 16 weeks. Protocol: familiarization, warm- up, exercises (aerobic and strength exercises for upper and lower limbs and trunk), cool-down stretching, and relaxation	Patient determined	30 °C ±2 °C	Improvement in postural sway (lower center of pressure sway in different situations)	NA	Pain (VAS – 100 mm during rest and movement) and function (FIQ)	Improvement in pain (lower VAS scores) and function (lower FIQ scores)	VAS: Rest: −2.12 (−2.90 to −1.23) Movement: –1.94 (−2.70 to −1.08)

Abbreviations: 6MWT, 6-min walking test; AAEP, pool-based aquatic aerobic exercise program; ABD, aquatic biodance; AEP, gymnastic-based aerobic exercise program; AIMS, Arthritis Impact Measurement Scales; ARG, aquatic respiratory exercise-based program; BDI, Beck Depression Inventory; CG, control group; DWR, deep water running; Edu, education group; EG, exercise group; EuroQoL-5D, EuroQol Research Foundation Quality of Life Questionnaire; EuroQoL-VAS, EuroQol Research Foundation Quality of Life Questionnaire Visual Analog Scale; Ex, exercise group; Ex-Edu, exercise and education group; FIQ, Fibromyalgia Impact Questionnaire; FMS, fibromyalgia syndrome; HAS, Hamilton Anxiety Scale; HDRS, Hamilton Depression Rank Scale; HG, hydrotherapy group; HR, heart rate; HRQOL, health-related quality of life; HT, hydrotherapy; ISSEP, home-based isometric strength and stretching exercise program; LE, land-based exercise group; LTPAI, leisure-time physical activity instrument; MMPP+DWR, multimodal physiotherapy program+deep water running; MPI-S, Multidimensional Pain Inventory – Swedish Version; MPQ, McGill Pain Questionnaire; NA, not applicable; NPRS, numerical pain rating scale; PASAT, Paced Auditory Serial Addition Task; PE, pool-based exercise group; PPT, pressure pain threshold; PSQI, Pittsburgh Sleep Quality Index; PTM, physical therapy modalities; PTM+BT, photobiomodulation+balneotherapy; PTM+HT, photobiomodulation+hydrotherapy; RCT, randomized controlled trial; ROM, range of motion; RPE, rate of perceived exertion; SAI, State Anxiety Inventory; SF-36, Medical Outcomes Study 36-item Short Form Health Survey; STAI, State-Trait Anxiety Inventory; TENS, transcutaneous electrical nerve stimulation; TG, training group; VAS, visual analog scale; VAT, ventilatory anaerobic threshold; VO₂, oxygen uptake.

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