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.
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.
OBJECTIVES: To synthesise the available evidence on pharmacological and non-pharmacological interventions recommended for fibromyalgia syndrome (FMS).
METHODS: Electronic databases including MEDLINE, PsycINFO, Scopus, the Cochrane Controlled Trials Registry and the Cochrane Library were searched for randomised controlled trials comparing any therapeutic approach as recommended in FMS guidelines (except complementary and alternative medicine) with control interventions in patients with FMS. Primary outcomes were pain and quality of life. Data extraction was done using standardised forms.
RESULTS: 102 trials in 14 982 patients and eight active interventions (tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors (SNRIs), the gamma-amino butyric acid analogue pregabalin, aerobic exercise, balneotherapy, cognitive behavioural therapy (CBT), multicomponent therapy) were included. Most of the trials were small and hampered by methodological quality, introducing heterogeneity and inconsistency in the network. When restricted to large trials with ≥100 patients per group, heterogeneity was low and benefits for SNRIs and pregabalin compared with placebo were statistically significant, but small and not clinically relevant. For non-pharmacological interventions, only one large trial of CBT was available. In medium-sized trials with ≥50 patients per group, multicomponent therapy showed small to moderate benefits over placebo, followed by aerobic exercise and CBT.
CONCLUSIONS: Benefits of pharmacological treatments in FMS are of questionable clinical relevance and evidence for benefits of non-pharmacological interventions is limited. A combination of pregabalin or SNRIs as pharmacological interventions and multicomponent therapy, aerobic exercise and CBT as non-pharmacological interventions seems most promising for the management of FMS.
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.
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.
OBJECTIVE: To use the meta-analytic approach to determine the effects of community-deliverable exercise on pain and physical function in adults with arthritis and other rheumatic diseases (AORD).
METHODS: Data sources consisted of 6 electronic databases, cross-referencing from retrieved studies and expert review. Study selection included 1) randomized controlled trials; 2) ≥ 1 exercise intervention group; 3) community-deliverable exercise interventions ≥ 4 weeks in duration; 4) control group; 5) adults ages ≥ 18 years with rheumatoid arthritis, osteoarthritis, fibromyalgia, lupus, gout, or ankylosing spondylitis; 6) published and unpublished studies; 7) studies published in any language between January 1, 1980, and January 1, 2008; and 8) data available for pain and/or physical function. Data abstraction included dual coding by 2 of the authors. Standardized effect sizes (g) and random-effects models were used to pool pain and physical function outcomes. Data were analyzed according to per-protocol and intent-to-treat (ITT) results. The minimally clinically important difference (MCID) and number needed to treat (NNT) were also calculated.
RESULTS: Thirty-three studies representing 3,180 men and women (1,857 exercise, 1,323 control) with rheumatoid arthritis, osteoarthritis, and fibromyalgia were included. Statistically significant and clinically important improvements were observed for pain (per-protocol g = -0.37 [95% confidence interval (95% CI) -0.53, -0.21], MCID -18%; ITT g = -0.20 [95% CI -0.33, -0.07], MCID -9%, NNT 9) and physical function (per-protocol g = 0.37 [95% CI 0.21, 0.52], MCID 15%; ITT g = 0.34 [95% CI 0.25, 0.43], MCID 10%, NNT 5).
CONCLUSION: Community-deliverable exercise improves pain and physical function in adults with the types of AORD included in the analysis. Dose-response as well as studies in those with other types of AORD is needed.
All of the specialists who deal in some way with fibromyalgia (FM) broadly agree that physical reconditioning programmes are useful, but it is not yet clear what type of physical activity is the most appropriate for different subsets of patients. The aim of this review was to examine the randomised controlled trials (RCTs) published between 1985 and August 2010 whose outcome measures indicate the effectiveness of different types of physical exercise (PE) on the main health domains affected by FM: pain, and physical and mental function. Studies that simultaneously used different types of PE or multimodal treatment strategies were excluded from the analysis, as were those in which the primary and secondary endpoints prevented any assessment of treatment efficacy in all three health domains. Twenty-seven studies were selected: 15 considered land-based physical aerobic exercise (PAE); seven exercises in water; and five muscle strengthening exercise (MSE). There was substantial uniformity in assessing the effectiveness of land- or water-based PAE and MSE in improving aerobic physical fitness (PF) and functional state. Water-based PAE offers some advantages over similarly intense land-based PAE in reducing spontaneous pain and improving depressive symptoms, but the data are insufficient to establish its overall superiority. Regardless of method, the latest findings concerning the neurophysiology of nociception indicate the fundamental importance of assigning workloads that do not exacerbate post-exercise pain.
BACKGROUND: Exercise has been recommended for improving global-well being in adults with fibromyalgia. However, no meta-analysis has determined the effects of exercise on global well-being using a single instrument and when analyzed separately according to intention-to-treat and per-protocol analyses. The purpose of this study was to fill that gap.
METHODS: Studies were derived from six electronic sources, cross-referencing from retrieved studies and expert review. Dual selection of randomized controlled exercise training studies published between January 1, 1980 and January 1, 2008 and in which global well-being was assessed using the Fibromyalgia Impact Questionnaire (FIQ) were included. Dual abstraction of data for study, subject and exercise program characteristics as well as assessment of changes in global well-being using the total score from the FIQ was conducted. Risk of bias was assessed using the Cochrane bias assessment tool. Random-effects models and Hedge's standardized effect size (g) were used to pool results according to per-protocol and intention-to-treat analyses.
RESULTS: Of 1,025 studies screened, 7 representing 5 per-protocol and 5 intention-to-treat outcomes in 473 (280 exercise, 193 control) primarily female (99%) participants 18-73 years of age were included. Small, statistically significant improvements in global well-being were observed for per-protocol (g and 95% confidence interval, -0.39, -0.69 to -0.08) and intention-to-treat (-0.34, -0.53 to -0.14) analyses. No statistically significant within-group heterogeneity was found (per-protocol, Qw = 6.04, p = 0.20, I2 = 33.8%; intention-to-treat, Qw = 3.19, p = 0.53, I2 = 0%) and no between-group differences for per-protocol and intention-to-treat outcomes were observed (Qb = 0.07, p = 0.80). Changes were equivalent to improvements of 8.2% for per-protocol analyses and 7.3% for intention-to-treat analyses.
CONCLUSIONS: The results of this study suggest that exercise improves global well-being in community-dwelling women with fibromyalgia. However, additional research on this topic is needed, including research in men as well as optimal exercise programs for improving global well-being in adults.
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.
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.
