The effect of aquatic exercises on pain and quality of life in patients with fibromyalgia

Managing the symptoms of this disease is a major challenge, which drives specialists to continuously search for effective and non-pharmacological treatment options. Among these options, aquatic exercise has emerged as a means to reduce pain and improve quality of life. This is due to the nature of water, which provides a safe environment free of excessive pressure on the joints and muscles.

Source: This review was carried out using the following databases in January 2024: Cochrane Library, PEDro, PubMed, SCOPUS, and Web of Science Aquatic Exercise in Physical Therapy Treatment for Fibromyalgia: Systematic Review - PubMed

Four clinical trials focusing on aquatic exercise as a treatment for patients with fibromyalgia were published, all between 2019 and 2024. All of them used aquatic exercise as part of a treatment program for patients. The studies used known scientific tools to measure pain (such as the VAS scale) and quality of life (such as the SF-36 or FIQ questionnaire).

Source: This review was carried out according to the PRISMA statement and was registered in PROSPERO (CRD42024510219)

The results showed a positive improvement in terms of pain and quality of life. These results support the integration of aquatic exercise into physical therapy programs for patients with fibromyalgia. However, the benefits may be similar to those resulting from other types of exercise, which shows the importance of individualizing the treatment program to suit each patient's needs.

Kinetic and aquatic exercises in fibromyalgia treatment

Kinetic exercises are one of the basic components of physical therapy for patients with fibromyalgia and have been proven to contribute effectively to alleviating the severity of symptoms and improving quality of life. Although exercising may be a challenge for people with fibromyalgia, adherence to a regular and supervised program can lead to improved physical fitness, reduced pain, improved sleep quality, and enhanced mental health. It has a positive effect on physical and functional performance and focuses on:

• Muscle strength.

• Flexibility.

• Aerobic capacity.

Aquatic exercises, which are a form of active exercise, have emerged as a low-impact environment that facilitates movement and reduces the burden on joints. Therefore, evaluating the effect of aquatic exercises on pain and quality of life in patients with fibromyalgia is a necessary step to understand their effectiveness within rehabilitation programs. Thus, aquatic exercises can be considered a beneficial treatment option for patients with fibromyalgia, as results indicate that improvement may be related to the ease of movement within the water. Performing exercises in the aquatic environment helps to:

• Improve muscle strength.

• Flexibility.

• Cardiovascular endurance.

In the low-impact environment, the intensity can be adjusted to suit each patient's abilities, and the feeling of comfort and buoyancy in the water may make these exercises more appealing, especially to patients who are reluctant to exercise in traditional environments. Within the framework of comprehensive treatment, aquatic exercises can be linked to other therapeutic techniques that have an effect on pain regulation, such as:

• Transcranial Direct Current Stimulation

• Exergame Therapies

• Virtual Reality Therapies

which encourage movement and increase patients' adherence to exercises. Based on the analyzed studies, it is recommended to implement aquatic exercise programs that extend from 6 to 16 weeks, with the training session lasting no less than 40 minutes on alternating days. The programs should preferably include:

• Aerobic exercises and strengthening exercises (with a focus on moving the upper and lower extremities).

• Adjusting the exercise intensity (using heart rate and the Borg RPE scale).

Diet and lifestyle for patients with Fibromyalgia

The impact of dietary and lifestyle modifications on fibromyalgia is important, with a focus on anti-inflammatory diets, antioxidants, and gluten-free diets, in addition to supplements such as magnesium, coenzyme Q10, and vitamin D, microbiome, sleep, exercise, and cognitive behavioral therapy. Some foods may cause inflammation by stimulating the secretion of pro-inflammatory cytokines, which leads to the activation of pain, fatigue, and an increase in the majority of fibromyalgia symptoms. Scientific articles published between 1994 and 2022 using the PubMed and EMBASE databases, with a special focus on randomized controlled trials, meta-analyses, and evidence-based therapeutic guidelines, showed the important role that diet and lifestyle modifications play in alleviating the symptoms of fibromyalgia. Therefore, dietary and lifestyle modifications, such as improving sleep, exercising, and losing weight, can be important steps in managing fibromyalgia through these systems:

• Anti-inflammatory diet: Plant-based and vegan diets have shown an ability to lower inflammation markers. Studies have shown that following a vegan diet improves markers of inflammation, cholesterol, weight, and pain symptoms in patients with fibromyalgia. Also, consuming virgin olive oil, ancient whole grains such as wheat, and adhering to a healthy diet are all factors that have been shown to alleviate symptoms, especially in patients who suffer from digestive problems. Research also indicates that some supplements such as vitamins A and D, polyphenols (like green tea and soy), probiotics, and ginseng also have anti-inflammatory effects. Since fatigue in patients with fibromyalgia is associated with hyperactivity of the immune system and inflammatory processes, following an anti-inflammatory diet, especially within a multifaceted lifestyle that includes exercise and cognitive behavioral therapy, can improve quality of life and significantly reduce the severity of symptoms.

• Antioxidant system: The accumulation of reactive oxygen species (ROS) leads to damage to cells and tissues by activating inflammatory processes. Studies have shown a clear increase in nitric oxide and lipid peroxidation levels in patients with fibromyalgia, which is matched by a significant decrease in natural antioxidants, with a link between these changes and the severity of symptoms. Some supplements such as coenzyme Q10 (Co-Q10) and antioxidant vitamins have proven effective in alleviating symptoms, although research results on compounds such as alpha-lipoic acid have been inconclusive. The Mediterranean diet, which is rich in antioxidants, has also shown significant benefits in reducing inflammation and improving general health. Also, a promising treatment is Ozone therapy, which works by stimulating mild oxidative stress, which reactivates the body's self-defense systems and has shown positive results without side effects. These combined results indicate that enhancing the antioxidant balance may represent a promising strategy in alleviating fibromyalgia symptoms and improving patients' quality of life.

• Minerals and supplements system: Minerals and nutritional supplements play a promising role in alleviating fibromyalgia symptoms. Research has shown that magnesium supplements, along with antidepressants such as amitriptyline, may contribute to reducing neuropathic pain due to magnesium's ability to inhibit certain neural receptors. Some studies have also proven that iron can improve the hematological symptoms associated with the disease. In contrast, coenzyme Q10 (CoQ10) has received special attention due to its role as a powerful antioxidant, and it has been shown that patients with a CoQ10 deficiency who take it as a supplement feel a significant improvement in pain, anxiety, and inflammation, in addition to an increase in antioxidant levels. Other supplements that have also shown anti-inflammatory and antioxidant properties include ginger and turmeric. As for creatine, its effect and ability to support muscle strength have been researched, and it has shown that it helped enhance muscle strength in patients with fibromyalgia but without a significant effect on other symptoms such as pain or fatigue.

• Gluten and fibromyalgia: There is a potential link between fibromyalgia and non-celiac gluten sensitivity (NCGS), as both share chronic inflammatory characteristics and similar symptoms such as muscle and joint pain, irritable bowel syndrome, and general fatigue. Gluten consumption appears to have a pro-inflammatory effect by increasing the secretion of pro-inflammatory cytokines and inhibiting anti-inflammatory cytokines, which are factors directly associated with pain mechanisms. Clinical studies have revealed that following a gluten-free diet (GFD) may lead to a significant improvement in symptoms in patients with fibromyalgia, including a decrease in pain levels, a reduction in the number of tender points, and a decrease in reliance on medications. It has even helped some patients return to their normal lives and stop using painkillers. These results indicate that avoiding gluten may represent an effective part of a multi-dimensional treatment for patients with fibromyalgia, especially for those who suffer from recurrent digestive symptoms or show a potential sensitivity to gluten.

• Vitamin D and fibromyalgia: Vitamin D deficiency is a widespread health condition globally and is linked to common symptoms in patients with fibromyalgia such as general muscle pain, muscle weakness, and chronic fatigue, especially in those with reduced sun exposure. Multiple studies have indicated that vitamin D plays a pivotal role in regulating pain pathways in the central nervous system, especially after the discovery of its receptors and active enzymes in the brain. It also participates in regulating neurotransmitters (dopamine, serotonin, and acetylcholine), which may contribute to pain processing disorders in patients with fibromyalgia. In addition, vitamin D has an effect on inflammatory responses, as it enhances the secretion of transforming growth factor beta (TGF-β1), which inhibits inflammatory cytokines and reduces the production of nitric oxide associated with nervous system hypersensitivity to pain. Some research links low vitamin D to nervous system hyper-stimulation in patients with fibromyalgia, which may explain their increased pain and fatigue. However, correcting vitamin D deficiency is a fundamental step in the fibromyalgia treatment plan due to its potential effect in supporting muscle and bone health in the long term.

• Lifestyle modifications, exercise, and weight loss in fibromyalgia: Lifestyle modifications are an essential part of managing fibromyalgia and include exercise, improved sleep, weight loss, and psychological therapies. Aerobic and low-intensity exercises help reduce pain and fatigue and improve nervous system functions and autonomic nervous system balance. Cognitive Behavioral Therapy (CBT) has proven effective in modifying pain behaviors and enhancing psychological adaptation. Acupuncture is also considered an effective way to reduce pain by stimulating the secretion of natural analgesic substances in the body, such as serotonin and beta-endorphin. On the other hand, good sleep is essential for reducing pain and fatigue disorders, as poor sleep is linked to increased symptoms. Weight loss also reduces inflammation and pain sensitivity associated with a high BMI and leptin. Finally, Low-Level Laser Therapy (LLLT) is considered a safe and effective option for reducing pain and stress in patients who are unable to exercise. All these interventions represent integrated strategies for improving the quality of life of patients with fibromyalgia.

The effect of different types of exercise on adults with fibromyalgia

Exercise has been recommended as part of fibromyalgia treatment. However, some doubts remain about the benefits of exercise on the effects of aerobic exercise, resistance training, and stretching on pain, depression, and quality of life, which were examined through a systematic review. According to "Hagen et al.," there is empirical evidence that exercise reduces the symptoms of most musculoskeletal diseases, including fibromyalgia. Several studies found that different types of exercise, such as aerobic exercise, resistance training, and stretching, contribute positively to improving the quality of life in patients with fibromyalgia and clearly help reduce pain and depression.

• Aerobic exercise: reduces the feeling of pain, depression, and improves general quality of life, including the psychological and physical aspects associated with health.

• Resistance training: also reduces the feeling of pain and improves quality of life, and also improves the physical dimension of health-related quality of life. It was also noted that these exercises have a statistically insignificant positive effect on depression and the psychological dimension of quality of life.

• Stretching: reduces the feeling of pain and improves general quality of life and health-related quality of life, but its effect on depression was not statistically significant.

What we conclude

Different types of exercise, such as aerobic exercise, resistance training, and stretching, are effective non-pharmacological means of improving the health of patients with fibromyalgia. Many studies have shown that practicing these types of exercises contributes to reducing pain, improving mental state, and increasing quality of life in patients. It is recommended that exercise programs be designed individually to suit each patient's ability and the level of symptoms they experience (with exercise starting at a low intensity and then gradually increasing it according to tolerance). Adopting this individual approach in prescribing physical activity helps prevent the worsening of symptoms and enhances the effectiveness of the exercises. It is important to support patients in adopting an active and continuous lifestyle, with a focus on safe and appropriate exercises for their physical and mental capabilities.